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Big Fibroid operation refused in U.K & Was done successfully laparoscopically in India
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  Total Laparoscopic Hystrectomy  
 

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Indication:

Performed for all the indications for hysterectomy like Fibroid, Adenomyosis, PID, Medical treatment failure with DUB (Excessive period and painful period), pain in lower abdomen, prolapse etc. Removal of ovaries is discussed with patient to understand menopausal protocols in future after removal of uterus.

Objective:

Today most of the Gynecologists advise Total Laparoscopic Hysterectomy for removal of Uterus with vaginal suturing done Laparoscopically, as the best and safe method for most of the indications. PID, Tuberculosis, Endometriosis & past surgeries are the commonest causes of adhesions around pelvic genital organs and anterior abdominal wall. So all the hysterectomy today is advised to be removed Laparoscopically for obvious benefits.  Post Laparotomy adhesions are found in 20-70% of cases following various Gynecological surgeries leading to subsequent abdominal wall adhesions & postoperative pain requiring Laparoscopic Adhesiolysis. Fact may inspire all patients to ask primary surgeon for not offering initial Gynaec surgery by Laparoscopic approach. Adhesiolysis is the most rewarding surgery in pain relief. So patients with previous one/two/three/four LSCSs, big uterine mass is better and safely treated laparoscopically.

Benefits of Laparoscopy Surgery:

  • Shorter Hospital stay,
  • Earlier return to your routine work,
  • Cosmetically vary small scar,
  • Less pain after operation,
  • Best fertility enhancement & Fertility results following Laparoscopy,
  • Video-live operative file available in CD/DVD for future reference (Transparency about surgical procedure).
  • The possibility of post-operative adhesion formation will be less, and the possibility of pain because of post-operative adhesions will also be less. Chances of Vault prolapse are less,
  • Redo surgery are less,
  • Sexual quality function is better after removal of uterus and best chances of safely removal of adnexa/ovaries during hysterectomy without damaging intestine, Ureter and bladder in difficult cases.

Pre-operative Check Lists:

  1. Lab. Investigation for Surgery (Urine complete & Blood complete, HbsAg, HIV, R.B.S., S.G.P.T., S.Creatinine), Abdominal/Pelvic Trance vaginal USG report
  2. Specific Investigations for associated pathology.
  3. Operation planned from 4th to 10th day of Menstrual Cycle.
  4. Enema & preparation/shaving of local parts.


No. Of Cuts on Abdomen:
Four cuts: all of 5 mm size.

Average Stay in Hospital:

12-24 hours. (DAY CARE SURGERY)

Average Duration of Surgery:

60-90 minutes

Average Blood loss during Surgery:

20-40 cc

Average time after operation to resume normal activities/work:

Within 24 hours.

Anesthesia:

General Anesthesia (Patient will not feel any pain in Operation Theatre during surgery)

Operative Procedure:

Inside the Umbilicus small needle is introduced and Co2 gas is insufflated inside abdomen. Rather than creating a large incision and opening up the body, tiny incisions are made and a laparoscope is inserted. This slim scope has a lighted end. It takes pictures – actually fiber optic images - and sends them to a monitor so the surgeon can see what is going on inside.
Performing laparoscopy usually only requires four tiny incisions less than one half inch, (about 5-10 millimeters) in length. With previous midline scar on abdomen, we generally introduce verres needle through palmer’s point and then first 5 mm port is introduced through Palmer’s point.  . This allows the surgeon a better view and more working space to maneuver the laparoscope and surgical tools as needed. Using small incisions rather than opening the abdomen lessens recovery time as well as discomfort and makes surgical scars less noticeable. With help of palmer’s point port, second 5 mm port is kept supra umbilically on vision above the midline intra abdominal midline adhesions. Third & fourth ports are kept on Tr. & Lt side near anterior superior iliac spine on vision. Adhesiolysis is done with Bipolar & scissor and adhesions are stretched from one side simultaneously.

