- yesterday
https://www.laparoscopyhospital.com/SERV01.HTM
Laparoscopic hysterectomy has revolutionized gynecological surgery, offering minimally invasive solutions with faster recovery times. Recent innovations in this field, particularly the integration of Indocyanine Green (ICG) and the use of the U-Kit for contained morcellation, have further enhanced the safety and efficiency of these procedures. This article explores these advancements and their implications in modern gynecological surgery.
The Role of ICG in Laparoscopic Hysterectomy
Indocyanine Green (ICG) has emerged as a game-changer in laparoscopic surgeries. In the context of hysterectomy, ICG is used for its fluorescent properties, which provide surgeons with enhanced visualization of anatomical structures. When injected, ICG binds to plasma proteins and remains intravascular, allowing for real-time imaging of blood vessels, bile ducts, and lymphatic vessels. This enhanced visualization is crucial in preventing accidental damage to these structures during surgery, thereby reducing complications.
U-Kit: Revolutionizing Morcellation
Morcellation, the process of cutting larger tissues into smaller pieces for removal, has been a topic of concern due to the risk of spreading undiagnosed malignancies. The introduction of the U-Kit in laparoscopic hysterectomy addresses these concerns. The U-Kit, a specialized set of instruments designed for contained morcellation, ensures that tissue is morcellated within a confined bag, reducing the risk of tissue dissemination. This innovative approach significantly enhances patient safety.
Advantages of Combining ICG and U-Kit
The integration of ICG and U-Kit in laparoscopic hysterectomy represents a significant leap forward in surgical safety and efficacy. The use of ICG provides unparalleled clarity in visualizing critical structures, thus minimizing the risk of inadvertent damage. Meanwhile, the U-Kit's contained morcellation system mitigates the risk of spreading potential malignancies. Together, these technologies ensure a higher standard of care, with improved outcomes and reduced recovery times.
Clinical Outcomes and Patient Safety
Studies have demonstrated that the use of ICG and U-Kit in laparoscopic hysterectomy leads to better clinical outcomes. The precision offered by ICG-guided surgery translates to less intraoperative blood loss, fewer complications, and a lower likelihood of reoperation. The U-Kit's safe morcellation technique not only preserves the benefits of minimally invasive surgery but also adds an extra layer of safety for the patient.
Laparoscopic hysterectomy has revolutionized gynecological surgery, offering minimally invasive solutions with faster recovery times. Recent innovations in this field, particularly the integration of Indocyanine Green (ICG) and the use of the U-Kit for contained morcellation, have further enhanced the safety and efficiency of these procedures. This article explores these advancements and their implications in modern gynecological surgery.
The Role of ICG in Laparoscopic Hysterectomy
Indocyanine Green (ICG) has emerged as a game-changer in laparoscopic surgeries. In the context of hysterectomy, ICG is used for its fluorescent properties, which provide surgeons with enhanced visualization of anatomical structures. When injected, ICG binds to plasma proteins and remains intravascular, allowing for real-time imaging of blood vessels, bile ducts, and lymphatic vessels. This enhanced visualization is crucial in preventing accidental damage to these structures during surgery, thereby reducing complications.
U-Kit: Revolutionizing Morcellation
Morcellation, the process of cutting larger tissues into smaller pieces for removal, has been a topic of concern due to the risk of spreading undiagnosed malignancies. The introduction of the U-Kit in laparoscopic hysterectomy addresses these concerns. The U-Kit, a specialized set of instruments designed for contained morcellation, ensures that tissue is morcellated within a confined bag, reducing the risk of tissue dissemination. This innovative approach significantly enhances patient safety.
Advantages of Combining ICG and U-Kit
The integration of ICG and U-Kit in laparoscopic hysterectomy represents a significant leap forward in surgical safety and efficacy. The use of ICG provides unparalleled clarity in visualizing critical structures, thus minimizing the risk of inadvertent damage. Meanwhile, the U-Kit's contained morcellation system mitigates the risk of spreading potential malignancies. Together, these technologies ensure a higher standard of care, with improved outcomes and reduced recovery times.
Clinical Outcomes and Patient Safety
Studies have demonstrated that the use of ICG and U-Kit in laparoscopic hysterectomy leads to better clinical outcomes. The precision offered by ICG-guided surgery translates to less intraoperative blood loss, fewer complications, and a lower likelihood of reoperation. The U-Kit's safe morcellation technique not only preserves the benefits of minimally invasive surgery but also adds an extra layer of safety for the patient.
