- 2 days ago
https://www.laparoscopyhospital.com/SERV01.HTM
Hysterectomy, one of the most common surgical procedures performed in gynecology, has evolved significantly over the years. Total Laparoscopic Hysterectomy (TLH) and Bilateral Salpingo-Oophorectomy (BSO) represent advanced approaches in this field. The integration of Indocyanine Green (ICG) fluorescence imaging has further revolutionized these procedures, offering enhanced visualization and increased safety.
1. Introduction to TLH and BSO
TLH involves the removal of the uterus laparoscopically, offering a minimally invasive option compared to traditional surgery. BSO, the removal of both ovaries and fallopian tubes, is often performed concurrently. These procedures are indicated in various conditions, including uterine fibroids, endometriosis, and ovarian cancer.
2. The Role of ICG in Enhancing Visualization
Indocyanine Green, a fluorescent dye used in medical imaging, becomes visible under near-infrared light. When injected intravenously, ICG binds to plasma proteins and stays within the vascular system, allowing surgeons to visualize blood flow and tissue perfusion. In the context of TLH and BSO, ICG aids in identifying key structures such as blood vessels, ureters, and the boundaries of tumors.
3. Preoperative Considerations
Prior to surgery, patient selection and counseling are crucial. Not every patient is a suitable candidate for TLH and BSO using ICG. The benefits, risks, and alternatives should be thoroughly discussed. Preoperative imaging and preparation, including bowel preparation, are also necessary to ensure optimal surgical conditions.
4. The Surgical Procedure: A Step-by-Step Guide
Step 1: Anesthesia and Positioning - The patient is placed under general anesthesia and positioned to allow optimal access to the pelvic region.
Step 2: Trocar Placement and Abdominal Insufflation - Small incisions are made for trocar placement, and the abdomen is insufflated with gas to create a working space.
Step 3: ICG Injection - After initial inspection of the pelvic cavity, ICG is administered in both the ureter.
Step 4: Identification of Structures - Using a near-infrared camera, the surgeon identifies vascular structures, ensuring precise dissection and minimizing the risk of bleeding.
Step 5: Uterine Manipulation - Specialized instruments are used to manipulate the uterus, providing better access for dissection.
Step 6: Dissection and Removal - The uterus, and if indicated, the ovaries and fallopian tubes, are carefully dissected and removed.
Step 7: Hemostasis and Closure - Ensuring there is no bleeding, the incisions are closed.
Hysterectomy, one of the most common surgical procedures performed in gynecology, has evolved significantly over the years. Total Laparoscopic Hysterectomy (TLH) and Bilateral Salpingo-Oophorectomy (BSO) represent advanced approaches in this field. The integration of Indocyanine Green (ICG) fluorescence imaging has further revolutionized these procedures, offering enhanced visualization and increased safety.
1. Introduction to TLH and BSO
TLH involves the removal of the uterus laparoscopically, offering a minimally invasive option compared to traditional surgery. BSO, the removal of both ovaries and fallopian tubes, is often performed concurrently. These procedures are indicated in various conditions, including uterine fibroids, endometriosis, and ovarian cancer.
2. The Role of ICG in Enhancing Visualization
Indocyanine Green, a fluorescent dye used in medical imaging, becomes visible under near-infrared light. When injected intravenously, ICG binds to plasma proteins and stays within the vascular system, allowing surgeons to visualize blood flow and tissue perfusion. In the context of TLH and BSO, ICG aids in identifying key structures such as blood vessels, ureters, and the boundaries of tumors.
3. Preoperative Considerations
Prior to surgery, patient selection and counseling are crucial. Not every patient is a suitable candidate for TLH and BSO using ICG. The benefits, risks, and alternatives should be thoroughly discussed. Preoperative imaging and preparation, including bowel preparation, are also necessary to ensure optimal surgical conditions.
4. The Surgical Procedure: A Step-by-Step Guide
Step 1: Anesthesia and Positioning - The patient is placed under general anesthesia and positioned to allow optimal access to the pelvic region.
Step 2: Trocar Placement and Abdominal Insufflation - Small incisions are made for trocar placement, and the abdomen is insufflated with gas to create a working space.
