User login
The removal of the multiple-kilogram uterus using MIGSs
It has now been 30 years since the first total laparoscopic hysterectomy was performed. The benefits of minimally invasive gynecologic surgery (MIGS) – and of minimally invasive hysterectomy specifically – are now well documented. Since this milestone procedure, both instrumentation and technique have improved significantly.
This includes traditional laparoscopy, as well as the robotically assisted laparoscopic approach. However, certain patient characteristics also may influence the choice. A uterus that is undescended, combined with a narrow introitus, for instance, can be a contributory factor in choosing to perform laparoscopic hysterectomy. Additionally, so can an extremely large uterus and an extremely high body mass index (BMI).
These latter two factors – a very large uterus (which we define as more than 15-16 weeks’ gestational size) and a BMI over 60 kg/m2 – historically were considered to be contraindications to laparoscopic hysterectomy. But as the proficiency, comfort, and skill of a new generation of laparoscopic surgeons increases, the tide is shifting with respect to both morbid obesity and the very large uterus.
With growing experience and improved instrumentation, the majority of gynecologists who are fellowship-trained in MIGS are able to routinely and safely perform laparoscopic hysterectomy for uteri weighing 1-2 kg and in patients who have extreme morbid obesity. The literature, moreover, increasingly features case reports of laparoscopic removal of very large uteri and reviews/discussions of total laparoscopic hysterectomy being feasible.
In our own experience, total laparoscopic hysterectomy (TLH) of the very large uterus can be safely and advantageously performed using key instruments and refinements in technique, as well as thorough patient counseling regarding the risk of unexpected sarcomas. Recently, we safely performed total laparoscopic hysterectomy for a patient with a uterus that – somewhat unexpectedly – weighed 7.4 kg.
Surgical pearls
Performing safe and effective total laparoscopic hysterectomy for large uteri – and for morbidly obese patients – hinges largely on modifications in entry and port placement, patient positioning, and choice of instrumentation. With these modifications, we can achieve adequate visualization of critical anatomy and can minimize bleeding. Otherwise, the surgery itself is largely the same. Here are the principles we find most helpful.
Entry and port placement
Traditionally, for TLHs, a camera port is placed at the umbilicus to provide a full view of the pelvis. For the larger uterus – and in women who are extremely obese – we aim to introduce the laparoscope higher. A reliable landmark is the Palmer’s point in the left upper quadrant. From here, we can identify areas for the placement of additional trocars.
In general, we place ancillary 5-mm ports more cephalad and lateral to the uterus than we otherwise would. Such placement facilitates effective visualization while accommodating manipulation of the uterus and allows us to avoid bleeding around the vascular upper pedicles. Overall, we have much better control through all parts of the surgery when we operate lateral to the uterus.
Patient positioning
In addition to the Trendelenburg position, we have adopted an “airplaning” technique for patients with a very large uterus in which the bed is tilted from side to side so that the left and right sides of the body are rotated upward as needed. This allows for gravitational-assisted retraction when it otherwise is not possible.
Instrumentation
For morbidly obese patients, we use Kii Fios advanced fixation trocars. These come in 5- and 10-mm sizes and are equipped with an intraperitoneal balloon that can be inflated to prevent sliding of the trocar out of the abdominal wall.
By far the most valuable instrument for the morbidly obese and the very large uterus is a 30-degree laparoscope. With our higher port placement as described, the 30-degree scope provides visualization of critical structures that wouldn’t be possible with a 0-degree scope.
The Rumi uterine manipulator comes with cups that come in different sizes and can fit around the cervix and help delineate the cervicouterine junction. We use this manipulator for all laparoscopic hysterectomies, but it is a must for the very large uterus.
Extensive desiccation of the utero-ovarian pedicles and uterine arteries is critical, and for this we advise using the rotating bipolar RoBi instrument. Use of the conventional bipolar instrument allows us to use targeted and anatomically guided application of energy. This ensures certainty that vessels whose limits exceed the diameter for advanced bipolar devices (typically 7 mm) are completely sealed. In-depth knowledge of pelvic anatomy and advanced laparoscopic dissection is paramount during these steps to ensure that vital structures are not damaged by the wider thermal spread of the traditional bipolar device. For cutting, the use of ultrasonic energy is important to prevent energy from spreading laterally.
Lastly, we recommend a good suction irrigator because, if bleeding occurs, it tends to be heavy because of the enlarged nature of feeding vasculature. When placed through an umbilical or suprapubic port, the suction irrigator also may be used to help with the rotational vectors and traction for further uterine manipulation.
