Dr. Pulkit Nandwani, Gynaecologist, Associate Consultant
pulkitnandwani@ymail.com, 9971573637
Dr. Indu Bhatia, Director and Consultant Gynaecologist, Laparoscopic Surgeon
bhatiaglobal@gmail.com, 9810138656
Dr. Parveen Bhatia, Chairman, Institute of Minimal Access & Bariatric Surgery,
Sir Ganga Ram Hospital
& Medical Director, Consultant Laparoscopic and Bariatric Surgeon,
Bhatia Global Hospital & Endosurgery Institute, bhatiaglobal@gmail.com, 9810008507
Total hysterectomy has been shown to have more clinical benefits when performed with a laparoscopic approach in comparison to traditional open surgery. However, multiple puncture sites might increase trocar-associated complications, such as bleeding, hernias and wound infection and the cosmetic results are not always optimal. The umbilicus, an embryonic natural orifice, is an anatomical structure that may be used to perform advanced gynaecological procedures, further reducing the morbidity associated with classical laparoscopic surgery. Single incision laparoscopic surgery (SILS) is principally an extension of the multiport laparoscopic surgery with an aim to reduce the trauma of access to body cavities and thereby residual scarring to the patients and hence a new weapon in the armamentarium of surgeon especially minimal invasive surgeon.
After the success of SILS appendectomy, SILS cholecystectomy and SILS hernia repair, we have now recently ventured into Single Incision Total Laparoscopic Hysterectomy (SITLH). The indications for SITLH are limited as of now, but as our experience and confidence increases, larger size uterus and patients with previous surgeries will also be attempted. Advancing technology has launched articulating instruments and flexible camera tips in market which will facilitate in difficult cases.
PROCEDURE
Step I. Abdominal wall access
We prefer to give a 11mm intraumbilical vertical skin incision (& not supra/infraumbilical or transverse incision). This incision utilizes the depth of umbilicus thus limiting the whole of incision intraumbilically. The laxity of umbilical skin further facilitates the space for trocar insertions. Subcutaneous tissue is separated and rectus sheath visualized. Veress needle is inserted in midline and pneumoperitoneum created upto 17mmHg.
S shaped retractors are inserted on either side in the skin incision and a skin flap developed circumferentially using a gauze held on a long artery forceps. This technique of making the skin flap gives upto 2.5cm space in the same 11mm incision. The assistant focusess the camera on the incision for clear visualization of rectus sheath and the extra light also helps. First, optical 10mm port is inserted in midline. We prefer the 10mm transparent port instead of the reusable one.
Secondary ports are made on either side of the optical port, one little above while the other little below to avoid clashing of instruments. The ports are inserted in different directions with about 0.5cm distance in between the ports. We use the 5mm Lina® threaded trocars for secondary operating ports. Threading prevents slippage of the port. Long size ports are preferred. One 5mm trocar is threaded fully inside, while the other 5mm trocar only one thread is inserted. This keeps the handles of instruments at different levels to avoid clashing. To insert, the port is first slided into the skin flap (at about 450 angulation) and then at the proper position the port is made vertical and rectus sheath pierced. This creates more than 0.5cm space in between two ports.
This technique, developed by us, obliterates the need of any special access port currently available in the market (like Covedien’s SILSTM port, Gelport or ASC Triport). These access ports are expensive and require atleast 2.5cm incision. Special articulating instruments (like Novare’s Real Hand instruments) can be used but we have been able to perform SILS with our usual nonarticulating instruments.
After port insertion, the pneumoperitoneum is decreased to 15mm Hg.
Step II. Diagnostic Laparoscopy
After first port insertion, diagnostic laparoscopy of pelvis and upper abdomen in done. With reference to adhesions and mobility of uterus, if SILS is decided then further secondary trocars are placed in the same incision as described above.
Step III. Uterine manipulation
Uterine manipulation can be done vaginally with a simple endometrial curette or laparoscopically using a myoma screw.
