Single port laparoscopic hysterectomy
We utilize the Kleppinger forceps and the 45-cm Harmonic Ace Shears for all of our dissection. Because the uterus is held on some tension, we first coagulate all vascular pedicles with the Kleppinger forceps before cutting. For safety, the uterine arteries are transected fairly high, just cephalad to the internal os. This gives us plenty of room to safely grasp and recoagulate a bleeding pedicle without fear of injuring the ureter.
Sequential instrument placement is key to this technique. If sword fighting occurs, one must reexamine the sequence of instrument placement and pay greater attention to the direction of extra-abdominal hand movements and subsequent angles. Again, the laparoscope and grasper must be inserted, positioned, and frozen in place before the active instrument is introduced.
Once one side of the uterus has been dissected free and the uterine artery transected, then all instruments are removed and replaced in a mirror-image manner to access the opposite side. Essentially, the camera and grasper switch trocars, and the active instrument remains in the middle.
Abdominal entry is performed with the traditional open laparoscopy technique described by Dr. Harrith Hasson of Chicago (Am. J. Obstet. Gynecol. 1971;110:886-7). While single-channel trocars generally require a 5- to 10-mm incision, LESS multichannel ports require a slightly larger incision. We recommend a straight vertical incision of about 2 cm through the center of the umbilicus.
The position of the surgeon also differs from multipart laparoscopy. With LESS, the surgeon stands in line with the port and the pathology, usually between the patient’s head and shoulder, and holds either the grasper or camera while operating the active blade. To prevent sliding in a steep Trendelenburg position, the patient is placed on an egg-crate mattress, and both the patient and the mattress are taped to the table. The arms also are tucked to the sides in a manner more resembling robotic positioning than the positioning traditionally associated with laparoscopic surgery. For morcellation, the patient is brought to the standard supine position and then returned to steep Trendelenburg afterward.
Other surgical tips
• Uterine manipulation. In most of our cases of LESS hysterectomy, placement of a traditional uterine manipulator has been unnecessary and, in fact, detracts from the simplicity of our approach, which utilizes the single-tooth tenaculum to manipulate and expose the uterus. We quickly learned that even lightweight manipulators compromise uterine mobility and interfere with the creation of necessary angles. The manipulator becomes like a ball and chain on the cervix.
For total laparoscopic hysterectomy, however, a uterine manipulator can be helpful for the colpotomy. Late placement of the manipulator in these cases – after the lateral attachments are dissected and before colpotomy is performed – works perfectly.
• Control of the uterine vessels. Access to the uterine vessels can be difficult with LESS. It requires severely angulating the uterus to expose the uterine artery and vein, allowing a more direct approach from the umbilicus. With the uterus on significant tension, initial cauterization with the bipolar forceps is performed before ligating the vessels with the harmonic scalpel.
• Cervical amputation. We use a monopolar loop (LiNA Loop or Storz SupraLoop) for amputation of the uterine fundus in supracervical hysterectomies. We place the loop after we’ve carried our dissection down to the middle of the cardinal ligament. The loop is placed at the level of the internal os.
Placement of the LiNA Loop device was more challenging than we expected, as the camera and grasper must be removed and reinserted on opposite sides in order to visualize the entire loop, a process during which the loop can potentially loosen and trap small bowel or other tissue on the nonvisualized side.
Our solution has been to tighten the loop on the cervix and place a Kelly clamp on the shaft of the loop before switching our instruments from side to side. The clamp keeps the loop snug against the cervix. This technique allows us to visualize one side, remove the instruments, and then visualize the other side without worrying that the loop may loosen and cause damage.
• Vaginal cuff closure. When the vaginal apex is easily accessible, transvaginal closure is the simplest method. The vaginal cuff can be closed intracorporeally with a conventional straight needle driver and a curved grasper; however, intra-abdominal closure of the cuff can be technically challenging in LESS. Historically, I used the angulating 5-mm Endo Grasp and a 0-Vicryl suture on a CT-2 needle and secured the stitch on both ends with absorbable Lapra Ty anchors (Ethicon Endo-Surgery). Increasingly, however, I use the EndoStitch (Covidien, Mansfield, Mass.), a 10 mm suturing device, to place interrupted stitches, and I secure each one with the TK Ti-Knot Device (LSI Solutions), an automated knot-tying device.*