Technique
We usually operate from top to bottom, transecting the upper pedicles such as the infundibulopelvic (IP) ligaments or utero-ovarian ligaments first, rather than the round ligaments. This helps us achieve additional mobility of the uterus. Some surgeons believe that retroperitoneal dissection and ligation of the uterine arteries at their origin is essential, but we find that, with good uterine manipulation and the use of a 30-degree scope, we achieve adequate visualization for identifying the ureter and uterine artery on the sidewall and consequently do not need to dissect retroperitoneally.
When using the uterine manipulator with the colpotomy cup, the uterus is pushed upward, increasing the distance between the vaginal fornix and the ureters. Uterine arteries can easily be identified and desiccated using conventional bipolar energy. When the colpotomy cup is pushed cephalad, the application of the bipolar energy within the limits of the cup is safe. The thermal spread does not pose a threat to the ureters, which are displaced 1.5-2 cm laterally. Large fibroids often contribute to distorted anatomical planes, and a colpotomy cup provides a firm palpable surface between the cervix and vagina during dissection.
When dealing with large uteri, one must sometimes think outside the box and deviate from standard technique. For instance, in patients with distorted anatomy because of large fibroids, it helps to first control the pedicles that are most easily accessible. Sometimes it is acceptable to perform oophorectomy if the IP ligament is more accessible and the utero-ovarian pedicle is distorted by dilated veins and adherent to the uterus. After transection of each pedicle, we gain more mobility of the uterus and better visualization for the next step.
Inserting the camera through ancillary ports – a technique known as “port hopping” – helps to visualize and take down adhesions much better and more safely than using the camera from the umbilical port only. Port hopping with a 30-degree laparoscope helps to obtain a 360-degree view of adhesions and anatomy, which is exceedingly helpful in cases in which crucial anatomical structures are within close proximity of one another.
In general it is more challenging to perform TLH on a patient with a broad uterus or a patient with low posterior fibroids that are occupying the pelvis than on a patient with fibroids in the upper abdomen. The main challenge for the surgeon is to safely secure the uterine arteries and control the blood supply to the uterus.
Access to the pelvic sidewall is obtained with the combination of 30-degree scope, uterine manipulator, and the suction irrigator introduced through the midline port; the cervix and uterus are deviated upward. Instead of the suction irrigator or blunt dissector used for internal uterine manipulation, some surgeons use myoma screws or a 5-mm single-tooth tenaculum to manipulate a large uterus. Both of those instruments are valuable and work well, but often a large uterus requires extensive manipulation. Repositioning of any sharp instruments that pierce the serosa can often lead to additional blood loss. It is preferable to avoid this blood loss on a large uterus at all costs because it can be brisk and stains the surgical pedicles, making the remainder of the procedure unnecessarily difficult.
Once the uterine arteries are desiccated, if fibroids are obscuring the view, the corpus of the uterus can be detached from the cervix as in supracervical hysterectomy fashion. From there, the uterus can be placed in the upper abdomen while colpotomy can be performed.
In patients with multiple fibroids, we do not recommend performing myomectomy first, unless the fibroid is pedunculated and on a very small stalk. Improved uterine manipulation and retroperitoneal dissection are preferred over myomectomy to safely complete hysterectomy for the broad uterus. In our opinion, any attempt at myomectomy would lead to unnecessary blood loss and additional operative time with minimal benefit.
In patients with fibroids that grow into the broad ligament and pelvic sidewall, the natural course of the ureter becomes displaced laterally. This is contrary to the popular misconception that the ureter is more medially located in the setting of broad-ligament fibroids. To ensure safe access to the uterine arteries, the vesicouterine peritoneum can be incised and extended cephalad along the broad ligament and, then, using the above-mentioned technique, by pushing the uterus and the fibroid to the contralateral side via the suction irrigator, the uterine arteries can be easily accessed.
Another useful technique is to use diluted vasopressin injected into the lower pole of the uterus to cause vasoconstriction and minimize the bleeding. The concentration is 1 cc of 20 units of vasopressin in 100-400 cc of saline. This technique is very useful for myomectomies, and some surgeons find it also helpful for hysterectomy. The plasma half-life of vasopressin is 10-20 minutes, and a large quantity is needed to help with vasoconstriction in a big uterus. The safe upper limits of vasopressin dosing are not firmly established. A fibroid uterus with aberrant vasculature may require a greater-than-acceptable dose to control bleeding.
It is important to ensure that patients have an optimized hemoglobin level preoperatively. We use a hemoglobin level of 8 g/dL as a lowest cutoff value for performing TLH without preoperative transfusion. Regarding bowel preparation, neither the literature nor our own experience support its value, so we typically do not use it.
