Laparoscopic technique of exposure for gynecological procedures

A short video showing the techniques of exposure for gynaecological procedures, explaining the rationale behind it and advantages. Simple techniques, such as ovarian and uterine suspension, uterine manipulation shown in the beginning followed by more complicated suspension. Tricks for aortic lymph node dissection and bladder resection.

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Laparoscopic   technique   of   exposure   for   gynecological   procedures

Authors
A Wattiez
Abstract
A short video showing the techniques of exposure for gynaecological procedures, explaining the rationale behind it and advantages. Simple techniques, such as ovarian and uterine suspension, uterine manipulation shown in the beginning followed by more complicated suspension. Tricks for aortic lymph node dissection and bladder resection.
Keywords
gynecology, tips and tricks
Media type
Duration
09'00''
Publication
2007-03
Popular
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Audio
en tw
Subtitles
en
E-publication
WeBSurg.com, Mar 2007;7(03).
URL: http://www.websurg.com/doi-vd01en2024.htm

Laparoscopic   technique   of   exposure   for   gynecological   procedures

1. Benefits of exposure 00'08''
Laparoscopy is not widely accepted, and has a reputation for being complex, difficult to perform, to teach and learn. To overcome these obstacles we have to return to fundamental surgical principles, and more importantly, adequate exposure of the operative field. There are four major benefits of using correct exposure. Firstly, the assistant becomes an active and efficient aid for the surgeon. Secondly, it improves surgical performance: the surgeon has a better view and a larger working space, becomes more confident and operates with both hands and greater comfort. Thirdly, surgical safety principles are reinforced particularly during difficult moments. Fourthly, although performing these techniques takes some time at the start of the procedure, good exposure will ultimately save time over the course of the intervention. First we will speak about preoperative measures to be taken to ensure good exposure. Exposure starts by preparing the bowel before procedure. In gynaecological surgery, good access to the pelvic area is crucial. This means avoiding dilatation of bowel loops and although controversial, the use of osmotic agents in combination with laxatives 48 hours before surgery has been advocated by some gynaecologists. A correct positioning of the patient on the operating table will allow easy access to the operative field. Extension of the legs helps to access the anterior pelvic area. 45° flexion of the legs allows better access to the posterior pelvic area and promontorium by changing the angle of the lumbar lordosis. Careful positioning of the coccyx at the edge of the table will prevent the patient from slipping upwards while in Trendelenburg position. It allows satisfactory uterine mobilisation. Now the exposure properly speaking. Firstly the patient is placed in Trendelenburg position with a tilt up to 30°.
2. Initial steps 02'00''
The intrapreritoneal pressure is set at 15 mm Hg to help the cranial retraction of the bowel by pulling up the mesentery. The next step is to free the pelvis of the bowel by placing it beyond the promontorium with a well coordinated sequence of movements as you can see here in this short video. Your forceps should be used as a retraction device rather than a grasping tool during these movements. Then the intraperitoneal pressure is reduced to 12mm Hg and the angulation of the Trendelenburg position is also reduced until the bowel loops begin to return into position: this usually happens at 11 to 15 degrees’ angulation. Uterine manipulators allow good access to pelvic spaces by mobilising the uterus and help to identify dissection planes. They allow to antevert and retrovert the uterus, and to supplement this action, some devices provide extra flexion. The Tintara model is useful in cases of endometriosis, adnexal pathologies, investigation of fertility as well as for subtotal hysterectomies. As well as being atraumatic and being a good uterine manipulator, it also enables a dye test. The Clermont-Ferrand model is excellent for total hysterectomy. It has a ceramic valve that protects the vaginal cuff from electrical burns and also has a plastic valve system that maintains the pneumoperitoneum. As a first step in the procedure, the sigmoid colon is freed from the lateral pelvic side wall. Generally on the right side, the ileo-caecal region does not interfere with access to the pelvic area except in cases with previous pathology of previous adhesions due to appendicitis. Then adhesiolysis should be performed. Nowadays the new suspension technique is used to create an adequate exposure in laparoscopy. Suspension can be achieved by fixation to the abdominal wall or to other internal organs or attachments such as the round ligaments. Trans-abdominal fixation can be secured by clamps or knots. Clamps can be beneficial because the degree of tension can be adjusted during the operation. The sigmoid colon can be suspended in this manner by using a monofilament thread on a straight needle, which is suspended right through the abdominal wall and held by the clamp. The suspension starts by taking the fatty tissue on the opposite sides of the colon. The mesentery should not be used in this case because of the risk of bleeding. The tension should not be created by pulling the colon up to the abdominal wall but with the help of the assistant who will gently elevate the tissues with atraumatic graspers. The degree of suspension is adjusted as needed. The ovaries can be suspended in the same way by trans-abdominal or internal suspension. Yet as a reminder, the suspension technique can only be used after adequate adhesiolysis. The benefit of suspension does not only provide a good view of the pelvic area but also helps to prevent any accidental injury to the organs by instruments which are not in our visual field. The vaginal suspension can be used after subtotal hysterectomy in the promontofixation procedure. It allows to access both the anterior and posterior area and ensures correct placement of the mesh. The vagina is fixed to the abdominal wall with the help of the Berci needle. Before the promontofixation is completed, we should remove the suspension such as in order to apply correct tension. Uterine suspension is helpful in cases in which uterine manipulators cannot be used, for example in virgin patients or for technical reasons. It allows to keep access to the vagina and to the rectum at the same time and to maintain the pneumoperitoneum during the suturing of the vagina. It is important not to go through the cavity especially when the patient has a desire for future pregnancy. Here we have an example of uterine suspension for myomectomy. The suspension in this case also eases the suturing in the end. For the technique of lumbo-aortic lymphadenectomy, suspension in three places of the parietal peritoneum is used.