TLH


Surgeon(s)/Speaker(s): Dr. Lakshmi Kona

Surgical Procedure: Gynecology-Uterus - TLH

Location: Gleneagles Global Hospital Hyderabad



Indexsteps

1. Port positions : a. 10MM Supra umbilical b.5mm right and left midclavicular parts at the level of umbilicus c.5mm ports left at Anterior Axillary at level of umbilicus

2. Using Ligasure : using ligasure taking down at Infundibulopelvic ligaments and tubes on both sides

3. Dividing round Ligaments : dividing round ligaments and broad ligament both sides

4. Displacing the Bladder : Opening of UV fold displacing the bladder away from the uterus

5. Taking down of uterines : Taking down of uterine both sides

6. Vaginal vault : Opening at vaginal vault and removal at uterus per vagina

7. Closure at vault : Closure at vault and check for haemostasis



port positions

1. Working With Ports : * Standard 5 ports * 5-10mm Umbilicus * Two 5mm ports on either side of umbilicus at the same level in mid clavicular line/semilunar line * Two 5mm ports on either side 2cm above and medial to anterior superior iliac spine



precautionary_measures

1. TLH-Precautions : 1.Keep a flat good bipolar forceps ready-capable of putting enough pressure to control uterines. 2.Avoid cutting into uterine wall-leave a small stump on uterine side while dissecting tubes,round ligament & ovarian ligament. 3.Avoid holding bowel wall to empty pouch of Douglas- retract holding appendix epiploicae on sigmoid colon. 4.Avoid cutting UV fold too high - remain in the loose area. 5.Avoid blunt dissection of bladder. 6.Dissect posterior leaf of broad ligament and cut the uterosacral ligaments before taking the uterines. 7.Clamp and seal uterines high and flush on uterus to create long uterine stump. 8.Skeletonize cervix by cutting precervical fascia. 9.Avoid cutting into cervix. 10.Identify vault- avoid dissecting uterine stump too low. 11.Avoid monopolar current at vault angles and posterior wall. 12.Avoid excessive force while delivering uterus per vaginum-cut uterus. 13.Suture uterosacral ligaments to vault. 14.Ensure Mucosa to mucosa approximation of vault- avoid bladder wall. 15.Ensure total homeostasis and flush clean all blood. 16.All 10mm ports -suture close fascia



pre_post_measures

1. Preoperative investigations : Surgical Profile- *U/S abdomen *PAP Smear *Endometrial biopsy

2. Preoperative measures : 2 Days liquid diet:new:2 Nights tab.dulcolax:new:No enema

3. Postoperative measures : Sips of water,avoid dry mouth:new:Early ambulation-avoid urinary catheter

4. Warning signs in the postoperative period : Increasing pain and tenderness abdomen:new:Prolonged ileus



Surgical Instruments

1. 10mm Trocar

2. Specimen retrieval bag

3. 30 degree 10mm telescope

4. Veress needle