Uterine manipulator introduced inside the uterus after judging the utero-cervical length with dilator to delineate vaginal fornices and manipulate uterus during hysterectomy. Bipolar desiccation used for both infundibulopelvic ligaments/ broad ligaments for desiccation and cut till bladder peritoneum. Bladder peritoneum is dissected from lateral broad ligament window and on vaginal cup for safe bladder dissection with previous LSCSs case. After bladder peritoneum dissected sufficiently down uterine pedicles are dissected & cut with bipolar desiccation & cut with scissor laterally. Vaginal fornix’s on the cup is cut with monopolar hook/spatula circularly and uterus removed from below. Anterior and posterior vaginal edges are identified and sutured with No.1 Vicryl by continuous stitches. Suction irrigation done with Ringer lactate. Cystoscopy done after lasix injection for checking both ureteric jets and bladder. Prophylactic Laparoscopic McCall’s culdoplasty- i.e. both utero-sacral ligaments are attached with anterior & posterior vaginal vault with non-absorbable suture gives assured step for preventing future vault prolapse.

Most of the time many patients undergo laparoscopy as Day care procedure, returning home within 24 hours of surgery. For normal laparoscopy procedure takes about 55 to 75 minutes only. For more complicated case it may take 1-2 hour. Most begin feeling much better within one day.

Post-operative Course:

  • Patient remains drowsy/sedated for 2-3 hours after laparoscopy but conscious & pain free.
  • Patient can take fluids 3-4 hours after laparoscopy & light food after 7-8 hours.
  • She may feel little abdominal & shoulder pain after laparoscopy for 24 hours but it cam be relived with pain killer tabs.
  • Most of the patients can walk normally without support and can take normal diet 12 hours after the laparoscopy.
  • She can be discharged on the same day of the operation.
  • Few patients may feel nausea & vomiting after laparoscopy, which can be very well controlled with injection in post-operative room.
  • Patient can do her normal activity within 24 hours after laparoscopy. Patient is advised to take antibiotics & analgesic tabs. for 5 days following laparoscopy.
  • Patient is advised to report to doctor for severe pain or bleeding or fever in postoperative period (Day-1 to Day-5) immediately.
  • Patient is advised to come for follow up 7 days after the Laparoscopy for dressing.

Indications

  • Performed for Menorrhagia,
  • Pain in lower abdomen or for any of the indication for removal of the uterus.
  • In P/v examination and TVUSG showing positive findings.
  • Laparoscopic approach is especially helpful with previous abdominal adhesions,
  • Previous 1/2/3/4 LSCS, with adnexal mass & for very large uterus,
  • Endometriosis,
  • PID.

Advantages

  • Total laparoscopic hysterectomy is going to become popular, as we have understood pelvic floor support better.
  • Good Bipolar cautery performance is must during LH.
  • We believe that we can do NDVH up to 12-14 wks size uterus easily, along with material after NDVH is very easy procedure & ideal way of vault support.
  • Total Laparoscopic Hysterectomy (TLH) gives better sexual quality after operation compared to other methods.
  • Even removal of both ovaries is safer with Laparoscopic approach. Chances of postoperative vault prolapse are less with Laparoscopic hysterectomy compared to NDVH.
 

Diagnostic laparoscopy

PCOD Drilling
Endometriosis
Chocolate cyst
Ectopic Pregnancy
Rectovaginal Endometriosis
Ovarian Cyst
Dermoid Cyst
Laparoscopic Fibroid
Laparoscopic Tubal reversal
Laparoscopic Burch's procedure
Laparoscopy for T.O.Mass
Laparoscopic Adhesiolysis
Laparoscopic Vaginoplasty
Total Laparoscopic Hystrectomy
Laparoscopic Vault
(Post-hystrectomy) Repair
Laparoscopic Tubal Ligation
Laparoscopic prolapase repair with preserving uterus
Laparoscopic VVF Repair
Laparocopic Misplaced Cu-T removal
Endoscopic Training Centre