Total Laparoscopic Hysterectomy (TLH): management of a bowel complication

  • Abstract
    We present the case of a 65-year-old patient, diagnosed with uterine fibroids that have increased in volume over the last months. The patient had previously undergone a rectosigmoid resection and an appendectomy due to an adenocarcinoma. This surgery was streamed live worldwide, and it provides a unique opportunity to learn how to assess, diagnose, and treat intraoperative unexpected complications.
  • 00'19" Case presentation
    We present the case of a 65-year-old patient. She has a past surgical history of rectosigmoid resection due to an adenocarcinoma, as well as a gynecological curettage for post-menopausal bleeding. The patient was diagnosed with a fibroma that grew rapidly over the last months. Consequently, a hysterectomy and double adnexectomy were planned. A Clermont-Ferrand uterine manipulator is used for this surgery.
  • 02'13" Initial adhesiolysis and restoring normal anatomy
    The taking down of adhesions between the large bowel and the posterior lateral uterine wall is initiated. There is no information on how the anastomosis was performed for the previous surgery. However, it is expected that the resection line will be lower than the cul-de-sac.
  • 03'15" Diagnosis and management of intraoperative bowel injury
    During adhesiolysis, fecal material is visualized, indicating a bowel injury. The surgeon carries on with the adhesiolysis at a higher level in order to find an adequate plane and avoid the lesion, and a suture is prepared to repair the complication. A gentle and careful dissection is performed, with an additional difficulty of the distorted anatomy and the presence of very fibrotic tissue, which makes it difficult to work in the appropriate plane. Due to the previous bowel resection, the normal tissue is hardly recognized. Therefore, the surgeon visualizes the right ureter and promontory, and dissects its peritoneum in order to progress caudally and locate the normal edge of the bowel. It is of major importance to restore a normal anatomy, to achieve an easier mobilization of the remaining rectum in order to isolate the lesion and repair it. The assistant grabs the right adnexa and keeps a constant traction, in order to help the surgeon advance laterally to the lesion. Progress is made caudally until the rectovaginal space is reached. Once the anatomy has been restored and the proper plane has been identified, the bowel lesion can be repaired. A monocryl 3/0 stitch is made to repair the bowel perforation. It is preferred to close the defect before pushing the rectal probe so as not to displace feces into the abdominal cavity. Once the injury has been repaired, the surgeon makes sure that there is not a second injury on the bowel, as there previously seemed to be.
  • 17'10" Bipolar coagulation and division of left broad ligament
    The two peritoneal layers of the ligament are separated. Due to the presence of an anterior myoma, the uterine anatomy is slightly distorted. As a result of this, it is convenient to identify the left ureter. Once this has been accomplished, a fenestration is performed on the posterior leaflet of the broad ligament. Because an adnexectomy is going to be performed, the fenestration is created parallel to the tube. The ureter is now displaced laterally, and consequently the probability of injuring it intraoperatively is greatly decreased. The ureter can be identified in the lateral side of the fenestration. The insertion of the uterosacral ligament is identified. The uterine vessels are then visualized. A para-uterine vein shows some bleeding, hence a careful proximal and distal coagulation is performed.
  • 19'35" Question from the audience: what about a protective ileostomy in this case?
    We are dealing with a clear straightaway perforation of the bowel, caused by the use of cold scissors. The patient has received two prophylactic doses of antibiotics intraoperatively. Should the injury be recognized and treated during the surgery, it is not necessary to perform a protective ileostomy as opposed to what would happen in the case of an inadvertent bowel perforation. Half of bowel injuries are not diagnosed during surgery, which greatly impoverishes their prognosis.
  • 21'20" Left adnexectomy
    Because of the patient’s age, a double adnexectomy must also be performed. A careful dissection is now performed in order to separate the ovary from the pelvic wall. The second most frequent location for ureteral injuries in laparoscopy is the ovarian fossa. Once the ovary has been freed, the assistant pulls it medially. Now there is a well-defined cutting plane and there is no risk of damaging the ureter, as a result of previous maneuvers.
  • 24'36" Coagulation and division of right broad ligament and right adnexectomy
    Monopolar dissection of the vesicouterine peritoneum is achieved. The same process is performed as for the left adnexectomy, paying special attention to the right ureter and to the strong adhesions that result from the previous surgery. In order to correctly visualize the ureter, the peritoneum is dissected from cranial to caudal. Once the ureter has been correctly identified, we are able to visualize the uterine artery at its origin and to coagulate it in order to devascularize the uterus. When performing the adnexectomy, there is a risk of damaging the branches of the posterior trunk of the iliac vein. It is therefore preferable to remain as close as possible to the adnexa at all times, and not to work too close to the pelvic wall.
  • 36'45" Dissection of vesicouterine space
    After coagulation and division of the adnexa, the vesicouterine space is dissected. The vesicouterine peritoneum is divided using monopolar energy and the myoma is separated from the bladder. The second assistant pushes the uterus forward into the cavity while the first assistant grasps the bladder and pulls it anteriorly, allowing for adequate and easy identification of the vesico-vaginal plane. The valve of the uterine manipulator is identified inside the vagina.
  • 38'25" Coagulation and division of uterine vessels
    The left cardinal ligament is cut. The second assistant strongly pushes the uterus into the cavity. This maneuver separates the uterine artery from the ureter, and once again reduces the risk of injuring the latter. The uterine vessels are now bilaterally coagulated and cut.
  • 40'38" Colpotomy
    By means of the monopolar hook, and starting on the right superior angle of the vagina, we proceed to the division of the vaginal wall. The vaginal cup serves as guide to perform the division, and it avoids removing excessive vaginal tissue. Hemostasis is carefully performed in the margins of the vaginal cuff. The second assistant provides help by rotating the cup and also by moving the uterus in the proper direction.
  • 42'38" Removal of uterus and hemostasis
    It is important to avoid excessive coagulation of the margins of the vagina as it prevents posterior dehiscence of the vaginal cuff.
  • 44'12" Closure of vagina using Vicryl 2/0 suture
    Extracorporeal knots are performed as they allow for a better tension control. After suturing, the thread of the last stitch is used in order to suspend the vagina to the abdominal wall. This provides a better view of the rectum while performing safety tests.
  • 47'00" Safety tests for rectum
    First, a gas test is performed. The pelvis is irrigated and gas is injected into the rectum in order to ensure the integrity of the rectal wall by making sure that no bubbles appear in the water. This test is negative. Secondly, a methylene blue test is carried out, and also turns out to be negative. A second safety stitch is placed by means of a Vicryl suture over the bowel injury, paying attention not to reduce the lumen.
  • 51'25" Second suture over vagina, including its fascia and both uterosacral and cardinal ligaments
    This suture is also performed with Vicryl 2/0.
  • 53'00" Lavage of the cavity - Placement of drainage
  • Related medias
    We present the case of a 65-year-old patient, diagnosed with uterine fibroids that have increased in volume over the last months. The patient had previously undergone a rectosigmoid resection and an appendectomy due to an adenocarcinoma. This surgery was streamed live worldwide, and it provides a unique opportunity to learn how to assess, diagnose, and treat intraoperative unexpected complications.