The most important technical consideration for all laparoscopic surgery is port placement (see Chapter 23). The umbilical site typically is used in patients without a previous history of surgery or intra-abdominal infection. In cases of previous surgery where there was a midline incision or a history of a pelvic-abdominal incision, an open laparoscopy is recommended or an alternative site is chosen to introduce the primary cannula. The open laparoscopy is essentially a mini-laparotomy at the umbilicus. The alternative site is the left upper quadrant. The standard closed technique involves the use of pneumoperitoneum needle (Verres needle), insufﬂation, and primary trocar insertion. An alternative technique is the direct trocar insertion (no insufﬂation prior to trocar insertion). A meta-analysis showed no advantage of one technique over the other (24). Gynecologists should use the approach with which they have most experience.
If the left upper quadrant is used, the surgeon should be aware of the closest anatomic structures to the left costal margin (see Chapter 23, Fig. 23.3). Typically the cannula is introduced below the left costal margin in the midclavicular line. The closest structures to this area are the stomach and the left lobe of the liver. Therefore, an oral gastric tube should be introduced to empty the stomach before starting the procedure.
The patient is kept in a horizontal (not Trendelenburg) position until proper peritoneal access is confirmed. The angle of insertion of the primary trocar will depend on the size of the patient. Typically for nonobese or overweight patients a 45-degree angle from the horizontal is used and with obese patients a 60-to 80-degree angle or open technique is used.
Proper placement of accessory ports is critical to allow the steps of a laparoscopic hysterectomy. The authors typically use three lateral accessory ports and do not use a suprapubic port. Lateral ports offer the surgeon an ergonomic approach in which both hands can be used comfortably. The most important step when placing lateral ports is to avoid the inferior epigastric vessels, which are branches of the external iliac artery and vein. (see Chapter 23, Fig. 23.3). Direct visualization is best. These vessels (typically two veins and an artery) are seen through the peritoneum medial to the insertion of the round ligament in the deep inguinal ring. They cannot be transilluminated. Ports are placed approximately 8 cm from the midline and 8 cm above the pubic symphysis.
Laparoscopic hysterectomy requires traction and countertraction to identify the vascular pedicles and the ureter, which is accomplished with the uterine manipulator. In the case of a large uterus, a laparoscopic tenaculum is required. The procedure starts with coagulating and transecting the round ligament (Fig. 24.29). The incision is carried anteriorly to create a bladder peritoneal ﬂap by sharp dissection of the loose areolar cervicovesical tissue. The retroperitoneal space is opened and the ureter identified on the medial leaf of the broad ligament (Fig. 24.30). The ovarian vessels (infundibulopelvic ligament) or the utero-ovarian ligaments are coagulated and transected, depending on whether the ovaries will be removed (Fig. 24.31). The surgeon can proceed vaginally (LAVH), but there will not be any improved uterine descent because the transected tissue has no major role in uterine support.
Figure 24.29 The right round ligament is grasped and desiccated with a bipolar device.
Figure 24.30 The round ligament has been transected, the peritoneum is opened lateral to the right ureter, which is identified in the retroperitoneal space.
Figure 24.31 The right infundibulopelvic ligament is grasped with a bipolar device, desiccated and cut.