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Conducting a Total Laparoscopic Hysterectomy (TLH) coupled with an appendectomy in a patient who has multiple myomas and a history of two Cesarean sections requires meticulous surgical planning and execution. This procedure involves the laparoscopic removal of the uterus, treatment of the myomas, and removal of the appendix, which may be indicated for various reasons, including prophylactic measures in gynecological surgeries or existing appendiceal conditions.
This complex surgical approach demands thorough preoperative evaluation and careful intraoperative technique to manage the potential challenges posed by the patient's history of Cesarean sections and the presence of myomas. The procedure necessitates detailed imaging to assess the myomas' location and size and to understand the altered anatomy due to previous surgeries, aiming to minimize the risk of complications such as adhesions and excessive bleeding.
The key to a successful outcome in this scenario lies in the surgical team's ability to navigate these challenges with precision, employing advanced laparoscopic skills and ensuring comprehensive care throughout the patient's surgical journey, from preoperative preparation to postoperative recovery.
Performing a Total Laparoscopic Hysterectomy (TLH) alongside an appendectomy in a patient with multiple myomas and a history of two cesarean sections requires careful consideration and planning due to the complexities involved. The approach combines the removal of the uterus via laparoscopic techniques, addressing the myomas (fibroids), and simultaneously conducting an appendectomy, which might be indicated for various reasons such as chronic appendicitis or as a prophylactic measure during gynecologic surgeries.
This combined surgical procedure necessitates meticulous preoperative planning and intraoperative management to navigate the altered anatomy and potential adhesions from previous surgeries, particularly the cesarean sections. The presence of multiple myomas adds to the complexity, requiring strategic dissection and removal while minimizing the risk of complications.
It's essential to conduct a thorough preoperative assessment, including imaging studies to map the myomas and evaluate the abdominal and pelvic anatomy. The surgical team should be prepared for potential challenges such as adhesions, bleeding, and the need for precise surgical technique to ensure the safety and efficacy of the procedure.
Overall, the success of a TLH with appendectomy in this patient scenario hinges on careful surgical planning, adept use of laparoscopic instruments, and comprehensive patient care from the preoperative to the postoperative phase.
Conducting a Total Laparoscopic Hysterectomy (TLH) coupled with an appendectomy in a patient who has multiple myomas and a history of two Cesarean sections requires meticulous surgical planning and execution. This procedure involves the laparoscopic removal of the uterus, treatment of the myomas, and removal of the appendix, which may be indicated for various reasons, including prophylactic measures in gynecological surgeries or existing appendiceal conditions.
This complex surgical approach demands thorough preoperative evaluation and careful intraoperative technique to manage the potential challenges posed by the patient's history of Cesarean sections and the presence of myomas. The procedure necessitates detailed imaging to assess the myomas' location and size and to understand the altered anatomy due to previous surgeries, aiming to minimize the risk of complications such as adhesions and excessive bleeding.
The key to a successful outcome in this scenario lies in the surgical team's ability to navigate these challenges with precision, employing advanced laparoscopic skills and ensuring comprehensive care throughout the patient's surgical journey, from preoperative preparation to postoperative recovery.
Performing a Total Laparoscopic Hysterectomy (TLH) alongside an appendectomy in a patient with multiple myomas and a history of two cesarean sections requires careful consideration and planning due to the complexities involved. The approach combines the removal of the uterus via laparoscopic techniques, addressing the myomas (fibroids), and simultaneously conducting an appendectomy, which might be indicated for various reasons such as chronic appendicitis or as a prophylactic measure during gynecologic surgeries.
This combined surgical procedure necessitates meticulous preoperative planning and intraoperative management to navigate the altered anatomy and potential adhesions from previous surgeries, particularly the cesarean sections. The presence of multiple myomas adds to the complexity, requiring strategic dissection and removal while minimizing the risk of complications.
It's essential to conduct a thorough preoperative assessment, including imaging studies to map the myomas and evaluate the abdominal and pelvic anatomy. The surgical team should be prepared for potential challenges such as adhesions, bleeding, and the need for precise surgical technique to ensure the safety and efficacy of the procedure.
Overall, the success of a TLH with appendectomy in this patient scenario hinges on careful surgical planning, adept use of laparoscopic instruments, and comprehensive patient care from the preoperative to the postoperative phase.