Step 3: ICG Injection - After initial inspection of the pelvic cavity, ICG is administered in both the ureter.
Step 4: Identification of Structures - Using a near-infrared camera, the surgeon identifies vascular structures, ensuring precise dissection and minimizing the risk of bleeding.
Step 5: Uterine Manipulation - Specialized instruments are used to manipulate the uterus, providing better access for dissection.
Step 6: Dissection and Removal - The uterus, and if indicated, the ovaries and fallopian tubes, are carefully dissected and removed.
Step 7: Hemostasis and Closure - Ensuring there is no bleeding, the incisions are closed.
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LearningTranscript
00:00hello friend this is a case of total laparoscopic hystectomy and we will do it with the icg
00:08and various needles introduce supramolical and this is the two click after that
00:18irrigation suction and hanging drop test is performed as usual
00:22and insufflation is started now in this case we will use indosanine green to prevent the uretric injury
00:32and we'll show you how to prevent and how it looks icg has revolutionized the way how the
00:39surgery was performed in the past and it has a lot of advantage it will illuminate the entire
00:45ureter as well as it can give some of the illumination of the bladder as well
00:49so we will use the various needle and the preset pressure is 15 actual pressure we are waiting to
00:58reach up to 15 and then once it will reach to the preset pressure automatically flow rate will stop
01:08so now approximately 3.5 liter gas has been introduced and now the actual pressure is
01:14reached to the preset pressure and now we will remove the various needle so during introduction
01:20of various needle once we give only one millimeter prick so that gas would not leak around the various
01:27needle and now enlarge this incision to 11 mm after that we will little bit dilate with a mosquito
01:34and this trocar we will introduce we apply a lot of betadine around the trocar to prevent any port side
01:40infection and we always autoclave all the port and now gas will be reattached and the flow rate will
01:49be increased to maximum flow rate 10 liter per minute and this is the baseball diamond concept
01:54we can put the index finger on the uv fold and 7.5 centimeter lateral to the umbilicus this is the
02:01second port now percent head will be 30 degree down and with the eight dramatic grasper we will strap
02:12all the bovel above the sacral parliamentary and this is the percent head is going down and table is
02:18also going down so this is a steep trainer position and now table is also going down so that handle of
02:26the instrument should come at the level of your elbow and now we will do cystoscopy and this is the
02:32cystoscopy is preparing to introduce into the bladder and here we are in urethra and now as soon as you will
02:42enter into the bladder you should increase the elevation angle to see the uretric ridge so this is
02:47uretric ridge here and we can see both the side of the uretric orifice is visible so this is the left
02:56side of uretric orifice and we can see the urine also coming out and this is the place where ureter
03:03is bulging in the posterior wall uterus is bulging in posterior wall and this is the uretric ridge
03:10and now we will put the uretric catheter we can see here urine is coming out of the
03:16right ureter and we are using simple six french uretric catheter
03:20and approximately 12 centimeter of the uretric catheter will be introduced inside the ureter
03:29and approximately 5 ml of the icg that is aura green it comes in the 10 ml vial and it has 2.25
03:40milligram icg so half the vial we have pushed into the left ureter and another 5 ml you will push in
03:48the right ureter and once you push it we should wait for couple of minutes so that it should take
03:55some time to bind with the plasma protein of the uretric mucosha and we are just waiting it is
04:02injected already and we have this is three three line means it is 15 centimeter inside and now icg is
04:09injected little bit leak may be outside the ureter that will illuminate the bladder
04:16so it is emitting near infrared light and we can see it is little bit leaking is okay after that
04:23this bladder is distended because of the cystoscopy so we should put a foliage and we should deflate
04:30the bladder uterus is below uterus is not big it's a small uterus and this patient has a little
04:38prolapse also so we can see here a spy mode and we can see this right ureter is illuminating overlay mode
04:45also you can do so that you can see even with the color you can see the ureter is illuminated this
04:52is right side of ureter and this is the left side of ureter so icg has done its job and within few
04:59minutes it will be more illuminated after that we are putting a uterine manipulator because uterus is
05:06small so you have to use a small size of the colpartumizer approximately two so approximately
05:122.5 centimeter of the colpartumizer is used and a small tip here we are using mungiskar uterine
