Pelosi minilaparotomy hysterectomy: Effective alternative to laparoscopy and laparotomy
This new modality—useful for normal, large, and fibroid-ridden uteri—combines the technical benefits of standard laparotomy with the convalescent advantages of laparoscopic surgery.
Instead, manage this type of uterus by performing a deliberate in situ supracervical hysterectomy through the minilaparotomy incision. At the end of this procedure, morcellate the amputated fibroid uterus.
Begin the surgery by dividing the upper uterine attachments. Regardless of uterine size, the origins of the round and adnexal ligaments will always be lateral to and within easy reach of a transverse minilaparotomy incision. (Access to these areas is the only factor that determines the feasibility of this procedure; uterine size is completely irrelevant.) We have found that these elongated ligaments are quite lax. Thus, in most cases it is relatively simple to navigate your index finger laterally and, using digital traction, elevate these structures into the minilaparotomy incision (FIGURE 6A). You can then clamp, cut, and suture the ligaments in the standard fashion in whatever sequence is most efficient.
Thanks to the retractor, minimal assistance is necessary during the surgery. You can create additional exposure by deflecting the uterus toward the opposite side of the pelvis using external abdominal pressure and the uterine manipulator.
Once both round ligaments and adnexal pedicles are divided, dissect the bladder flap to expose the uterine arteries (inward pressure on the uterine manipulator provides helpful countertraction). Then clamp, divide, and ligate the uterine arteries (FIGURE 6B).
The uterus is now ready for supracervical amputation. Upward traction on the isthmus by means of a rubber tourniquet facilitates uterine division (FIGURE 6C). After the uterus is amputated, push it toward the upper abdomen to increase exposure for suturing of the cervical stump (if the cervix is preserved) or for cervical excision and vaginal cuff closure (when total hysterectomy is chosen).
Next, remove the uterine specimen by morcellation through the minilaparotomy incision. Using the Doyen ladder-shaped uterine morcellation technique (originally described in the early 1920s) grasp an area of the uterus and, alternating right and left, make deep but incomplete incisions on the uterus, creating a ladder shape.2 Because of its elasticity, the retractor can stretch quite significantly without tearing the edges of the abdominal incision (FIGURE 6D). This allows the easy exteriorization of uteri with diameters considerably larger than that of the retractor, mimicking the stretching of the perineum during the crowning of the fetal head.
When the surgery is complete, remove the retractor, close the minilaparotomy incision, and apply a vertical pressure dressing over the incision. Neither vaginal packing nor bladder catheterization is required.
FIGURE 5 Hysterectomy for the fibroid uterus
A. Develop a plane of dissection between the myoma and myometrium.
FIGURE 5 Hysterectomy for the fibroid uterus
B. Deliver the myoma through the incision; if it is too large to remove intact, morcellate it with a scalpel or scissors.
FIGURE 5 Hysterectomy for the fibroid uterus
C. After reducing the uterine size by selective myomectomy, deliver the debulked uterus through the abdominal incision. Then proceed with an extracorporeal total or subtotal hysterectomy.
A short learning curve
Since it uses conventional open techniques and traditional instrumentation, this method can be learned and mastered quickly.
We tend to think of this procedure as a transabdominal “vaginal” hysterectomy, since the average diameter of the minilaparotomy opening is approximately the same as the vaginal canal. Further, as in vaginal hysterectomy, only 1 portion of the uterus, adnexa, or ligaments must be exteriorized at a given time. Thus, this approach requires less general exposure but offers effective targeted exposure.
The technique also removes the need for frequent use of traumatic metal retractors, extensive bowel packing, and extended incision exposure. The benefits: diminished postoperative discomfort and bowel dysfunction.
High success rates. We have performed more than 100 minilaparotomy procedures using this technique in patients in whom vaginal hysterectomy was contraindicated. Uterine weight ranged from 80 g to 2,500 g. Mean operating time was 50 minutes. All patients were discharged within 36 hours. Mean return to work time was 12 days, and there have been no intraoperative or postoperative complications. All surgeries were successfully completed without laparoscopy or conversion to traditional laparotomy.
FIGURE 6 Hysterectomy for the large, solid, fibroid uterus
A. Draw the upper uterine attachments to the surgical field with finger traction.
FIGURE 6 Hysterectomy for the large, solid, fibroid uterus
B. Divide the round ligaments and proximal adnexal pedicles, then carry out division of the uterine vessels bilaterally.
FIGURE 6 Hysterectomy for the large, solid, fibroid uterus
C. After dividing both round ligaments, adnexal pedicles, and uterine vessels, place the uterine isthmus in traction with a rubber tourniquet and perform an in situ supracervical amputation.