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LearningTranscript
00:00hello friends this is a case of total laparoscopic hystectomy together with the appendectomy in the
00:06same patient and we are using supraumblycal port and various needle is being introduced
00:14after putting the various needle in just we will do irrigation suction and hanging drop test to
00:18confirm that we are safely inside the abdomen so this is suction and here it is the hanging drop
00:26test and we can see this ball of the disposable variational is sinking down that means we are in
00:33after that you can attach the tubing of the insufflator and we start the flow at the rate of
00:38one liter per minute so this patient was suffering from abnormal uterine bleeding and she was having
00:45also acute episodes of appendicitis few months ago for that she was treated by simple you know medical
00:53treatment so here 3.5 liter gas is almost inside the abdomen and we can see abdomen is homogeneously
01:01distending and after that we will remove the various needle out because in this situation it is
01:07important that homogeneous distance should be there now we are enlarging the incision to 11 mm that
01:13incision is important to introduce the optical port and that is necessary to introduce because outer
01:21diameter diameter of the port is 11 mm after that we are introducing one and you know mosquito and
01:26dilating the incision so that any circuitaneous band should not be there and then introducing this
01:32first optical port optical port should must go perpendicular and then we are introducing the
01:39telescope inside so this is the telescope going inside the abdomen
01:44now we will do the diagnostic laparoscopy just to have a see that everything is okay
01:51and then we will put the another two port that is ipsilateral port most of the hystectomy we do only
01:57by three port so this upper border of pubic symphysis you can put the index finger and thumb over the arm
02:02like us and this snuff box is your first port that is the right hand port and these two ports are 5 mm it
02:10should be cut along the langer's line and then we are introducing the 5 mm this is working port for
02:18the right hand after that again 7.5 centimeter lateral and 7.5 centimeter below then the third port will
02:27be introduced for the left hand and here we are doing diagnostics so patient head should be down and
02:33table should be put down as much as possible so that the handle of the instrument should reach at the
02:39level of your elbow and after that you will move all the bubble up and we will see the diagnostic
02:45laparoscopy so the total laparoscopic hystectomy is a very simple surgery if you will do it in a proper
02:52task analysis then it can be easily performed especially if you are using harmonic and ligature
02:59here we can see some adhesions were there these adhesions were due to the previous laparotomy in this
03:04patient and we are using harmonic to remove those adhesions these are flimsy adhesions those are not
03:11very you know strong adhesions and these are only momentum there is no bowel in this adhesion so it
03:17can be easily separated just by harmonic you can touch as near as possible to the abdominal valve and those
03:24adhesions is dropping down to remove the these adhesion gravity will help you if you have a harmonic just
03:31keep on cutting keeping the vibrating jaw under vision and automatically it will keep on dropping down
03:38and you don't need third instrument to pull it down and it is slowly slowly separated we can see this
03:47is the median umbilical ligament and two medial umbilical ligament is also visible now all the small
03:53this is sacral pulmonary all the small bubble has to be pushed up here we can see ureter and here appendix
04:00this is you can see pistolsis of ureter is visible this is ip ligament of the right side this patient
04:06has a multiple fibroids also so this is the sigmoid colon which is adhered in the left side
04:13and this is the left ip ligament cul-de-sac we can see one posterior cervical fibroid is also there
04:20so she has a previous two time cesarean section so there is some adhesion as well
04:25now in this case just to make safer side we will do systoscopy and introduce the infrared uretery
04:34catheter so this is the systoscope which is getting introduced and after that this is the you can see
04:39uretery corifice and this is the right uretery corifice and we will put the catheter here so we are using
04:46simple uretery catheter here just to introduce icg so there are two options you have either infrared
04:53uretery catheter or endosinine grain so this 15 centimeter of the infrared uretery catheter is
05:00being introduced and now we will introduce other side also so right side is over now this is uretery
05:06wrist and you will follow it soft end of the guide wire is introduced and this is the simple uretery catheter
05:12that is also 15 centimeter introduced on the left side your right is present left both the side uretery
05:20catheter is introduced and after that 55 ml icg we will introduce either side in the uretery catheter
05:28and now this is the uterine manipulator which is giving antiversion and contralateral traction
05:34so this is very easy and now four centimeter lateral to the uterus this is we are cutting the round
05:40ligament this is the ligature which is dissecting the round ligament followed by we will do the
05:46fallopian tube and followed by ovary and ligament when you are taking fallopian tube together with