Category
📚
LearningTranscript
00:00hello friends this is a case of total laparoscopic hystectomy for a large
00:06uterus this is approximately 18 centimeter of the uterus with a large
00:12fibroid inside and patient has abnormal uterine bleeding and we will do total
00:17laparoscopic hystectomy so we are introducing various needle and this is
00:23irrigation suction and hanging drop test is done and we will start pneumoperitonium
00:28so in this patient we will do something more also we are using here in the
00:34right ureter we will use infrared uretric catheter and in the left ureter we
00:39are planning to introduce ICG so that we can compare the vision of both of them
00:45and this is a project of our one of the master students so we will compare the
00:50ICG with the infrared uretric catheter and we will also do the contained
00:56morcellation because this uterus cannot be taken out through the vaginal root so
01:00we will put in the endo bag and we will do morcellation of the uterus that is a
01:04contained morcellation so now pneumoperitonium is created and then we
01:09will use the optical port so this is optical port is introduced then now we
01:17will introduce the telescope here and we will use two ipsilateral port also on the
01:23left side so this is 7.5 centimeter lateral to the umbilicus and because it is
01:30little large uterus so we will go just lateral to the umbilicus and another again
01:357.5 centimeter lateral and below the second port
01:39so we can see this is a large uterus and it is almost reaching up to the saccal
01:53momentary up to the cecum we can see and here after lifting the uterus we can push
02:00the barbell above and here is the appendix and this is common iliac vessel and after
02:12just lifting the uterus we can see saccal momentary below and ureter is crossing the
02:17common iliac vessel you can see peristalsis of ureter also and this is just above the
02:26saccal momentary the fundus is reaching and it is a large uterus not very large but it
02:31is approximately 18 centimeter uterus so now after just doing initial diagnostic
02:39laparoscopy we are using the cystoscopy this is ureteric ridge and we can see
02:46here that at seven o'clock this is right ureteric orifice and at five o'clock this is
02:52left ureteric orifice so you can see the peristalsis also and urine coming out
02:58through the ureteric orifice so both the ureter is nicely visible and after that we
03:06will put the guide wire and transparent ureteric catheter first to the right ureter
03:12so this is guide wire is introduced after that 15 centimeter of the transparent we are using
03:25a striker u kit here on the right ureter so two dark line means 10 centimeter and further
03:34we will push so that 15 centimeter of the transparent ureteric catheter is introduced on the right ureter
03:42so we can see here this is a three dark line that means it is 15 centimeter and after we are
03:58introducing the simple ureteric catheter on the left side and that also will be introduced
04:05approximately 10 centimeter and 5 ml icg we will introduce into this ureter after introducing the
04:12icg we will wait for two minutes so that icg can bind with the ureteric mucosa and we will after that we
04:19will take the catheter out because immediately she will take the catheter out it will not stain so we
04:26can see this is a blinking of the infrared ureteric catheter on the right side due to u kit and on the
04:34left side we are putting a spy mode and this is sigmoid colon is pushed little medially and this is
04:40icg on the left ureter so both has very nice illumination but there is a difference this is
04:47continuous lighting on on the right side you have a blinking so this is done and after that we will
04:53start our surgery so this is the left round ligament so this is the left round ligament four centimeter
05:02lateral after that this is the left fallopian tube three centimeter lateral to the uterus and this
05:11is the left ovarian ligament is also taken together with the major ovarian and major salpings and then
05:192.5 centimeter over the broad ligament uterus is giving contralateral traction and then we will
05:28go left side right side left side left side is over now this is right round ligament
05:36and right side we have used u kit so you can see the continuous blinking of the u kit
05:45this is left fallopian tube
05:47and then left ovarian ligament is also taken
05:57we have used here one contralateral port as well
06:00because left side we have a less space and uterus is large so it is very difficult to go by ipsilateral
06:07so later we will put one contralateral port for this side of uterine artery
06:12and this side of colpotomy so now this is anterior leaf of the broad ligament which we will separate
06:19and for this we are using harmonic scalpel
06:26so left hand atrometric grasper is stretching the anterior leaf of the broad ligament
06:33and with the right hand harmonic we will separate the
06:37uv fold and anterior leaf of the broad ligament stretching is very important
06:41to prevent any injury of the ascending uterine branch and to prevent bleeding
06:51assistant is pushing the colpotomizer cranially so that bladder will remain down and you can have the
06:58proper nt means cranial traction as well as retroversion
07:04so now we will continue the opening the uv fold on the right side