Morcellation and patient counseling
Uteri up to 12 weeks’ gestational size usually can be extracted transvaginally, and most uteri regardless of size can be morcellated and extracted through the vagina, providing that the vaginal fornix is accessible from below. In some cases, such as when the apex is too high, a minilaparotomic incision is needed to extract the uterus, or when available, power morcellation can be performed.
A major challenge, given our growing ability to laparoscopically remove very larger uteri, is that uteri heavier than about 2.5 kg in weight cannot be morcellated inside a morcellation bag. The risk of upstaging a known or suspected uterine malignancy, or of spreading an unknown malignant sarcoma (presumed benign myoma), should be incorporated in each patient’s decision making.
Thorough counseling about surgical options and on the risks of morcellating a very large uterus without containment in a bag is essential. Each patient must understand the risks and decide whether the benefits of minimally invasive surgery outweigh these risks. While MRI can sometimes provide increased suspicion of a leiomyosarcoma, malignancy can never be completed excluded preoperatively.
Removal of a 7.4-kg uterus
Our patient was a 44-year-old with a markedly enlarged fibroid uterus. Having been told by other providers that she was not a candidate for minimally invasive hysterectomy, she had delayed surgical management for a number of years, allowing for such a generous uterine size to develop.
The patient was knowledgeable about her condition and, given her comorbid obesity, she requested a minimally invasive approach. Preoperative imaging included an ultrasound, which had to be completed abdominally because of the size of her uterus, and an additional MRI was needed to further characterize the extent and nature of her uterus. A very detailed discussion regarding risk of leiomyosarcoma, operative complications, and conversion to laparotomy ensued.
Intraoperatively, we placed the first 5 mm port in the left upper quadrant initially to survey the anatomy for feasibility of laparoscopic hysterectomy. The left utero-ovarian pedicle was easily viewed by airplaning the bed alone. While the right utero-ovarian pedicle was much more skewed and enlarged, the right IP was easily accessible and the ureter well visualized.
The decision was made to place additional ports and proceed with laparoscopic hysterectomy. The 5-mm assistant ports were placed lateral and directly above the upper vascular pedicles. Operative time was 4 hours and 12 minutes, and blood loss was only 700 cc. Her preoperative hemoglobin was optimized at 13.3 g/dL and dropped to 11.3 g/dL postoperatively. The patient was discharged home the next morning and had a normal recovery with no complications.
Dr. Pasic is professor of obstetrics, gynecology & women’s health; director of the section of advanced gynecologic endoscopy; and codirector of the AAGL fellowship in minimally invasive gynecologic surgery at the University of Louisville (Ky.). Dr. Pasic is the current president of the International Society of Gynecologic Endoscopy. He is also a past president of the AAGL (2009). Dr. Cesta is Dr. Pasic’s current fellow in minimally invasive gynecologic surgery as well as an instructor in obstetrics and gynecology at the University of Louisville. Dr. Pasic disclosed he is a consultant for Ethicon Endo, Medtronic, and Olympus and is a speaker for Cooper Surgical, which manufactures some of the instruments mentioned in this article. Dr. Cesta had no relevant financial disclosures.
It has now been 30 years since the first total laparoscopic hysterectomy was performed. The benefits of minimally invasive gynecologic surgery (MIGS) – and of minimally invasive hysterectomy specifically – are now well documented. Since this milestone procedure, both instrumentation and technique have improved significantly.
This includes traditional laparoscopy, as well as the robotically assisted laparoscopic approach. However, certain patient characteristics also may influence the choice. A uterus that is undescended, combined with a narrow introitus, for instance, can be a contributory factor in choosing to perform laparoscopic hysterectomy. Additionally, so can an extremely large uterus and an extremely high body mass index (BMI).
These latter two factors – a very large uterus (which we define as more than 15-16 weeks’ gestational size) and a BMI over 60 kg/m2 – historically were considered to be contraindications to laparoscopic hysterectomy. But as the proficiency, comfort, and skill of a new generation of laparoscopic surgeons increases, the tide is shifting with respect to both morbid obesity and the very large uterus.
With growing experience and improved instrumentation, the majority of gynecologists who are fellowship-trained in MIGS are able to routinely and safely perform laparoscopic hysterectomy for uteri weighing 1-2 kg and in patients who have extreme morbid obesity. The literature, moreover, increasingly features case reports of laparoscopic removal of very large uteri and reviews/discussions of total laparoscopic hysterectomy being feasible.
