A cystoscopy after injection of intravenous indigo carmine is performed to ensure that both ureters are patent, and that there is no injury to the bladder. If there is no flow of dye through one or both of the ureters, I would first cut one of the angle sutures to determine whether the ureter has been obstructed or kinked by one of these sutures. If doing so does not open the ureter, the course of the ureter must be traced to identify the obstruction.
If the ureter can’t be easily seen through the peritoneum, a ureterolysis must be performed. I start at the pelvic brim as the ureter crosses over the anteromedial aspect of the psoas muscle and bifurcation of the common iliac artery. The peritoneum is tented and incised to follow the course of the ureter that lies just lateral to the peritoneal surface.
On the few occasions when I have cut the ureter, I knew it immediately and consulted a urologist to repair the damage. In cases in which there is no obvious ureteral damage, an intraoperative urologic consult is still appropriate. Of course, if a bladder perforation is identified, it must be closed and a catheter placed for 10-14 days. The choice of suture for cystotomy is normally a rapidly dissolving suture; closure should be performed in two layers, and cystoscopy is important to be sure that the trigone is not involved and the ureters are not compromised.
Vaginal Cuff Closure
Some surgeons are now using barbed suture to close the vaginal cuff in a double-layer closure, but I have continued using figure-of-eight sutures of O-PDS. I do not believe there are any disadvantages of a double-layer closure with barbed suture; rather, the question for me has been, is it better? Will there be any less incidence of dehiscence post procedure?
The authors of a new review on vaginal cuff dehiscence conclude that a two-layer cuff closure with bidirectional barbed suture – along with judicious use of electrocautery – may potentially decrease the risk of cuff dehiscence, although the extent of the effect is uncertain (Am. J. Obstet. Gynecol. 2012;206:284-8). Others have commented that laparoscopic cuff closure with or without robotic assistance fails to take large enough tissue bites, and therefore is inherently weaker than traditional abdominal or vaginal cuff closure.
I agree that both issues – overtreatment of the vaginal cuff with electrosurgery, and failure to take large enough bites when closing the cuff – are common denominators in vaginal cuff dehiscence. The magnified visualization that characterizes the laparoscopic and robotic approaches – and particularly the robotic approach – can inadvertently lead to smaller bites being sutured. When large enough bites of tissue are taken, the cuff will heal nicely and will not dehisce unless there is infection or tissue compromise.
In general, suturing is the most challenging part of laparoscopic hysterectomy and a big part of the learning curve. The key lies in mastering a few maneuvers. I try to make the conversion from open suturing to laparoscopic suturing as seamless as possible. I suture from the left side of the patient with my ports a fist apart so that I don’t crowd myself. I introduce my needles into the abdomen by back-loading the needles and placing them through the 5-mm port.
I use a needle holder made by Olympus that is the same shape and has the same handle as the one I use for open surgery. The needle must always lie perpendicular to the needle holder and must be grasped at the tip of the needle holder. This way, the needle can be placed and, with a simple turn of the wrist, engaged into the tissue. The needle is then retrieved and the process repeated. There is no substitute for practice; with repetition, this maneuver becomes very natural.
Once the suture has been placed, the needle is removed from the abdomen by leaving an inch-long tail and by pulling the needle, suture first out, along with one of the 5-mm ports; this will guarantee that the needle exits without difficulty. A closed knot pusher allows the surgeon to apply enough tension to the suture so that the knots are nice and tight without the risk of the knot pusher slipping off the suture. Intracorporeal knot tying also has been performed very successfully, but it entails an additional level of skill.
Dr. Levine is the program director of minimally invasive gynecologic surgery and codirector of the Minimally Invasive Surgical Institute at Mercy Hospital, St. Louis. He reported that he has no disclosures relevant to this Master Class.