Advancements in robotic hysterectomy
I prefer to use three instruments during the procedure: the fenestrated bipolar grasper, the monopolar scissors, and the mega suture-cut needle driver.
The ureters are identified. Retroperitoneal dissection is utilized to confirm the ureteral path if needed. Depending on the patient’s desires and history, salpingectomy may be performed.
Isolation and transection of the infundibulopelvic ligaments or the utero-ovarian ligaments are then undertaken. The dissection is carried to the middle of the round ligament, well away from the uterus (where you would place suture when performing TAH). The round ligament is transected, allowing the anterior and posterior leaves of the broad ligament to separate and be visualized. These initial steps will secure two of the four main blood supplies, avoid early uterine artery bleeding, and maximize uterine mobility with larger uteri.
To outline the bladder flap, the location of the Koh ring, VCare cup, or McCarus-Volker Fornisee at the cervicovaginal junction should be noted and used as a general target. The bladder is then filled through the Foley to confirm its location and is then emptied. The anterior leaf of the broad ligament is then picked up and tented with the fenestrated bipolar grasper.
The monopolar scissors are employed to incise the anterior leaf from where the round ligament was transected to the area just cephalad of the cervicovaginal ring and the border of the bladder, in a fashion similar to TAH. Each of these steps is performed bilaterally.
Next, in preparation for the anterior colpotomy, further development of the bladder flap is necessary. Aggressive and continuous cephalad pressure of the uterine manipulator with the ring/cup is critical to create a clear delineation of the cervicovaginal junction. Creation of the bladder flap is then completed in the caudad direction approximately 1-2 cm over the ring/cup (see image 2).
The anterior colpotomy is initiated with the posterior displacement of the uterine fundus using the RUMI II articulating tip (CooperSurgical) by rotating the handle counterclockwise. This movement simultaneously allows for pressure and emphasis to be placed on the anterior portion of the Koh ring.
Using a clockface as the reference, the anterior colpotomy is initiated at the 12 o’clock position with the monopolar scissors (settings: 30 watts). Once the ring/cup is successfully identified, the colpotomy is extended from the 12 o’clock position to the 2 o’clock and 10 o’clock positions, stopping to avoid the uterine arteries bilaterally.
To begin the posterior colpotomy, the uterine fundus is repositioned anteriorly while maintaining aggressive, continuous cephalad pressure. Again, the RUMI II allows for anterior displacement of the uterine fundus with posterior pressure and emphasis on the Koh ring by turning its handle – this time in the clockwise direction. The posterior colpotomy is initiated at the 6 o’clock position and extended upward to the 4 o’clock and 8 o’clock positions, stopping to avoid the uterine arteries bilaterally.
For taking down the uterine arteries, the optimal placement of the uterus is a midplane position. A clear view of the uterine sidewall is created with retraction using a grasper on the remnant of the round ligament. While maintaining this view, the uterine artery is grasped, cauterized, and transected high up on the uterine sidewall.
The initial pedicle is created well away from the ring/cup in a fashion similar to the placement of a curved Heaney clamp when performing a TAH (see image 3).
Subsequently, each pedicle is then cauterized and transected close to the uterine sidewall, allowing it to fall away from the uterus as progress toward the vaginal ring/cup is made. This portion of the procedure is similar to creating pedicles with straight Heaney clamps during a TAH. Aggressive cephalad pressure is placed on the uterine manipulator and cup throughout the process, further allowing the ureters to fall away with the formation of each pedicle. Upon reaching the vaginal ring/cup, the circumferential colpotomy is completed at the 3 o’clock and 9 o’clock positions.
The specimen is then removed intact transvaginally or is morcellated. Large uteri may be morcellated endoscopically or may be removed by traditional vaginal morcellation techniques to avoid additional costs.
To decrease the chances of vaginal cuff dehiscence, it is critical to use low monopolar energy settings, create appropriate tension to allow efficient and quick colpotomies, and create an adequate bladder flap to allow incorporation of 1-2 cm of vaginal cuff tissue in the closure.