In our own experience, total laparoscopic hysterectomy (TLH) of the very large uterus can be safely and advantageously performed using key instruments and refinements in technique, as well as thorough patient counseling regarding the risk of unexpected sarcomas. Recently, we safely performed total laparoscopic hysterectomy for a patient with a uterus that – somewhat unexpectedly – weighed 7.4 kg.
Surgical pearls
Performing safe and effective total laparoscopic hysterectomy for large uteri – and for morbidly obese patients – hinges largely on modifications in entry and port placement, patient positioning, and choice of instrumentation. With these modifications, we can achieve adequate visualization of critical anatomy and can minimize bleeding. Otherwise, the surgery itself is largely the same. Here are the principles we find most helpful.
Entry and port placement
Traditionally, for TLHs, a camera port is placed at the umbilicus to provide a full view of the pelvis. For the larger uterus – and in women who are extremely obese – we aim to introduce the laparoscope higher. A reliable landmark is the Palmer’s point in the left upper quadrant. From here, we can identify areas for the placement of additional trocars.
In general, we place ancillary 5-mm ports more cephalad and lateral to the uterus than we otherwise would. Such placement facilitates effective visualization while accommodating manipulation of the uterus and allows us to avoid bleeding around the vascular upper pedicles. Overall, we have much better control through all parts of the surgery when we operate lateral to the uterus.
Patient positioning
In addition to the Trendelenburg position, we have adopted an “airplaning” technique for patients with a very large uterus in which the bed is tilted from side to side so that the left and right sides of the body are rotated upward as needed. This allows for gravitational-assisted retraction when it otherwise is not possible.
Instrumentation
For morbidly obese patients, we use Kii Fios advanced fixation trocars. These come in 5- and 10-mm sizes and are equipped with an intraperitoneal balloon that can be inflated to prevent sliding of the trocar out of the abdominal wall.
By far the most valuable instrument for the morbidly obese and the very large uterus is a 30-degree laparoscope. With our higher port placement as described, the 30-degree scope provides visualization of critical structures that wouldn’t be possible with a 0-degree scope.
The Rumi uterine manipulator comes with cups that come in different sizes and can fit around the cervix and help delineate the cervicouterine junction. We use this manipulator for all laparoscopic hysterectomies, but it is a must for the very large uterus.
Extensive desiccation of the utero-ovarian pedicles and uterine arteries is critical, and for this we advise using the rotating bipolar RoBi instrument. Use of the conventional bipolar instrument allows us to use targeted and anatomically guided application of energy. This ensures certainty that vessels whose limits exceed the diameter for advanced bipolar devices (typically 7 mm) are completely sealed. In-depth knowledge of pelvic anatomy and advanced laparoscopic dissection is paramount during these steps to ensure that vital structures are not damaged by the wider thermal spread of the traditional bipolar device. For cutting, the use of ultrasonic energy is important to prevent energy from spreading laterally.
Lastly, we recommend a good suction irrigator because, if bleeding occurs, it tends to be heavy because of the enlarged nature of feeding vasculature. When placed through an umbilical or suprapubic port, the suction irrigator also may be used to help with the rotational vectors and traction for further uterine manipulation.
Technique
We usually operate from top to bottom, transecting the upper pedicles such as the infundibulopelvic (IP) ligaments or utero-ovarian ligaments first, rather than the round ligaments. This helps us achieve additional mobility of the uterus. Some surgeons believe that retroperitoneal dissection and ligation of the uterine arteries at their origin is essential, but we find that, with good uterine manipulation and the use of a 30-degree scope, we achieve adequate visualization for identifying the ureter and uterine artery on the sidewall and consequently do not need to dissect retroperitoneally.
When using the uterine manipulator with the colpotomy cup, the uterus is pushed upward, increasing the distance between the vaginal fornix and the ureters. Uterine arteries can easily be identified and desiccated using conventional bipolar energy. When the colpotomy cup is pushed cephalad, the application of the bipolar energy within the limits of the cup is safe. The thermal spread does not pose a threat to the ureters, which are displaced 1.5-2 cm laterally. Large fibroids often contribute to distorted anatomical planes, and a colpotomy cup provides a firm palpable surface between the cervix and vagina during dissection.
When dealing with large uteri, one must sometimes think outside the box and deviate from standard technique. For instance, in patients with distorted anatomy because of large fibroids, it helps to first control the pedicles that are most easily accessible. Sometimes it is acceptable to perform oophorectomy if the IP ligament is more accessible and the utero-ovarian pedicle is distorted by dilated veins and adherent to the uterus. After transection of each pedicle, we gain more mobility of the uterus and better visualization for the next step.
