Diet Although little manipulation of the bowel occurs during vaginal hysterectomy, there is some slowing of gastrointestinal motility. This slowing rarely occurs to a degree that limits some form of oral intake soon after surgery. Most patients experience some degree of nausea after surgery, which, combined with drowsiness from analgesics, usually makes them disinterested in food on the evening after surgery. A clear liquid diet is suitable during the first night after surgery, and on the first full postoperative day, a regular diet can usually be consumed. The patient is often the best judge of what she can tolerate as her appetite returns.
Preoperative Preparation The main limitations to a laparoscopic approach are medical or anesthetic disorders that do not allow adequate pneuomperitoneum or proper ventilation (34). Extensive and dense pelvic abdominal adhesions from previous surgery and very large uterine size are relative contraindications, although this decision can be made after assessing the peritoneal cavity (see Chapter 23). If the uterine size limits access to the uterine vessels, laparoscopic hysterectomy may not be possible. Obesity is not a contraindication to laparoscopic hysterectomy. The increased morbidity from laparotomy in patients with high body mass (BMI) can be minimized with laparoscopy.
Different classifications were proposed for the types of laparoscopic hysterectomy. Laparoscopic hysterectomy is defined as a laparoscopic-assisted vaginal hysterectomy (LAVH) if the uterine vessels are occluded vaginally. The Cochrane review authors recommended that if the vessels are occluded laparoscopically, or if part of the operation is performed vaginally, the procedure be called laparoscopic hysterectomy, and, if no component is performed vaginally, the procedure should be called a total laparoscopic hysterectomy (41).
Patient Positioning The patient is placed in dorsal lithotomy position with legs placed in Allen or Yellowfin stirrups (Allen Medical Systems, Acton, MA). Attention to proper leg placement will avoid nerve injury. Hyperﬂexion of the hips should be avoided because this may cause femoral nerve palsy. The patient should be placed on an egg crate mattress or beanbag cushion to limit patient movement in the Trendelenburg position. The arms are tucked on the patients’ side and protected with egg crate–type material. No shaving or clipping is necessary. Shoulder braces should not be used as they are associated with brachial plexus injury.
The steps to follow before introducing the first trocar are:
Perform an examination under anesthesia.
Place a Foley catheter to drain the bladder.
Introduce a uterine manipulator (e.g., Koh colpotomizer [Cooper Surgical Inc., Trumbull, CT] or VCare [Conmed Corp., Utica NY]).
Place an oral gastric tube.
Instrumentation The most important instrument is the one used to occlude blood vessels. A multitude of energy forms exist, including electrosurgery, lasers, and ultrasonic scalpel (see Chapter 23). Some surgeons use stapling devices, although the cost of these stapling devices is high, and an energy-occluding device is needed to access areas that a stapler cannot. The versatility of the devices with energy makes them the method of choice to occlude vessels. There are no valid clinical data showing that one instrument is safer than another. The preferred one involves bipolar energy because gynecologists are experienced with this form of energy.
Surgical Technique of Laparoscopic Hysterectomy Peritoneal Access