Total Laparoscopic Hysterectomy Ligasure Harmonic Lateral view technique
Surgeon(s)/Speaker(s): Dr. Neeraj Gupta
Surgical Procedure: Gynecology-Uterus - TLH
Location: Kirloskar Hospital Hyderabad
Indexsteps
1. Veress needle insertion : Veress needle insertion
2. First port insertion : First port insertion
3. Abdominal organ anatomy : Abdominal organ anatomy
4. Anterior pelvic wall anatomy : Anterior pelvic wall anatomy
5. Secondary ports placement : Secondary ports placement
6. External view of ports : External view of ports
7. Uterus anatomy & myoma screw : Uterus anatomy & myoma screw
8. About Ligasure : About Ligasure
9. Left pedicle dissection : Left pedicle dissection
10. Lateral view technique : Lateral view technique
11. Harmonic & broad ligament dissection : Harmonic & broad ligament dissection
12. Left uterosacral ligamemt dissection : Left uterosacral ligamemt dissection
13. Right ureter course : Right ureter course
14. Bladder dissection : Bladder dissection
15. Left uterine sealing & cut : Left uterine sealing & cut
16. Left cervical dissection : Left cervical dissection
17. Right pedicle dissection : Right pedicle dissection
18. Right uterosacral ligament dissection : Right uterosacral ligament dissection
19. Right bladder pillar dissection : Right bladder pillar dissection
20. Right uterine sealing & cut : Right uterine sealing & cut
21. Right cervical dissection : Right cervical dissection
22. Vault opening & dissection : Vault opening & dissection
23. Endoknife morsulation uterus : Endoknife morsulation uterus
24. Vaginal extraction uterus : Vaginal extraction uterus
25. Salpingectomy : Salpingectomy
26. Vault suturing : Vault suturing
27. Abdominal wash & saline instilled : Abdominal wash & saline instilled
28. Port close suture passer : Port close suture passer
29. External wounds- sticking- sensorcaine : External wounds- sticking- sensorcaine
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