Inserting the camera through ancillary ports – a technique known as “port hopping” – helps to visualize and take down adhesions much better and more safely than using the camera from the umbilical port only. Port hopping with a 30-degree laparoscope helps to obtain a 360-degree view of adhesions and anatomy, which is exceedingly helpful in cases in which crucial anatomical structures are within close proximity of one another.
In general it is more challenging to perform TLH on a patient with a broad uterus or a patient with low posterior fibroids that are occupying the pelvis than on a patient with fibroids in the upper abdomen. The main challenge for the surgeon is to safely secure the uterine arteries and control the blood supply to the uterus.
Access to the pelvic sidewall is obtained with the combination of 30-degree scope, uterine manipulator, and the suction irrigator introduced through the midline port; the cervix and uterus are deviated upward. Instead of the suction irrigator or blunt dissector used for internal uterine manipulation, some surgeons use myoma screws or a 5-mm single-tooth tenaculum to manipulate a large uterus. Both of those instruments are valuable and work well, but often a large uterus requires extensive manipulation. Repositioning of any sharp instruments that pierce the serosa can often lead to additional blood loss. It is preferable to avoid this blood loss on a large uterus at all costs because it can be brisk and stains the surgical pedicles, making the remainder of the procedure unnecessarily difficult.
Once the uterine arteries are desiccated, if fibroids are obscuring the view, the corpus of the uterus can be detached from the cervix as in supracervical hysterectomy fashion. From there, the uterus can be placed in the upper abdomen while colpotomy can be performed.
In patients with multiple fibroids, we do not recommend performing myomectomy first, unless the fibroid is pedunculated and on a very small stalk. Improved uterine manipulation and retroperitoneal dissection are preferred over myomectomy to safely complete hysterectomy for the broad uterus. In our opinion, any attempt at myomectomy would lead to unnecessary blood loss and additional operative time with minimal benefit.
In patients with fibroids that grow into the broad ligament and pelvic sidewall, the natural course of the ureter becomes displaced laterally. This is contrary to the popular misconception that the ureter is more medially located in the setting of broad-ligament fibroids. To ensure safe access to the uterine arteries, the vesicouterine peritoneum can be incised and extended cephalad along the broad ligament and, then, using the above-mentioned technique, by pushing the uterus and the fibroid to the contralateral side via the suction irrigator, the uterine arteries can be easily accessed.
Another useful technique is to use diluted vasopressin injected into the lower pole of the uterus to cause vasoconstriction and minimize the bleeding. The concentration is 1 cc of 20 units of vasopressin in 100-400 cc of saline. This technique is very useful for myomectomies, and some surgeons find it also helpful for hysterectomy. The plasma half-life of vasopressin is 10-20 minutes, and a large quantity is needed to help with vasoconstriction in a big uterus. The safe upper limits of vasopressin dosing are not firmly established. A fibroid uterus with aberrant vasculature may require a greater-than-acceptable dose to control bleeding.
It is important to ensure that patients have an optimized hemoglobin level preoperatively. We use a hemoglobin level of 8 g/dL as a lowest cutoff value for performing TLH without preoperative transfusion. Regarding bowel preparation, neither the literature nor our own experience support its value, so we typically do not use it.
Morcellation and patient counseling
Uteri up to 12 weeks’ gestational size usually can be extracted transvaginally, and most uteri regardless of size can be morcellated and extracted through the vagina, providing that the vaginal fornix is accessible from below. In some cases, such as when the apex is too high, a minilaparotomic incision is needed to extract the uterus, or when available, power morcellation can be performed.
A major challenge, given our growing ability to laparoscopically remove very larger uteri, is that uteri heavier than about 2.5 kg in weight cannot be morcellated inside a morcellation bag. The risk of upstaging a known or suspected uterine malignancy, or of spreading an unknown malignant sarcoma (presumed benign myoma), should be incorporated in each patient’s decision making.
Thorough counseling about surgical options and on the risks of morcellating a very large uterus without containment in a bag is essential. Each patient must understand the risks and decide whether the benefits of minimally invasive surgery outweigh these risks. While MRI can sometimes provide increased suspicion of a leiomyosarcoma, malignancy can never be completed excluded preoperatively.
Removal of a 7.4-kg uterus
Our patient was a 44-year-old with a markedly enlarged fibroid uterus. Having been told by other providers that she was not a candidate for minimally invasive hysterectomy, she had delayed surgical management for a number of years, allowing for such a generous uterine size to develop.
The patient was knowledgeable about her condition and, given her comorbid obesity, she requested a minimally invasive approach. Preoperative imaging included an ultrasound, which had to be completed abdominally because of the size of her uterus, and an additional MRI was needed to further characterize the extent and nature of her uterus. A very detailed discussion regarding risk of leiomyosarcoma, operative complications, and conversion to laparotomy ensued.