Myoma screw definitely helps in positioning the uterus. We like the myoma screw on a needle designed by Dr. Rakesh Sinha, BEAMS hospital, Mumbai (made by Creative Surgical®) for its sturdiness.
Step IV. Dessication of Attachments
The infundibulopelvic ligaments are dessicated using Harmonic ACE (if salphingo-oophorectomy is desired) or the upper pedicle consisting of tubes, round ligament and ovarian ligament is dessicated.
Step V. Pushing the Bladder down
Bladder is pushed down with sharp as well as blunt dissection (using rolled gauze piece).
An open gauze is rolled in a “cigar shaped” manner by the scrub nurse, and then the corners are cut sharply so that the loose threads of gauze don’t fall into the peritoneal cavity. Rolled gauze, held on a grasper, is introduced into the peritoneal cavity through the 10mm optical port. The gauze should push on the cervix posteriorly and not on the bladder. It should be a “planar” push.
To remove the gauze, edge of the gauze is held by grasper. The grasper holding the gauze along with the 5mm port is removed from the skin. As the grasper is catching the gauze, the gauze is pulled out of the abdominal tract.
Step VI. Uterine Vessels Dessication
“Kiss the uterus but from a safe distance” meaning one should not be very close to the uterus. Too medial approach can damage the vascular supply of uterus while a too lateral approach can injure the ureter. While remaining parallel to the uterus, we take small but sure steps with Harmonic ACE.
After bladder dissection, uterine vessels become easily visible. We prefer to coagulate the uterine vessels first using bipolar and then dessicate with Harmonic ACE. With this approach, we hardly encounter any bleeding.
Step VII. Colpotomy
“Tampoons are enough rather than fancy cups”. A Tampoon made with gauze and held by sponge holding forceps is inserted into the posterior fornix. The posterior fornix is bulged out and uterosacrals made taut.
The uterus is anteverted at this point either by myoma screw in situ or by endometrial curette. Posterior colpotomy is done using monopolar hook. With that tampoon still in place to prevent gas leakage, another tampoon is inserted into the anterior fornix for anterior colpotomy in similar manner. Both the colpotomy incisions are reunited using monopolar or Harmonic ACE. Pneumoperitoneum loss can be prevented by just placement of a single gauze or tampoon intravaginally and applying babcock forceps on the labia majora.
Step VIII. Delivery of uterus
Either vaginally or by morcellation
In larger uterus, morcellation may be required. It has not yet been done in single incision laparoscopic surgery. But with the emerging and advancing technology, any day a 5mm morcellator will be launched, solving this problem also. But till then if need arises, we can change the 10mm port to 12mm port and morcellation can be guided by 5mm telescope (cystoscope with hysteroscopic sheath).
Step IX. Colpotomy closure
Can be done vaginally or laparoscopically. Either way, we believe in using delayed absorbable (vicryl no 1-0) continous suturing.
Step X. Single Incision closure
After check laparoscopy to ensure hemostasis, ureter and bladder integrity, the secondary ports are removed. The 10mm port is slided off the peritoneal cavity under vision so that all the gas comes out (the scope remains in and the canula is pulled out).
After deflating the abdomen properly, the incision is closed. With S retractors in place the edges of the rectus sheath of the 10mm port is held by long artery forceps and sutured together using vicryl no-1 (prevents any chance of herniation) Subcuticular sutures using monocryl no 3.0 are applied on the skin. The incision falls back into the depth of umbilicus. Thus making it a “Scarless” surgery.
Our technique is very cost effective because custom made access ports and specially designed articulating instruments are not used . Other than these ports being expensive, they also require a 2.5cm incision. While with our technique we give the usual 11mm incision.
SILS is the next big step in laparoscopic surgery worldwide. It offers a huge cosmetic advantage and also enables much quicker recovery for the patient compared to conventional lap surgery. For the patient it is extremely appealing to be offered surgery through a single small cut, than through multiple incisions. |
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