TOTAL LAPAROSCOPIC HYSTERECTOMY (TLH)

What is total laparoscopic hysterectomy? 

Total laparoscopic hysterectomy is minimal access surgical procedure which facilitate the removal of non prolapse uterus through vagina route and procedure done by through small incision in the abdomen & using laparoscope (10mm telescope 30 degree) & a utrine manipulator. 

-Function of the uterus :

- Important role in human reproduction. 

- Implantation and nourishment of the     fertilized ovum takes place. 

 -Helps pushing out the baby during birth through muscle contraction.

What is causes of hysterectomy :

1.Endometriosis

2.Ovarian cyst 

3.Painful sex 

4.Fibroids 

5.Adenaxal mass

6.Pelvic pain 

7.Narrow public arch or poor vaginal descent

8.Adenomyosis

9.Uterine prolapse, which is a sliding of the uterus from its normal position into the vaginal canal.

10.Cancer of uterus, cervix & ovaries.

-Indications of hysterectomy:

Heavy menstrual bleeding

Pelvic pain

Uterine prolapse (vaginal hysterectomy)

Gynaecological malignancy (usually ovarian, uterine or cervical)

Hysterectomy may also be performed as a life saving procedure in the management of major postpartum haemorrhage.

-What is the symptoms? 

-Fever 

-Offensive vaginal discharge or heavy 

  bleeding 

-Severe nausea or vomiting 

-Inability to empty your bladder or bowels 

-Severe pain

-Contraindication of hysterectomy surgery :

In this condition patient will not physical fit for surgery due to following reason

1.asevere COPD or cardiac disease.

2.Generalised peritonitis. 

3.Previous extensive abdominal surgery 

4.Hug cervical or broad ligament myoma.

-Preparation before the surgery :

1.Routine anesthesic &medical check up &take medical history. 

2.Physical exam.

3.Blood and urine test.

4.special test (eg. Electrocardiogram)

5.Review of medication & supplement 

6.Some medication (blood thinner) to be stopped before surgery. 

7.Discuss the doctor if there are any concern

8.Preparation the night before eating a light meal.

9.Stop drinking & eating after midnight. 

10.Relaxation & rest prior to surgery 

11. Check into hospital. 

12.Change home cloths & wear hospital Gown

13.Surgeon & anesthesiologist come and meet you and explain about surgery & anesthesia. 

14.Taken to the operating room by a nurse.

Procedure of total laparoscopic hysterectomy 

Preparation in the operation theatre:

Start intravenously fluid or antibiotic for prevent infection and  fluids allowed to run until administration of the prescribed dose is completed.(as per doctors advised )

Anesthesia :

Total laparoscopic hysteroscopy procedure done under the general anesthesia in which patient asleep or unconscious during whole surgery. 

General anesthesia for pain relief during surgery and comfort to patient.

Fentanyl citrate and muscle relaxtant given to the patient and Endotracheal intubation will given and hypnotic agent like propofol given. 

Than anesthesist continue watching monitor and watch vital signs including pulse, spo2(saturation ), E.C.G,  body temperature and blood until the  patient  will not shifted from operation theatre to recovery  

-Position of the patient:

After the anesthesia Patients are placed in a lithotomy position. The arms are tucked at the sides. keep the table in a low position and have a monitor directly facing to surgeon and another monitor is front of uterine manipulator assistant for comfortably work.

-Inspection of instruments and equipment by surgeon :

Before starting the surgery,  surgeon inspect  all the equipment & instruments  in the operating room and should routinely inspect equipment for any malfunction or servicing needs.  

Instruments and equipment require 

1. Telescope 10mm or 5mm 30 degree

2. Uterine manipulator 

3.Grassper 5mm (2)

4.endo needle holder

5.Endo curved scissor, straight scissor

6.Hook & unipolar cord, bipolar forcep     or bipolar cord

7.Harmonic and ligasure. 

-Scrub & Painting :

Patient painted by betadiene solution antibacterial solution its contains povidone- Iodine. Paint all over the abdominal area and pelvic region to thigh then drapped by sterile drap.

