What are the steps for laparoscopic hysterectomy?

Under normal circumstances, no woman wants to get rid of her uterus, because the uterus is extremely important to every woman, but many women are indeed very unfortunate and may have some serious uterine diseases, such as the well-known uterine fibroids, as well as adenomyosis and uterine prolapse, etc. In order to treat these diseases, patients may need to accept the reality of hysterectomy. At this time, laparoscopic total hysterectomy is required. The operation process of this operation is introduced in detail below.

Laparoscopic hysterectomy surgical steps:

1. Lithotomy position, with head down and feet up 20°, and a dedicated uterine manipulator.

2. Routine disinfection, laying towels and covering sheets.

3. Select the four-hole method in the lower abdomen to inflate and puncture the cannula and place the endoscope.

4. Routinely explore the pelvis to understand the size, position, and relationship of the uterus to surrounding organs.

5. To handle the round ligament of the uterus, clamp the round ligament of the uterine horn inward and upward, and use bipolar electrocoagulation forceps to electrocoagulate a 1-2 cm segment 2-3 cm outside the uterine horn, and cut the round ligament with scissors. Treat the contralateral round ligament in the same way.

6. Cut the reflected peritoneum of the uterus and bladder and the anterior leaves of the broad ligaments on both sides along the broken ends of the round ligaments. Use a flushing tube to inject normal saline into the broad ligament and the reflected peritoneum of the bladder to separate them. Then cut the anterior leaves and reflected peritoneum separately. Then use a blunt probe or a homemade separation "peanut" made of forceps to push the bladder downward and slightly separate the outer edge of the anterior leaf of the broad ligament outward and downward.

7. Attachment processing

(1) Removal of the appendages: Lift one side of the fallopian tube to expose the ovarian-pelvic infundibulum ligament. Use bipolar electrocoagulation forceps to fully electrocoagulate the ligament to close the blood vessels in the ligament. The ligament should be wide enough and carefully cut in the middle. You can also use scissors to cut an incision in the peritoneum at the lower edge of the infundibulocochlear ligament, then use separation forceps to pierce the hole and pass one end of the No. 7 silk thread, lead both ends of the silk thread to the outside of the abdomen, tie a knot, and then use a push rod to push it in and tighten it. In the same way, make two ligatures on the pelvic wall side and one ligature near the ovary side, and cut the ligament between the two knots.

(2) Preserve the attachments: Use bipolar electrocoagulation forceps to electrocoagulate the isthmus of the fallopian tube 2 cm away from the uterine horn and then cut it off. Then electrocoagulate the ovarian proper ligament and cut it. Be careful to ensure that the electrocoagulation is thorough and not too close to the uterus, otherwise it may cause bleeding. The above-mentioned puncture method can also be used to ligate and cut the fallopian tube and ovarian proper ligament respectively.

8. Continue to separate the bladder reflected peritoneum and push the bladder downward. Pay attention to the clear layers. The whitish cervical fascia can be seen. The tissues on both sides are the bladder columns. After electrocoagulation separation, push the bladder to the external os of the cervix. The isthmus of the uterus and the uterine artery can be seen by separating them to both sides.

9. Cutting off the uterine artery is an extremely important step. If the above separation goes smoothly, the uterine artery can be seen. If it cannot be revealed, during separation, pull the uterus to the opposite side to create a certain tension in the isthmus of the uterus, and continue to apply pressure and flush water between the cut broad ligaments. It is best to use separation forceps to gently separate 1 cm away from the uterus to find the uterine blood vessels. Do not stick to the isthmus of the uterus during separation, otherwise it will easily cause bleeding. After the uterine blood vessels are identified, the following methods can be used to deal with the uterine artery:

(1) Bipolar electrocoagulation: Use bipolar electrocoagulation forceps to electrocoagulate the uterine blood vessels close to the isthmus of the uterus. After the blood vessels are closed, they are cut off. Pay attention to the thorough and wide coagulation.

(2) Titanium clip method: First, free the uterine blood vessels, at least 1 to 2 cm in length, use two titanium clips on the pelvic side and one titanium clip on the uterine side, cut them between the second titanium clip on the pelvic side and the titanium clip on the uterine side, and then electrocoagulate the remaining ends.

(3) Suture method: Use a 2-0 laparoscopic suture needle or a 3/8 arc suture needle with No. 6 silk thread to suture through the uterine blood vessels at the isthmus of the uterus. Push the knot pusher in outside the cavity. The first two knots are tied on the pelvic wall side of the uterine blood vessels, and the third knot is tied on the side close to the uterus. Cut the uterine blood vessels outside this knot.

(4) Use a cutting and closing device to cut and close the uterine blood vessels along the isthmus of the uterus at one time. But the cutting and closing device is expensive.

10. Use bipolar electrocoagulation forceps to electrocoagulate and cut the uterosacral ligament and most of the main uterine ligaments in several times.

11. Make an incision in the anterior vaginal fornix and remove the uterus.

12. The surgical assistant puts wet gauze into a plastic bag, inserts it into the anterior vaginal fornix through the vagina, and pushes it into the pelvic cavity. The surgeon pulls the uterus cephalad and can identify the top of the anterior vaginal fornix to be incised under the microscope. The electrocoagulation hook is used to incise the vaginal fornix wall, and the vaginal packing can be seen. Pull the uterus in the direction opposite to the part to be cut, so that this part has a certain tension, and then use the electrocoagulation hook to cut the vaginal vault wall in sequence to separate the entire uterus. Make sure there is enough filling in the vagina to prevent leakage of abdominal gas.

13. Before the operation, a special uterine manipulator for hysterectomy can be inserted into the vagina, and a water bag can be injected to fix it. A matching cervical cap can be put on the cervix to prop up the vaginal vault. The surgeon can see the propped-up vaginal vault under the microscope. After dealing with the sacral ligament and part of the main ligament, the surgeon can use an electrocoagulation hook to cut the vaginal wall along this boundary and remove the entire uterus.

14. The removed uterus can be removed through the vagina, and gauze can be replaced to prevent gas leakage. The vaginal stump and reflected peritoneum can be sutured intermittently under the microscope. The vaginal stump can also be sutured transvaginally.

15. Flush the abdominal and pelvic cavity, check for active bleeding in water, aspirate the accumulated fluid, expel the gas, remove the lens and cannula, and suture each puncture hole.