05:52you can take the major salpings as well and this is very easy and if you have to remove the tube what
05:58we will do in this case that should be done at the end of the surgery generally we don't start with the
06:04ip ligament otherwise your ovary and tube will keep on hanging and the posterior dissection of the
06:09plutonium will be little difficult in those cases now this is the ovarian ligament is also done after
06:17that we will go other side and again this is the contralateral traction and now the uterus is at three
06:23o'clock position and then we will do we can see here icg is showing the ureter and this is you can see
06:30easily illuminating this is the left ureter and if you want to see the right ureter again you can lift
06:36the ip ligament and you can see the right ureter as well so this is now major salpings and major ovarian
06:43which is taken by the ligature and after that remaining part of the major salping and major ovarian
06:53and this is separated as single unit and you can desiccate and you can cut after that you will go
07:022.5 centimeter over the broad ligament on the right side more than 2.5 you should not go without
07:08separating the entry and posterior leaf now uterus is again put to the three o'clock position and we
07:15will separate here the right side this is the right round ligament followed by this is fallopian tube
07:32so it is important to remain little away from the uterus to have the you know the preventing the
07:52reverse bleeding and bleeding from ascending uterine as well as advantage is that you can lateralize the
07:59entry and posterior leaf of the broad ligament more laterally to get rid of the ureter so this is
08:05done after that we have both the pedicle this is 2.5 centimeter over the broad ligament is also
08:13desiccated then uterus will be at five o'clock position that means fully retroverted and towards the
08:19right because of this posterior fibroid it will be little difficult but still you can do it and you can
08:25push the fundus of the uterus towards the you know right end of the cycle parliamentary and then you
08:32can separate the anterior leaf of the broad ligament here left hand has a lot of role which will keep
08:38the anterior leaf lifted and with the right hand you can separate the anterior leaf of the broad ligament
08:44after that you can make a lateral window here you can see as nearer as possible to the uterus you
08:50should separate the uv fold because of little bit adhesion before the bladder is also adhered so
08:56we have to be careful and now while you are taking the anterior leaf of the broad ligament assistant
09:03will move the uterus from you know five o'clock to seven o'clock position and now this entire anterior
09:10leaf of the broad ligament is done after that we will separate the bladder to separate the bladder here
09:16you should be careful because we can see this is bladder and you have to make a lateral window
09:22always better to make a lateral window like that lift it and then make a lateral window with the help
09:27of the you know grasper and here you can see this is the pearly white vaginal fascia and then you may
09:34have to cut the muscles of the bladder as an ear as possible to the uterus to separate the bladder
09:40so it's a combination of basically sharp as well as blunt dissection and in that situation making
09:46going lateral to medial is always safer so that bladder will not open and this is separating it
09:53and these all are muscles of the bladder which you have to cut as near as possible to the uterus
10:00in these cases you have to be careful that once you have this window and left hand is introduced in
10:06between the muscle and vagina then only you should cut the bladder muscle otherwise it will be difficult
10:13to do so these all are bladder muscles which is getting cut and the left hand grasper is pushing
10:22it up as well as this is pearly white color below you can see and the bulge of the corporatomizer will
10:27help you to identify the vagina so slowly slowly it is separating and this is the bulge below is the this is
10:35the vagina here and this is the lateralizing the bladder pillar so we can see all what we have cut
10:42and pushed away is the bladder now these are the bladder pillar which you can cut and then bluntly you
10:48can do the further lateralization oh and you can rub it over the corporatomizer so in cases of the adhered
10:56you know bladder it is very important that you should be very careful and it should be a combination of sharp
11:02as well as blunt dissection sharp dissection and near the you know uterus and going with the tunnel by
11:10the left hand pulling the bladder up and right hand should do the lateralization and this is now
11:16separated you can see the pearly white color vaginal fascia with the crisscross pattern of the vessel is
11:22identified and entire bladder is getting separated over the corporatomizer appropriate size of the
11:29corporatomizer is necessary now we are taking the posterior peritoneum and for that also you should
11:34be very careful that uterus should be at one o'clock position and then with the left hand you should
11:41stretch the peritoneum posterior peritoneum in ferro medially and with the right hand you can cut the
11:47peritoneum above the arc of utero cycle ligament stretching the peritoneum is important otherwise the
11:54you know vibrating tip of harmonic will knock the uterine vein and you will start having the bleeding