05:18manipulator and this contralateral traction is given at nine o'clock position and now you will take the
05:23round ligament fallopian tube and ovarian ligament so this is like a sure we are using only three port is
05:30used in this case and five mm ports are there working ports so this is round ligament is done
05:37after that this is fallopian tube and here is the ovarian ligament later we will do bso also so this
05:43is a tlh with the bilateral salpingo phrectomy and then you can go only 2.5 centimeter over the broad
05:51ligament and now again the uterus is pushed towards three o'clock position and the same thing we will
05:57repeat to the left side so the atraumatic rasper is stretching the round ligament and which is
06:04coagulated and cut followed by fallopian tube and then ovarian ligament so contralateral traction by
06:12the uterine manipulator is very useful to stretch the round ligament and bso we will do later we can see
06:19this is the ovary ovary is almost atrophic and this is done left side is done after that we can
06:27see this ureter again with the icg mode and it is humiliating see this is how we damage the ureter
06:33like that so icg if it is there you can prevent damaging the ureter and now this is anterior leaf
06:40of the broad ligament left hand instrument is stretching the anterior leaf of the broad ligament
06:45and right hand will separate the anterior leaf of the broad ligament continuing to the uv fold and
06:53again going to the right side so during that separation left hand has a rod of roll to stretch
06:59the peritoneum so that you will get a good aureolar plane and uterus should be retroverted during
07:05opening of the anterior leaf of the broad ligament after that uterus should be again here we can see
07:10again icg what bladder is illuminated and this is the junction of ureter and here ureter is also showing
07:17you the insertion into the bladder now this is again uterus is at six o'clock and this is bladder
07:24separation the blunt you know separation of the bladder is essential so harmonic jaw should not be
07:31opened once you will not open the harmonic jaw it will be quadrangular and it will not do the sharp
07:37injury and slowly bladder pillar is also lateralized either side and this is the pearly white colored
07:43vaginal fascia over the crisscross pattern of the vessels are there bladder pillar is also lateralized
07:50and that way you can push the ureter also away and this is now the left side of the bladder pillar
07:56that also has to be lateralized and here will be ureter if you put the icg mode again you can see
08:02the elimination of the ureter here this is the portion and this is that's why lateralization is
08:07important so anterior leaf of the broad ligament is fully separated and bladder is also separated
08:14after that uterus should be moved at one o'clock position and this is the posterior peritonium which
08:19is separating we should try that nothing should be cut except peritonium so the harmonic she give
08:26inferromedial traction and the left hand has a lot of role here to separate the peritonium otherwise
08:32knocking effect of the tip of the harmonic can injure the vessel and while you are separating
08:38the posterior peritonium we should be above the arc of uterocircular ligament and when you are
08:43separating it assistant will move the uterus from one o'clock to eleven o'clock and this is now slowly
08:49gradually left hand is making a tunnel and the right hand is opening the peritonium of the right side
08:56and this is now again you will push the peritonium down so that ureters will also drop down
09:02even if you are not using icg the proper skeletonization is important and we can see here
09:10ureter is drop down again you can ask the assistant to press the camera icg mode and you can look both
09:16the ureter so this is now entry and posterior leaf of the broad ligament is nicely opened and now ureter
09:24is also lateralized here we can see this is ureter of the left side here it is visible green color and
09:31uh this is the right side of ureter here this is an icg is illuminating the both the side
09:39so now posterior peritonium is also this is the ureter of the right side so it is now completely
09:45safe and it is dropped down after that we will coagulate the uterine artery generally our trick
09:50is that we coagulate once either side and then we cut second time so that even if it is like i
09:57sure has not done a hundred percent job if little time is spent then it create the proximal thrombus
10:04and that will be completely bloodless surgery so generally we coagulate two or three times so this
10:09is the left side of uterine is coagulated and after that this is the right side of the uterine getting
10:15coagulated so both the side is uterine is coagulated and assistant is giving proper contralateral traction
10:25that is required otherwise you should use four ports and now the second time we are cutting the
