Total laparoscopic hysterectomy (TLH) using the LigaSure™ Retractable L-hook Laparoscopic Sealer/Divider

  • Abstract
    Total laparoscopic hysterectomy has gradually assumed an important part in gynecologic practice. The described “10-step” technique is the most followed strategy to be successful in this procedure. Technological innovation has brought in new devices which combine a safe use of bipolar (vessel-sealing) energy with monopolar current (hook) in the same instrument. In this didactic video, we aim to show the advantages (with some technical tips) of using this new versatile instrument.
  • 00'19" Introduction
    In this video, we describe a total laparoscopic hysterectomy following a 10-step technique.
  • 00'28" Direct entry technique and patient position
    The Clermont-Ferrand uterine manipulator was placed in the uterus and a direct entry technique was performed using an optical port. After first entry, the patient was placed in a Trendelenburg position to have a better exposure of the pelvis. The abdominal and pelvic cavities were carefully inspected including the different organs.
  • 01'07" Bowel mobilization
    The bowel was mobilized cranially and ureteral pathways were meticulously identified on both sides. On the right side, the ureter crosses the external iliac artery. On both sides, the ureters run medially to the infundibulopelvic ligaments.
  • 01'50" First step
    After identification of the anatomical landmarks, the coagulation and division of the round ligament was performed as the first step of the procedure.
  • 02'19" Second step
    The second step is the opening of the anterior leaflet of the broad ligament up to the vesicouterine fold using the monopolar hook of the LigaSure™ device.
  • 02'52" Third step
    The third step consists in the fenestration of the posterior leaflet of the broad ligament by applying careful hemostasis on small vessels.
  • 03'41" Forth step
    The same steps were performed on the contralateral side. The right round ligament is coagulated and divided. The anterior leaflet of right broad ligament is opened up to the vesicovaginal fold. The posterior leaflet of the right broad ligament is fenestrated.
  • 05'00" Fifth step
    Because this was a total laparoscopic hysterectomy with conservation of the ovaries, we did a bilateral salpingectomy in order to reduce the risk of ovarian carcinoma. The utero-ovarian ligament was sealed and divided using the vessel-sealing device. During the salpingectomy procedure, the mesosalpinx was spared as much as possible in order to preserve the future ovarian vascularization.
  • 06'31" Sixth step
    The sixth step is the dissection and opening of the vesicovaginal space using careful movements, trying to isolate the bladder and going in the vesicovaginal avascular space.
  • 07'53" Seventh step
    After bladder dissection, the uterine vascular pedicle was skeletonized in order to better identify the uterine artery and veins, making sure to apply the sealing device in a precise way.
  • 09'45" Eighth step
    After both vascular uterine pedicles were coagulated and divided, we started to open the vagina using the monopolar hook and the cup of the uterine manipulator which shows and delineates the vaginal cuff. Careful hemostasis was applied onto the small bleeders of the vaginal cuff using the bipolar instrument.
  • 11'39" Ninth step
    The vagina was closed using a multifilament absorbable suture. The anterior and posterior mucosas and fascias of the vagina were closed and re-approximated using intracorporeal knots. Finally, a last stitch joining both uterosacral ligaments was made to reduce the risk of post-hysterectomy vaginal cuff prolapse.
  • 12'32" Tenth step
    The hemostasis was controlled at the end. The ovarian pedicles were checked. And the specimen was finally sent for histological analysis.
  • Related medias
    Total laparoscopic hysterectomy has gradually assumed an important part in gynecologic practice. The described “10-step” technique is the most followed strategy to be successful in this procedure. Technological innovation has brought in new devices which combine a safe use of bipolar (vessel-sealing) energy with monopolar current (hook) in the same instrument. In this didactic video, we aim to show the advantages (with some technical tips) of using this new versatile instrument.