Laparoscopic challenges: The large uterus
Total laparoscopic hysterectomy is possible when the uterus is larger than 14 weeks’ gestational size—if you incorporate several novel techniques and use the right instruments
IN THIS ARTICLE
Once the upper body of the uterus has been removed by morcellation, the lower uterine segment and cervix must be removed—using your procedure of choice—to finish the hysterectomy.
Morcellating the upper uterine body
If the uterus remains attached to the cervix, it already has one fixed point of stability. During morcellation, the assistant has one hand available to direct the camera. Blood loss during morcellation of the uterus while it is still attached to the cervix is minimal because the ascending vascular bundles on either side have been interrupted under direct vision.
For greater control of the large uterus, a second port can be placed on the assistant’s side for a second grasper, as described above. Most of the large uterus that is still connected to the cervix can be morcellated in the anterior abdominal space in horizontal fashion, as for the free uterine mass just described.
Uterine manipulation by the assistant keeps the uterus away from critical structures as it is reduced to 8 to 10 weeks’ size. Once this size is attained, resume normal technique for total laparoscopic hysterectomy to separate the remaining tissue from the vagina.
2 types of morcellators in use today
One has a disposable 15-mm blade that attaches to a drive unit adjacent to the OR table (Gynecare-Ethicon Women’s Health and Urology). The other has a sterile, reusable drive unit with a disposable blade (Storz). Both work well on large uteri.
The reusable drive unit has more power to morcellate calcified fibroids and offers a choice between 12-mm, 15-mm, and 20-mm disposable blades for faster morcellation.
Concluding the procedure
Chips of fibroid and uterine tissue created during morcellation often remain in the pelvis after the uterus has been removed. Place them in a 10-cm specimen-collection bag and extract it through the vagina after removal of the residual uterus and cervix. This is faster and easier than recovering them one at a time with the gall bladder stone scoop through a trocar port. The value of the OR time saved with use of the specimen-collection bag is significantly greater than that of the disposable collection device.
CASE RESOLVED
You perform total laparoscopic hysterectomy and find 6-cm fibroids in both broad ligament areas and over the cervical–vaginal junction on the left. You use a “puppet string” to apply directed traction to the fibroids to simplify their extraction. The 45° endoscope allows clear visualization of the ascending vascular bundle on both sides, and the mechanical scope holder allows a fixed field of view for the meticulous dissection required to remove the broad-ligament fibroids.
You morcellate the entire 663-g uterus and remove it in pieces through the abdominal wall. The extensive morcellation required, coupled with technical issues related to the patient’s morbid obesity, prolong the procedure to more than 4 hours.
Postoperatively, the patient voids without a catheter, walks around the nursing unit, and eats half a sandwich within 4 hours. She is discharged home in less than 24 hours and is able to drive 4 days after her surgery.