12:00so only peritoneum should be cut and peritoneum should be dropped down this help you to lateralize
12:06the ureter and this help you to skeletonize the uterine artery so this step is important even if
12:12you are using icg or infrared uretery catheter it is important that further lateralization of the ureter
12:19and opening an anterior and posterior leaf of the broad ligament is good many people they don't take
12:25posterior peritoneum but generally we always take posterior peritoneum because if you will
12:30skeletonize it properly hemostasis of the you know this uh this is icg again and exclamation will be
12:38better and the ureter will also be safe you can see again this is a spy mode and both the ureter is
12:45you can see dropped down already ureter is dropped down because of opening of the peritoneum and then
12:51easily in the spy mode of the in this icg you can see the both the ureter now this is the uterine
12:58artery and this is the uterine artery of the left side which is coagulating at two places generally we
13:04use the ligature two or three time reason being we are reusing the ligature so this is why it is better
13:12not to just cut at one time because compression force in between the jaw of ligature decreases
13:18because of multiple use so that's why it is better to apply multiple time so here it is over the left
13:26side is done and now this is the right side of uterine is also getting with the ipsilateral port and
13:31you should apply two or three time as near as possible to the cervix and after that this is also cut
13:38and here you can see lumen of uterine is nicely visible if you have any reverse bleeding you can
13:44coagulate a couple of more time and then you can separate the entire after that this is over we can
13:50see that there is no bleeding if you have any bleeding especially from angle of vagina you can couple of
13:56more time you can apply ligature because it is always better to stop all the bleeding at this time
14:03don't wait for the colpotomy because after colpotomy you will not have any traction and then you know
14:10stopping those bleeding will be difficult so now this is colpotomy started as you are doing colpotomy
14:15with the open jaw of the harmonic with only the vibrating jaw and while you are starting at six
14:21o'clock and then going up then your assistant will keep on rotating it accordingly while you are going
14:29anterior uterus should be retroverted when you do posterior colpotomy uterus will be
14:36antiverted and when you are doing lateral colpotomy you should be contralateral traction
14:42and proper traction is essential to achieve a good colpotomy because if the tissue is under a stretch
14:49the cutting with the harmonic is easy just you will touch it and it will keep on splitting
14:54and we should remain within the ring of the white color of this teflon coat of the colpotomizer
14:59so that you will not have any vaginal shortening and another advantage when you do posterior colpotomy
15:05you will not injure the utero cycle ligament of course cervical part of utero cycle ligament will
15:11be injured but vaginal part we should try to keep intact that will be better and it will not create
15:17any wall prolapse so we can see this is the right lateral colpotomy and then posterior and if you see
15:24carefully the arc of utero cycle ligament is still intact and that has a great advantage that you will
15:30not have the increased chances of uterine prolapse so it's over after that you can pull the uterus sometime
15:37if you have a fibroid you need to bisect it little bit and then uterus will be taken out through the vagina
15:44after that we will do here the remaining surgery so this is appendix and you can lift appendix entromedial
15:56it is hardly two minute procedure appendectomy with the same port with three port you don't have to make
16:01any extra port and then directly with the harmonic or ligature you can take the major appendix and try to
16:07go up to the base at the level of the tinea coli and you know while you are cutting it little traction
16:14should not be excessive otherwise it may bleed so slowly slowly you can rearrange the grasper to catch
16:22it in the middle and then you can keep on cutting the major major appendix
16:38and this is a cecum and you can see tinea coli also so this appendix ectomy is done
16:44posterior plutonium if it is intact that also you should separate
16:48and for that your telescope should rotate at nine o'clock position light cable so that you can see
16:54posteriorly so it is over and it is properly a skeletonized after that you can bring a pre-tired
17:01loop and this pre-tired loop you can use misra's knot as you know mr knot configuration is one one one
17:08one one that is one hitch one wind one lock second wind second lock and third wind third lock
17:13so this mr knot will come with the vandarkar knot pusher and you can introduce the grasper into the
17:20loop and after that you can re-catch the appendix and then you try to bring the loop behind the
17:27structure and you go to the base we should try to go to the base as near as possible to the tinea coli
17:34tip of the vandarkar knot pusher should be trapped down so that there should not be any
17:38incomplete appendectomy as you can keep on the tinea coli automatically it will go to the base
17:45and there will be no any remaining appendix left so this is a single knot is more than sufficient