Procedure of Total laparoscopic hysterectomy :

-Abdominal Entry and Trocar Placement:

A 5-mm skin incision is made at the deepest part of the umbilicus using a 15no or 11no. blade.Surgeon elevate the deepest part of the umbilicus with a allies clamp and insert a Veris  needle and also some surgeon use hasan technique into the peritoneal cavity for create pneumoperitonium inside the abdomen. Which give to space to perform surgery and vision of organs

Switch on the Co2 gas.connect camera with the telescope, connect cold light source then surgeon inspect inside the abdomen and uterus then Three or more incision on abdomen for inserting 5mm instruments. 

-Insertion of a Uterine Manipulator:

First, place a Sims speculum into the vagina, hold the cervix with a tenaculum or allies and dilation of cervix done by hegars dilators then gently insert the manipulator. Uterine manipulator always insert after the putting laparoscope inside the abdomen.

-Steps of the surgery :

#Surgeon go inside the abdomen and assess the uterus. 

#Coagulation and cutting done by bipolar and harmonic & some surgeon use ligasure or enseal.

#Start with round ligament of the right side coagulate and cut.

#Then come to the fallopian tube and ovarian ligament then broad ligament coagulate and cut the upper pedical removal is completed. 

#Then come to left side of the round ligament and fallopian tube and ovarian ligament then broad ligament coagulate and cut 

#Then start dissection of peritoneum of anterior and posterior side and mobilized the bladder or bladder pushed away.

#Then coagulate and cut the uterine artery of both side one by one.

#Colopotomy start with the harmonic or hook then cevix is removed from the vaginal vault.

-Removal of the Uterus:

Pull the uterus into the vagina if it fits. The uterus can remain there to maintain pneumoperitoneum during suturing. Alternatively, the uterus is removed and a glove with a pair of 4 × 4 sponges is placed into the vagina to maintain pneumoperitoneum.Used to maintain pneumoperitoneum prior to and during vaginal cuff suturing.

After the removal of uterus and fallopian tube and if ovary removed than also ovary sent to  be laboratory for examination (Histopathology).

-Port Site Closure:

Port side closure done by suture or stapler and also with glu its depends on surgeon choice.

-Dressings : 

Small dressings done with G -dress and tegaderm.

Procedure takes place 1 to 2 hours and also its depends on uterus. if uterus is enlarged or too small than they take long time. And stay in hospital 2 to 3 days its depends on patient physical conditions and doctor's order.

What is the risk for complications after a hysterectomy?

Bleeding

ureter damage

bladder or bowel damage

infection

vaginal problems

ovary failure

early menopause

Pain during sexual intercourse

-Benefits of hysterectomy done by laparoscopy procedure :

Less blood loss

Shorter hospital stay

Speed return to normal activities 

Few chance of abdominal wall infection compared to open abdominal or vaginal hysterectomy. 

-Post op surgery :

Patient keep in recovery room for monitoring for few hours, then patient comfortable & fully come out from the anesthesia then patient shifted to ward.

Check urine output by nursing staff.urine should be cleared.

Check the vitals signs of the patient every one hour. 

Give antibiotics to prevent infection. 

Patient will feel some pain after surgery. Pain at the incision sites and in your abdomen is common. Patient  might also have pain in shoulders.  This is from the air put into your abdomen during the operation. The shoulder pain should go away in 24 to 48 hours.

Painkiller gives for reduce to pain.

Patient can ambulate (walk) with taking help of nursing staff from next day after the order by surgeon.

Catheter or foley's will removed after the 2 days by the instruction of surgeon. 

Don't take solid food after surgery till five days (also as per doctor advise)

-After the hospital discharge :

No elastic & tight clothes wear its bother you and irritate you  abdominal incision.

Drinks lots of water its helping with movement, flow & the constipation after surgery & get a stool softner.

Walking 

Wear supportive shoes

Don't drive untill you will feel comfortable and ask your doctor.