Laparoscopic total hysterectomy

It refers to complete hysterectomy under laparoscopic surgery, the uterus is removed from the vagina or not from the vagina, and the vaginal stump is closed by laparoscopy. That is, the whole process of hysterectomy is completed under laparoscopy. At present, laparoscopic hysterectomy can not completely replace transabdominal hysterectomy and vaginal hysterectomy, which is a minimally invasive surgery that may cause most patients with hysterectomy to avoid laparotomy. Treatment of diseases: uterine fibroids Indication a. Patients with uterine fibroids, increase the size of the uterus <10 ~ 12 weeks pregnant uterus. b. Abnormal uterine bleeding in patients with uterine fibroids. advantage: a. The surgery has less damage to the patient, less bleeding during surgery, less pain after surgery, quick recovery, and short hospital stay. b. Does not destroy the normal integrity of the abdominal wall, has minimal interference to the pelvic environment, and the gastrointestinal function recovers quickly. Contraindications a. Combine other organ diseases, such as severe cardiovascular disease, respiratory disease, hemorrhagic disease, etc., who cannot tolerate anesthesia. b. The uterus is too large. Preoperative preparation Cervical smear and diagnostic curettage were performed before surgery to exclude cervical and uterine malignant tumors. Surgical procedure a. The patient takes the bladder lithotomy position, guides the catheter, and puts it into the uterus. b. 5mm, 10mm puncture holes on both sides of the umbilicus and abdominal wall. c. Treatment of uterine round ligament and fallopian tube, ovarian intrinsic ligament (cut pelvic funnel ligament without retaining ovary). d. Open the anterior and posterior lobe of the broad ligament and the peritoneal reflex of the bladder, and push down the bladder. e. Treatment of uterine blood vessels: Methods for cutting off uterine blood vessels are: Titanium clip method: The uterine artery must be separated before applying the titanium clip. The near-pelvic wall side is close to the upper two titanium nails, a titanium nail on the uterine side, and then the uterine artery is cut. Cutting stapler method: The cutting stapler is performed along the uterus. When the tissue to be cut is inside the forceps, the stapler is cut tightly (also used for accessory removal). Sewing method: use 2/0 absorbable line, ordinary needle or laparoscope special sled needle to sew through the uterine blood vessels in the uterine isthmus, knot in the cavity or outside the cavity. Ultrasonic scalpel application method: the uterine blood vessels are clamped with ultrasonic scissors, and the heat generated by ultrasonic vibration is used to coagulate the tissue protein and then cut off. The ultrasonic scalpel can condense blood vessels of 5 mm. Ultrasonic scalpels can be used throughout the procedure. f. Cut the main ligament and treat it with electrocoagulation or ultrasonic scalpel. g. Cut the uterus from the anterior and posterior vaginal walls, remove the uterus from the vagina, put the uterus into the vaginal dome, and top the pelvic cavity. The surgeon cuts the vaginal wall along the dome by electrocoagulation. h. After clogging in the vagina, re-inflate the abdominal cavity and suture the vaginal wall under the microscope. i. Flush the pelvic hemostasis to close the puncture hole. complication Complications and management: Complications that may occur in general laparoscopic surgery may occur in LH. The main complications are vascular injury, bladder, fallopian tube injury, intestinal injury, incisional hernia, etc. Others include emphysema, infection, conversion to open surgery, small bowel obstruction, deep vein thrombophlebitis, pneumonia, etc., less common. Data show that the total incidence of complications of LH is 5.8% to 16%, which is significantly lower than TAH and TVH. Vascular injury: small blood vessel damage caused by abdominal wall puncture is more common, sometimes bleeding drops down the cannula, contaminating the surgical field, affecting the operation of the operation, at this time, the cannula can be pressed to the bleeding site, and the adrenaline physiology can be used when the compression is not effective. The saline is injected into the abdominal wall, and if it is still ineffective, the abdominal wall can be sutured to stop bleeding. It is still difficult to stop bleeding, and the bleeding affects the operator. It should be converted to open surgery. Large vessel injury is a rare and serious complication in laparoscopic surgery. If it is not detected and treated in time, it can endanger the patient's life. Most of the damage occurs in the abdominal aorta and its branches and inferior vena cava and its branches. Once large blood vessel damage is found, open the abdomen immediately. First, use a hand or gauze to stop bleeding, and then find the injury site, simply suture, for a large range of vascular injury, should be repaired. If necessary, please consult the surgeon. Urinary system damage: including bladder damage and ureteral injury. The incidence is higher than transabdominal and transvaginal hysterectomy, generally 1.35% to 2.8%. Bladder injury is the most common urinary tract injury in LH. It occurs mostly in the adhesion of the bladder near the separation of the bladder, separation of the cervical bladder space or electrocoagulation near the bladder. In patients with pelvic surgery, pelvic inflammatory disease, cervical fibroids, care should be taken. In the event of a bladder injury, it should be promptly discovered and treated. This is an important guarantee for avoiding secondary laparoscopic surgery or secondary laparotomy. Once bladder injury is found, it should be repaired under laparoscopy in time. Open surgery should be performed for those who have difficulty repairing. For patients with mild lesions and small extent, conservative treatment of Fo-1ey catheters can be performed after surgery. The incidence of ureteral injury is low, but it is not easy to find in time. The causes of injury include: electrocoagulation injury, which occurs in patients with difficult hemostasis at the side of the uterus. Ultraviolet coagulation of the ureter is caused by excessive blood coagulation; uterine fibroids cause ureteral displacement and accidental injury; endometriosis adhesion or pelvic inflammatory fibrosis causes accidental ectopic injury Ureter; the use of titanium clips when handling uterine arteries, resulting in ureteral injury. Once damage is discovered, it should be disposed of in a timely manner. For patients with mild contusion, retrograde insertion of ureteral stent; severe burn or severed, end-to-end anastomosis or ureteral bladder anastomosis should be considered. For patients with late detection and loss of function of the kidney, the affected kidney should be considered. Intestinal injury: The incidence is approximately 0.4%, which is similar to the incidence of intestinal injury during transabdominal (0.3%) and transvaginal (0.6%) hysterectomy. The main cause of small bowel injury during LH is electrocoagulation damage, including partial or full-thickness burns in the small intestine wall. Once the injury is found, repairs should be performed in time, and if necessary, converted to open surgery. Incisional hernia: Kadan et al. reported in 1993 that the incidence of abdominal incisional hernia was 0.12%. In recent years, its incidence has been on the rise. May be related to the following factors: multiple auxiliary incisions are used; large incisions are required for surgically removed specimens; new instruments require 10 to 12 mm or even 14 mm incisions; multiple incisions and insufficient instrument performance increase surgery Time; the application of the trocar fixation device increases the length of the incision. Generally, the incision occurs in the incision site of 10 mm outside the umbilicus and the umbilicus. In a few patients, multiple incisions may occur simultaneously. The preventive measures are as follows: the surgeon should use a small trocar (5mm) as much as possible; the trocar fixation device such as the fascia plug can extend the fascial incision by 1~2mm; for the incision above 10mm, the incision should be sutured; the specimen is cut. Take a large incision often, take a 12mm trocar incision in the upper part of the pubic bone; ventilate the pneumoperitoneum should be slow, and then remove the trocar after the abdominal wall is flat; it is not suitable for holding the breath or weight within 1 month after surgery; May not need general anesthesia, once the nausea and vomiting should be actively looking for the cause, those with suspicious symptoms should be taken in a supine position and standing abdominal X-ray film and CT or B-ultrasound. Incision repair or bowel resection should be performed according to the condition of invading the intestine.