17:51because as we have discussed before that in laparoscopy knots are either exactly right or
17:56hopelessly wrong so if you have a completely good knot you don't need to have the second one
18:03and after that we will cut the appendix approximately five millimeter away from the knot
18:08so that this knot should not slip and during cutting always keep vibrating jaw under vision
18:14and then this is cutting the appendix you should not worry about spillage because the
18:20distal end will get sealed and then it's done after that you can bring a claw forcep or a stone holding
18:27forcep and you can pull it through the vagina now we will do salpingectomy here this is the
18:32io ligament infundibulo ovarian ligament and directly with the ligature you can remove the tube and
18:39major salpings together and you can separate it so tube is better to remove because some of the
18:45literature say that tube has a potential of creating the ovarian cancer so this is the tube of the right
18:52side is removed and similarly you can remove the tube of left side and again you can pull through the
18:58vagina so after removal of the uterus taking the tube out is very easy because you have a free space
19:04and enough entromedial traction can be given so that we don't take it in the beginning otherwise it
19:10will keep on hanging with the uterus and posterior vision is affected so both the tube has to be removed
19:18and it is done and it is very easy with the ligature or harmonic to do the salpingectomy
19:26and it's over after that from the same vaginal opening you can put the needle and you can do the
19:34wall closure so little bit suction irrigation is performed just to clean that area and now you will
19:39take a you know this is the utero cycle ligament of left side and then enter your vagina take care that
19:47you anchor it and pull it cranially and then rotate the needle so that bladder should not be taken because
19:52it is only three port if you have a four port then your assistant can help you to hold and that way
19:59assistant will give cranial traction but if you have a three port you have to do yourself with all the
20:05work with your one hand and this is the another utero cycle ligament also you can you can see this
20:11is ureter again icg mode was done just to identify the ureter and easily both the ureter can be
20:18whenever you want just pressing one button on the camera you can see the both ureter
20:24during the wall closure the first layer we do without locking and we lock only once you reach
20:29to the corner so we have reached to the left corner and now here it is suture is locked
20:35and after locking it you can hold it by the left hand and then again you pull the tail so both the
20:40and first layer will be approximated and it will be tight after that you return back during returning
20:46back entry and posterior both the leaf can be taken simultaneously because now you have a cranial
20:52traction and you don't have to worry that it will take a bite on the bladder but take care that always
20:58you should give cranial traction while you are picking the anterior vaginal vault because that
21:04way you will be safer and it will not damage the ureter and then you can lock it every time by pulling
21:10through the tail and it is locked and now this is the last knot which is again taken on the right
21:15corner and entry and posterior leaf both is taken and again going through the loop you can lock it so
21:20this way two layer suturing is done this is not the only option of suturing many people they suture
21:26different ways some people they use bob suture some people they use the you know extra corporeal
21:32square knot some people they use western knot and many of them they just use interrupted surgeon's knot
21:39so this is uh uh many way of closing the vault but generally we take two layer first layer without
21:45locking and second layer with lock and it will stop any oozing from the vaginal edges and now it is
21:54locked once you lock and then you feel that your needle end is a small then you can cut the needle
22:00end and you can take it out and then tail end can be used for tying the knot so this is now both the
22:07end and now you will make a sergeant's knot to terminate so first time it will be taken double
22:12wrap followed by two opposite alternating wrap and then you can make it tighter once you will tight it
22:18after that it will strong and then second and third will be c and reverse c so we can see this is c and
22:26reverse c and both is done here we can see little blood is collected so at the end you have to look
22:32that from where it is there but suppose it is from the ages once you tight the knot this type of oozing
22:38will automatically stop so once the all the knot is tightened this is c reverse c and again this is final c
22:45after that this suture will be cut out and removed from the 5 mm port so this is very easy and only
22:54one knot is required and all other are continuous suturing so now we are cutting the suture and taking
23:00the needle out once the needle is out after that you can do further suction irrigation and you can check
23:07for any bleeding so this is suction irrigation we are doing and absolutely no bleeding it is dry it might
23:14be some collected blood which might have collected to the cul-de-sac so thank you very much for watching
23:19this video this was just a simple case of total laparoscopic hystectomy together with the appendectomy
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