Intraoperatively, we placed the first 5 mm port in the left upper quadrant initially to survey the anatomy for feasibility of laparoscopic hysterectomy. The left utero-ovarian pedicle was easily viewed by airplaning the bed alone. While the right utero-ovarian pedicle was much more skewed and enlarged, the right IP was easily accessible and the ureter well visualized.
The decision was made to place additional ports and proceed with laparoscopic hysterectomy. The 5-mm assistant ports were placed lateral and directly above the upper vascular pedicles. Operative time was 4 hours and 12 minutes, and blood loss was only 700 cc. Her preoperative hemoglobin was optimized at 13.3 g/dL and dropped to 11.3 g/dL postoperatively. The patient was discharged home the next morning and had a normal recovery with no complications.
Dr. Pasic is professor of obstetrics, gynecology & women’s health; director of the section of advanced gynecologic endoscopy; and codirector of the AAGL fellowship in minimally invasive gynecologic surgery at the University of Louisville (Ky.). Dr. Pasic is the current president of the International Society of Gynecologic Endoscopy. He is also a past president of the AAGL (2009). Dr. Cesta is Dr. Pasic’s current fellow in minimally invasive gynecologic surgery as well as an instructor in obstetrics and gynecology at the University of Louisville. Dr. Pasic disclosed he is a consultant for Ethicon Endo, Medtronic, and Olympus and is a speaker for Cooper Surgical, which manufactures some of the instruments mentioned in this article. Dr. Cesta had no relevant financial disclosures.
It has now been 30 years since the first total laparoscopic hysterectomy was performed. The benefits of minimally invasive gynecologic surgery (MIGS) – and of minimally invasive hysterectomy specifically – are now well documented. Since this milestone procedure, both instrumentation and technique have improved significantly.
This includes traditional laparoscopy, as well as the robotically assisted laparoscopic approach. However, certain patient characteristics also may influence the choice. A uterus that is undescended, combined with a narrow introitus, for instance, can be a contributory factor in choosing to perform laparoscopic hysterectomy. Additionally, so can an extremely large uterus and an extremely high body mass index (BMI).
These latter two factors – a very large uterus (which we define as more than 15-16 weeks’ gestational size) and a BMI over 60 kg/m2 – historically were considered to be contraindications to laparoscopic hysterectomy. But as the proficiency, comfort, and skill of a new generation of laparoscopic surgeons increases, the tide is shifting with respect to both morbid obesity and the very large uterus.
With growing experience and improved instrumentation, the majority of gynecologists who are fellowship-trained in MIGS are able to routinely and safely perform laparoscopic hysterectomy for uteri weighing 1-2 kg and in patients who have extreme morbid obesity. The literature, moreover, increasingly features case reports of laparoscopic removal of very large uteri and reviews/discussions of total laparoscopic hysterectomy being feasible.
In our own experience, total laparoscopic hysterectomy (TLH) of the very large uterus can be safely and advantageously performed using key instruments and refinements in technique, as well as thorough patient counseling regarding the risk of unexpected sarcomas. Recently, we safely performed total laparoscopic hysterectomy for a patient with a uterus that – somewhat unexpectedly – weighed 7.4 kg.
Surgical pearls
Performing safe and effective total laparoscopic hysterectomy for large uteri – and for morbidly obese patients – hinges largely on modifications in entry and port placement, patient positioning, and choice of instrumentation. With these modifications, we can achieve adequate visualization of critical anatomy and can minimize bleeding. Otherwise, the surgery itself is largely the same. Here are the principles we find most helpful.
Entry and port placement
Traditionally, for TLHs, a camera port is placed at the umbilicus to provide a full view of the pelvis. For the larger uterus – and in women who are extremely obese – we aim to introduce the laparoscope higher. A reliable landmark is the Palmer’s point in the left upper quadrant. From here, we can identify areas for the placement of additional trocars.
In general, we place ancillary 5-mm ports more cephalad and lateral to the uterus than we otherwise would. Such placement facilitates effective visualization while accommodating manipulation of the uterus and allows us to avoid bleeding around the vascular upper pedicles. Overall, we have much better control through all parts of the surgery when we operate lateral to the uterus.
Patient positioning
In addition to the Trendelenburg position, we have adopted an “airplaning” technique for patients with a very large uterus in which the bed is tilted from side to side so that the left and right sides of the body are rotated upward as needed. This allows for gravitational-assisted retraction when it otherwise is not possible.
Instrumentation
For morbidly obese patients, we use Kii Fios advanced fixation trocars. These come in 5- and 10-mm sizes and are equipped with an intraperitoneal balloon that can be inflated to prevent sliding of the trocar out of the abdominal wall.
