Laparoscopic hysterectomy (case report)

1. Laparoscopic hysterectomy(case report) Dr Salama hamid Abbas FICOG_CABOG_DOG_DMAS AL_KARKH BIRTH HOSPITAL_BAGHDAD_September 2012

2. Definition Laparoscopic hysterectomy LH is a minimal access surgical procedure which facilitate the removal of non prolapsed uterus through vaginal route with the use of laparoscope

3. Classification of LH Garry &Reich classification Type 1 -diagnostic laparoscopic +vaginal hysterectomy Type2 -laparoscopic vault suspension after vaginal hysterectomy Type3 –LAVH (laparoscopic assisted vaginal hysterectomy) Type4 _ LH (laparoscopic ligation of uterine a.) Type5 _TLH Type6 –LSH (supracervical hysterectomy) Type7 –LHL (hysterectomy+lymphadenectomy) Type8_LHL+O (as above+omentectomy) Type9 _RLH (radical laparoscopic hysterectomy)

4. LAVHDefinitionIs the procedure using laparoscopic surgical technique & instruments to remove non prolapsed uterus with or without ovaries through the vagina

5. Indications of LAVH Are traditionally contraindications of non descent vaginal hysterectomy Previous pelvic surgery Endometiosis Previous cesarean section Pelvic peritonitis Suspected adnexal pathology Uterine myoma Ectopic pregnancy Acute or chronic PID Minimal uterine mobility &limited vaginal access

6. Contraindications 1.Severe COPD or cardiac disease 2.Generalized peritonitis 3.Previous extensive abdominal surgery 4.Hyper or hypocoaguable state 5.Uterus more than 24 weeks size 6.Huge cervical or broad ligament myoma

7. Hardware required Telescope 10mm 30 degree Uterine manipulator Grasper 5mm (2) Scissor 5mm Dissector 5mm Bipolar & monopolarelectrocautery Needle holder for suction irrigationSuccer

8. Procedure Preoperative measures Catheterization Bowel preparation Anaesthetic&medical check up Patient position Steep trendelenberg & lithotomyposition

9. Position of the surgical team Surgeon (1 or 2),assistant &camera man. Surgeon &camera man on the left side of the patient,the assistant is on the other side. During vaginal part of operation the surgeon & assistant are moved to work vaginally ,moniter is between patient legs

10. Port Position -Umblical 10 mm port for telescope -Two 5mm ports on each side of the telescope 5 cm distence for grasper,succer & electro-coagulation(working ports)

11. Surgerical Steps _Creation of pneumoperitoneum _Diagnostic lap aroscopy to see pelvic sidewall ,anterior & posterior culdesac _Elevation of uterus by the help of uterine manipulator Laparoscopic dissection _ _Vaginal procedure

12. Pneumoperitoneum

13. Port position

14. operative procedure Laparoscopic part Elevation of the uterus ------coagulation &cutting of round lig.& adnexa--------Dissection of bladder &broad lig. up to uterine artery bilaterally

15. Laparoscopic dissection

16. Vaginal procedure anteriorBladder is seperated from uterus,peritoneum is opened Retractor is placed into the bladder peritoneum Successive dissection around the cervix is performed until the proximal point that was performed laparoscopically is reached Successive clamping of transverse cervical ligaments & uterine arteries from below Closure of vault horizontally in one layer The pedicles were inspected laparoscopically from above

17. Removal of uterus totally

18. Closure of vagina from below

19. Ureteric Injury In LAVH 1% 1-2%In abdominal hysterectomy TLH 3-4%

20. Scarless hysterectomy

21. Operation and postoperative period passed smoothly

22. Team WorkDr Salama Hamid AbbasDr rabeah hamid abbasdr alaa hatem a.alkarimdr ammar hamid hannosh

23. Be not afraid of growing slowly Be afraid of standing still Thank you