07:14and this anterior leaf of the broad ligament is taken
07:17after that we will separate the bladder
07:30so with the closed jaw of harmonic here you can see the bulge of the colpotomizer
07:37is tanting the vagina and if the vagina is nicely tented then separation of the bladder will be easy
07:43you can see pearly white vaginal fascia with the crisscross pattern of the vessel
07:48and bladder pillar will be also lateralized
07:59again this is icg mode and you can see the bladder is illuminated green
08:05in icg sometime if you have some icg in the bladder little bit vagina also get a strain that is normal
08:12and now this is pushing the anterior leaf of the broad ligament on the right side
08:16as well as lateralizing the right bladder pillar and here you can see blinking of the icg is also
08:23visible so both the side it is separated posterior plutonium is difficult to separate in this patient
08:31because you know posteriorly you have it is difficult to do anti-version so we will not do
08:36anything for the posterior plutonium and directly we are taking the uterine artery without separating
08:42the posterior plutonium so two three time it is coagulated and after that we will cut the left
08:52uterine artery this is the left uterine artery is cut together with the mackenrot
08:59and it is done little bit we will cut the cervical vaginal fascia with the harmonic also you can use
09:10and assistant is thoroughly pushing and tenting the colpartomizer that is very important that
09:17appropriate size of the colpartomizer should be used so this is left side of the uterine artery is over
09:25after that we will go for the right side and for that we are using contralateral port for taking the
09:31uterine artery of the right side and this is important so that you can nicely get separated
09:40and this way little bit more with the ipsilateral so this is the right uterine artery is also taken
09:47and an assistant is giving nine o'clock traction for the uterus so both the side uterine we can see
09:56here ureter is very nearer that you can see blinking and now this is over and now this colpartomy is
10:03started and we are using harmonic to do colpartomy over the tip of the colpartomizer generally we start
10:11above the arc of utero cycle ligament at six o'clock position and then we take a circular fashion while
10:17you are cutting it assistant also will keep on moving the colpartomizer so that nicely you can
10:23separate the and you can cut the tented vagina easily with the vibrating jaw of the harmonic again
10:31this is icg mode and you can see the bladder and little bit vagina also get a strained
10:37and to prevent vaginal shortening we should remain as nearer as possible to the cervix at the time of
10:44doing colpartomy and proper cranial traction is very helpful here and that will keep the bladder below
10:51and it will keep ureter also lateral and then it is a stretched condition it will cut very easily
10:58so almost entire colpartomy is over and now little bit posterior was remain so that also is cut
11:06because this is a large uterus so it will not come out with the vaginal root so we will take this
11:19and now we will remove the colpartomizer and we will pack the vagina transiently
11:23with a sponge inside the gloves
11:29then this uterine manipulator will be removed out and the vagina will be packed with the sponge
11:37so this is removed tenaculum is separated and colpartomizer is removed
11:44after that we will use one more safe endo bag entire endo bag will be introduced inside the
11:50abdomen this is tube also we have removed right side we have already done bso and this is a
11:56tube of the left side which we are removing this is a stone holding forceps which will take the tube out
12:05and now this is the endo bag we have to fully open the endo bag inside the abdomen
12:10so that we can put the this uterus inside the endo bag so this has to be nicely opened and
12:20that will give you a good space to introduce the large uterus
12:27so this is cut resistance and tear resistance also so that will facilitate your contained morselation
12:34so that even if any sarcoma or anything is there it will be safe and now this uterus is introduced
12:42inside and then we are started the morselation and here we are using the storage morselator
12:49and this is the morselation started morselation is a time-taking process so you should have the
12:56patience and you should morselate entire morselation we will not show you because it will take approximately
13:04you know 15 to 20 minutes of time so this is
13:08very good morselator which can morselate up to 200 gram tissue per minute speed if you use at
13:161200 revolution per minute but generally for safer side we use 800 revolution per minute
13:23and this is morselating the entire uterus together with the few fibroid which is inside the uterus
13:30advantage of contained morselation is that if there is any fragmented tissue it will remain in the
13:38morselator and there will be no chances of metastasis although in every patient we don't use because it is
13:45expensive endo bag that takes you know approximately 12 000 rupees the cost for indian if you use more safe
13:54endo bag it will cost you approximately 500 dollars so that is very expensive so this is now taken out and
14:03we can see that all around morselator is pressing the momentum and bubble away so basically a pneumo
