Figure 24.32 After the bladder peritoneum is sharply dissected down to the level of the cervix, the uterine vessels are grasped with the bipolar devise and desiccated.
The uterus is then torqued away from the uterine artery to be occluded. The uterine artery is skeletonized by cutting the posterior peritoneum up to the uterosacral ligament, coagulated, and transected. The procedure is carried out on the other side. This area of occlusion is approximately the level of the internal os. If a supracervical hysterectomy was performed, the uterus can now be amputated. When this is done, the remaining endocervical canal should be cauterized.
The anterior dissection should be completed so that the bladder is completely off the anterior fornix area of the vagina (Fig. 24.32). Using a vaginal device such as the Koh, the surgeon can identify this area. Ensuring that no CO2 escapes from the vagina, and an incision is made on the vagina circumferentially around the cervix (Fig. 24.33). The uterus can be pulled out though the vagina or can be morcellated first, and then removed either vaginally or laparoscopically, whichever is easier.
The vaginal cuff is closed laparoscopically or vaginally with interrupted or continuous delayed absorbable suture (2-0 on CT-1 needle). To give added pelvic support, the uterosacral ligaments are reattached to the vagina (McCall’s culdoplasty) with delayed absorbable suture. Intravenous indigo carmine is given and the integrity of the bladder and ureters confirmed with cystoscopy, if desired, by the surgeon.
At the end of the procedure, the secondary ports should be removed under direct visualization to ensure that there is no bleeding. In order to minimize the risk of herniation, the fascia should be closed at port sites that are greater than 8 mm and at those sites where smaller ports have been used but there has been prolonged manipulation.
The patient is kept in the short stay unit and discharged within 24 hours if there are no complications. A regular diet as tolerated is given on the same day as the surgery. Ambulation is encouraged as soon as possible. Median time to return to work is 3 to 4 weeks (42).
Robotic-Assisted A surgical robot consists of a surgeon’s console with the instrument manipulators and view Laparoscopic screen, a robot tower with telerobotic arms that are attached to the patient, and the computer Hysterectomy interface equipment, which is housed in a separate tower (see Chapter 25 for a more complete discussion). Robotic assistance at laparoscopy has some advantages, including a three-dimensional
Figure 24.33 The vagina over the anterior fornix is identified and incision is made.
view, instruments with articulating tips that offer seven degrees of movement, scaling of movement, and more precise movements. The disadvantages are the bulky device around the patient that limits the assistant’s movements, the lack of haptic feedback, and the high cost of the robot. The robot device uses a 12-mm laparoscope and instruments that require 8 mm ports.
The robotic tower can be docked between the legs or on the patient’s side (side docked). Side docking allows access to the perineum and vagina so that the assistant can comfortably manipulate the uterus. A robot-assisted hysterectomy goes through the same steps as a laparoscopic hysterectomy. A right-handed surgeon should have the monopolar scissors or harmonic scalpel through a right robotic port and a vessel-sealing device such as a bipolar instrument through a left-sided robotic port. If a fourth robotic arm is used, the additional port is placed on the right side for right-handed surgeons.