By far the most valuable instrument for the morbidly obese and the very large uterus is a 30-degree laparoscope. With our higher port placement as described, the 30-degree scope provides visualization of critical structures that wouldn’t be possible with a 0-degree scope.
The Rumi uterine manipulator comes with cups that come in different sizes and can fit around the cervix and help delineate the cervicouterine junction. We use this manipulator for all laparoscopic hysterectomies, but it is a must for the very large uterus.
Extensive desiccation of the utero-ovarian pedicles and uterine arteries is critical, and for this we advise using the rotating bipolar RoBi instrument. Use of the conventional bipolar instrument allows us to use targeted and anatomically guided application of energy. This ensures certainty that vessels whose limits exceed the diameter for advanced bipolar devices (typically 7 mm) are completely sealed. In-depth knowledge of pelvic anatomy and advanced laparoscopic dissection is paramount during these steps to ensure that vital structures are not damaged by the wider thermal spread of the traditional bipolar device. For cutting, the use of ultrasonic energy is important to prevent energy from spreading laterally.
Lastly, we recommend a good suction irrigator because, if bleeding occurs, it tends to be heavy because of the enlarged nature of feeding vasculature. When placed through an umbilical or suprapubic port, the suction irrigator also may be used to help with the rotational vectors and traction for further uterine manipulation.
Technique
We usually operate from top to bottom, transecting the upper pedicles such as the infundibulopelvic (IP) ligaments or utero-ovarian ligaments first, rather than the round ligaments. This helps us achieve additional mobility of the uterus. Some surgeons believe that retroperitoneal dissection and ligation of the uterine arteries at their origin is essential, but we find that, with good uterine manipulation and the use of a 30-degree scope, we achieve adequate visualization for identifying the ureter and uterine artery on the sidewall and consequently do not need to dissect retroperitoneally.
When using the uterine manipulator with the colpotomy cup, the uterus is pushed upward, increasing the distance between the vaginal fornix and the ureters. Uterine arteries can easily be identified and desiccated using conventional bipolar energy. When the colpotomy cup is pushed cephalad, the application of the bipolar energy within the limits of the cup is safe. The thermal spread does not pose a threat to the ureters, which are displaced 1.5-2 cm laterally. Large fibroids often contribute to distorted anatomical planes, and a colpotomy cup provides a firm palpable surface between the cervix and vagina during dissection.
When dealing with large uteri, one must sometimes think outside the box and deviate from standard technique. For instance, in patients with distorted anatomy because of large fibroids, it helps to first control the pedicles that are most easily accessible. Sometimes it is acceptable to perform oophorectomy if the IP ligament is more accessible and the utero-ovarian pedicle is distorted by dilated veins and adherent to the uterus. After transection of each pedicle, we gain more mobility of the uterus and better visualization for the next step.
Inserting the camera through ancillary ports – a technique known as “port hopping” – helps to visualize and take down adhesions much better and more safely than using the camera from the umbilical port only. Port hopping with a 30-degree laparoscope helps to obtain a 360-degree view of adhesions and anatomy, which is exceedingly helpful in cases in which crucial anatomical structures are within close proximity of one another.
In general it is more challenging to perform TLH on a patient with a broad uterus or a patient with low posterior fibroids that are occupying the pelvis than on a patient with fibroids in the upper abdomen. The main challenge for the surgeon is to safely secure the uterine arteries and control the blood supply to the uterus.
Access to the pelvic sidewall is obtained with the combination of 30-degree scope, uterine manipulator, and the suction irrigator introduced through the midline port; the cervix and uterus are deviated upward. Instead of the suction irrigator or blunt dissector used for internal uterine manipulation, some surgeons use myoma screws or a 5-mm single-tooth tenaculum to manipulate a large uterus. Both of those instruments are valuable and work well, but often a large uterus requires extensive manipulation. Repositioning of any sharp instruments that pierce the serosa can often lead to additional blood loss. It is preferable to avoid this blood loss on a large uterus at all costs because it can be brisk and stains the surgical pedicles, making the remainder of the procedure unnecessarily difficult.
Once the uterine arteries are desiccated, if fibroids are obscuring the view, the corpus of the uterus can be detached from the cervix as in supracervical hysterectomy fashion. From there, the uterus can be placed in the upper abdomen while colpotomy can be performed.
In patients with multiple fibroids, we do not recommend performing myomectomy first, unless the fibroid is pedunculated and on a very small stalk. Improved uterine manipulation and retroperitoneal dissection are preferred over myomectomy to safely complete hysterectomy for the broad uterus. In our opinion, any attempt at myomectomy would lead to unnecessary blood loss and additional operative time with minimal benefit.