14:09endo bag is created in the contained morselation you cannot use the pneumoperitoneum pneumoperitoneum has to
14:17be removed and nemo endo bag has to be created so there are many videos in my uh channel so where you
14:24can see the detail of the content morselation how to use more safe endo bag how to introduce it inside
14:31the abdomen and how to safely do the morselation so here almost morselation is complete and after that
14:40we will remove the morselator and then we will take the endo bag also safely out so now this endo bag is
14:48taken out with that 15 mm port and then we will put the suture inside through the vagina by the side of
14:56the sponge and now we will start suturing of the vault generally we use number one vicryl with the curved
15:05needle and then we can start suturing and full thickness suturing has to be performed so you
15:11will take this is again icg mode and you can see left ureter is nicely illuminating and it will be
15:17continuous but you have to press one button or although overlay mode is also available but in a
15:23spy mode you can see icg much better little staining of the vagina with the icg is normal that happens
15:31and right side you can see it is blinking due to the infrared uretery catheter now you can take a bite
15:37on the right utero sacral ligament full thickness vaginal epithelium should must be taken
15:46so that any graduation tissue should not form and we will do two layer suturing continuous suturing
15:52we don't tie any knot and we start continuous suturing without locking first layer and in the
15:58retaining layer we will lock so first layer only we take three bite one on one utero sacral another in
16:04the middle
16:11cranial traction should be given bladder should be pushed below
16:14and then you should rotate the needle so that bladder should not be pricked
16:18and now this is the left utero sacral together with the left vaginal fascia and the left epithelium
16:31so now the suture is reached to the left side and then it is locked
16:36once it is locked then you can pull the tail also and you can tighten the first layer
16:50so this is first layer and it is tightened
16:55and after that you will return back during returning back every time we lock
17:00and returning back you can take both the layers simultaneously
17:05again this is icg mode and you can see the ureter is nicely visible
17:09this tip of the vagina which you can see green
17:13that is normal because the once the icg is in the bladder
17:17then it stay in the throughout the thickness of the bladder and then it is visible on the edges of the
17:23vaginal colpartum even that is normal so this is and right side of ureter is also safe you can see
17:31it is ukit it is blinking so both has its own advantage although in my personal opinion i want i
17:40i like ukit much better than icg because ukit has both advantage that is visual advantage as well as
17:48mechanical so that even if you will hold it by the ligash or accidentally it will give you mechanical
17:55tactile feedback and icg has an advantage that even if it is kinked ureter where sometime the
18:03you know catheterization is not possible uretery catheterization in that situation icg can be pushed
18:10because in cases of broad ligament fibroid or some other interior valve fibroid inferior uretery catheter
18:16doesn't go because of kinking the catheterization is not possible but putting the icg is possible
18:24so both has its own advantage and disadvantage so this is four four or five bite is taken
18:31during returning back and continuous interlocking suture is done to close the vault
18:46and now this is done after that we will tie a knot with the suture you can pull the suture once more
18:55so that first layer also will get again tightened due to persisting
19:01and now termination of the suture will be done by surgeon's knot
19:06so just first two single wrap and after that two opposite single alternating wrap first time double
19:16wrap sometime the tail is big you can take the wrap with the tail itself the wind and then you can slide
19:23it although take care that never hold the needle at a time of tightening the knot because accidentally
19:30needle can pick the iliac vessel or wobble so this is two one one first time double wrap followed by
19:37two opposite single wrap so this is the final knot and vault is closed after that we will do little
19:44suction irrigation few clots are there and we can see due to contained morselation any fragmented
19:50myoma part is not visible at all in any of the contamination of the abdominal cavity is not there
19:56and after that you can cut the suture and you can take the needle out
20:09so now we will use port closure because 15 mm port were used to put a morselator and the endowag
20:18so this is very important to close this port otherwise hernia will happen so we are using here the suture
20:23passage and generally always close it inferior and superior not prick it lateral or medial because
20:31that way you can prick the inferior epigastic vessel so port closure is essential to prevent any port side
20:38hernia so now and it should not be very tight otherwise it will be painful so just tight it loosely don't
20:45do very tight and that creates the necrosis of the muscles also so it's over thank you very much for
20:51watching this video
Recommended
10:18
12:32
5:36