10:31uterine artery so this is left side of uterine is cut and it is little bit pushed away and now this is
10:40the right side of uterine will be cut during that you should remain as near as possible to the you know
10:46uterus and the tip of the ligature should almost touch the colpartumizer so that the partial cooking of
10:53uterine will not be there so now this is colpartumia started generally we start above the arc of utero
11:00cycle ligament so generally the vaginal part of utero cycle ligament will not be damaged and with the
11:06harmonic tip you can slowly slowly keep the colpartumizer and you should remain within the
11:13ring of the colpartumizer so that there will be no any vaginal shortening we can see this patient has
11:18a small polyp which is projecting there and this was a cervical polyp also and now this is cutting
11:25so slowly slowly within the ring of the colpartumizer and assistant simultaneously is rotating the uterus
11:32with the uterine manipulator so that nothing except the vagina should be cut and that also should be
11:39at the level of the junction of the cervix so that there should not be any vaginal shortening
11:45so this is almost over assistant is synchronizing your movement with your movement of harmonic and
11:52now this is the right side of the colpartum and assistant is giving the contralateral traction
11:59and now this remaining part is over and after that you can remove the uterus so uterus will be
12:05but a small so it was taken out through the vagina and directly it is pulled after that we will give
12:11the anteromedial traction and if you have to remove the tube you will apply on io ligament otherwise
12:18over the ip ligament as nearer as possible to the ovary so that an assistant will push a stone holding
12:25forcep through the vagina so that once you do bso he will immediately pull it by the side and here one
12:32sponge is in the gloves to prevent the leak of the gas through the vagina and this is the bso of other
12:40side so because we are doing bso so we should apply over the ip ligament and if you are doing
12:47only a salpingectomy then you should apply over the io ligament so bilateral salpingeofleptomy
12:53is done and after that you can take the both the ovary out after that we will do some suspension of the
13:06you know vault also so bite is taken over the round ligament so that it will pull it cranially and then
13:12this is the utero cycle ligament of the right side including vaginal epithelium and it is taken
13:18after that we will take another bite over the anterior vagina and then again it is in the middle
13:24and this is the second bite over the posterior vagina and again over the anterior and this is
13:29the vaginal epithelium so basically we will divert the vaginal epithelium out so that it will be a
13:35little bit pulled up and there will be no any chances of cystosyl also to happen and then we will take
13:41the bite in the another round ligament this is the left round ligament and then it will be pulled
13:47like a purse string so that it will be pulled up and after that you can tie the knot so like total
13:53three bite is taken on the vagina and either side of the round ligament is also incorporated into that
14:00after that you can pull it because we have only three port if you have a four port assistant will
14:04pull the tail otherwise you have to take a bite and the first time we will take three wrap so that
14:10this is now the needle which is taking a bite and this is a returning bite so in the
14:16returning you can take both together the anti and posterior vagina both together and then it will
14:23return back again from the left side to right side here we are not locking any time because at the end
14:30we will pull all of them to just do the suspension of the wall so that it will be much better and there
14:38will be no wall collapse so it is pulling it up and after that we will tie the knot so it is sliding it
14:45and then it is pulled up and when we tie the knot here first time we will take three wrap so that it
14:51will not slip so this is first second and third wrap is taken and then such as knot will be taken you
14:59may use extra corporal square knot or western knot also in this case but because here it is a simple case
15:07so it is tightened and three knot if you will take first time it will not slip back so it is nicely
15:14tightened and you can see vault is pulled up and after that again you can take second or third knot
15:20because here tail was big so this is a c is taken by the tail itself and then you can catch the suture
15:26near the needle to take the second knot and take care that never pull the needle always pull the suture
15:35otherwise it can prick the iliac vessel and this is the last knot and again with the needle end again c was
15:42formed so this is over and now TLH is complete so this was just a simple case of a small uterus where
15:50TLH and BSO was performed and the vault was suspended with the uterine artery so thank you very much for
15:56watching this video have a nice day
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