In patients with fibroids that grow into the broad ligament and pelvic sidewall, the natural course of the ureter becomes displaced laterally. This is contrary to the popular misconception that the ureter is more medially located in the setting of broad-ligament fibroids. To ensure safe access to the uterine arteries, the vesicouterine peritoneum can be incised and extended cephalad along the broad ligament and, then, using the above-mentioned technique, by pushing the uterus and the fibroid to the contralateral side via the suction irrigator, the uterine arteries can be easily accessed.
Another useful technique is to use diluted vasopressin injected into the lower pole of the uterus to cause vasoconstriction and minimize the bleeding. The concentration is 1 cc of 20 units of vasopressin in 100-400 cc of saline. This technique is very useful for myomectomies, and some surgeons find it also helpful for hysterectomy. The plasma half-life of vasopressin is 10-20 minutes, and a large quantity is needed to help with vasoconstriction in a big uterus. The safe upper limits of vasopressin dosing are not firmly established. A fibroid uterus with aberrant vasculature may require a greater-than-acceptable dose to control bleeding.
It is important to ensure that patients have an optimized hemoglobin level preoperatively. We use a hemoglobin level of 8 g/dL as a lowest cutoff value for performing TLH without preoperative transfusion. Regarding bowel preparation, neither the literature nor our own experience support its value, so we typically do not use it.
Morcellation and patient counseling
Uteri up to 12 weeks’ gestational size usually can be extracted transvaginally, and most uteri regardless of size can be morcellated and extracted through the vagina, providing that the vaginal fornix is accessible from below. In some cases, such as when the apex is too high, a minilaparotomic incision is needed to extract the uterus, or when available, power morcellation can be performed.
A major challenge, given our growing ability to laparoscopically remove very larger uteri, is that uteri heavier than about 2.5 kg in weight cannot be morcellated inside a morcellation bag. The risk of upstaging a known or suspected uterine malignancy, or of spreading an unknown malignant sarcoma (presumed benign myoma), should be incorporated in each patient’s decision making.
Thorough counseling about surgical options and on the risks of morcellating a very large uterus without containment in a bag is essential. Each patient must understand the risks and decide whether the benefits of minimally invasive surgery outweigh these risks. While MRI can sometimes provide increased suspicion of a leiomyosarcoma, malignancy can never be completed excluded preoperatively.
Removal of a 7.4-kg uterus
Our patient was a 44-year-old with a markedly enlarged fibroid uterus. Having been told by other providers that she was not a candidate for minimally invasive hysterectomy, she had delayed surgical management for a number of years, allowing for such a generous uterine size to develop.
The patient was knowledgeable about her condition and, given her comorbid obesity, she requested a minimally invasive approach. Preoperative imaging included an ultrasound, which had to be completed abdominally because of the size of her uterus, and an additional MRI was needed to further characterize the extent and nature of her uterus. A very detailed discussion regarding risk of leiomyosarcoma, operative complications, and conversion to laparotomy ensued.
Intraoperatively, we placed the first 5 mm port in the left upper quadrant initially to survey the anatomy for feasibility of laparoscopic hysterectomy. The left utero-ovarian pedicle was easily viewed by airplaning the bed alone. While the right utero-ovarian pedicle was much more skewed and enlarged, the right IP was easily accessible and the ureter well visualized.
The decision was made to place additional ports and proceed with laparoscopic hysterectomy. The 5-mm assistant ports were placed lateral and directly above the upper vascular pedicles. Operative time was 4 hours and 12 minutes, and blood loss was only 700 cc. Her preoperative hemoglobin was optimized at 13.3 g/dL and dropped to 11.3 g/dL postoperatively. The patient was discharged home the next morning and had a normal recovery with no complications.
Dr. Pasic is professor of obstetrics, gynecology & women’s health; director of the section of advanced gynecologic endoscopy; and codirector of the AAGL fellowship in minimally invasive gynecologic surgery at the University of Louisville (Ky.). Dr. Pasic is the current president of the International Society of Gynecologic Endoscopy. He is also a past president of the AAGL (2009). Dr. Cesta is Dr. Pasic’s current fellow in minimally invasive gynecologic surgery as well as an instructor in obstetrics and gynecology at the University of Louisville. Dr. Pasic disclosed he is a consultant for Ethicon Endo, Medtronic, and Olympus and is a speaker for Cooper Surgical, which manufactures some of the instruments mentioned in this article. Dr. Cesta had no relevant financial disclosures.