Laparoscopic total hysterectomy and bilateral pelvic lymphadenectomy for endometrial cancer

This video shows a laparoscopic total hysterectomy and a bilateral pelvic lymphadenectomy for endometrial cancer. The patient is obese with a BMI of 34, which makes the surgical intervention more difficult. Anatomical landmarks are very well shown.

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Laparoscopic   total   hysterectomy   and   bilateral   pelvic   lymphadenectomy   for   endometrial   cancer

Authors
A Wattiez, J Nassif, C Zacharopoulou
Abstract
This video shows a laparoscopic total hysterectomy and a bilateral pelvic lymphadenectomy for endometrial cancer. The patient is obese with a BMI of 34, which makes the surgical intervention more difficult. Anatomical landmarks are very well shown.
Classification
basic techniques
Keywords
Laparoscopic total hysterectomy, bilateral pelvic lymphadenectomy, endometrial cancer
Media type
Duration
25'00''
Publication
2008-11
Popular
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Nov 2008;8(11).
URL: http://www.websurg.com/doi-vd01en2401.htm

Laparoscopic   total   hysterectomy   and   bilateral   pelvic   lymphadenectomy   for   endometrial   cancer

1. Right pelvic lymphadenectomy 00'01''
This patient has a BMI of 34 so she is quite obese. She has had a previous cholecystectomy by laparotomy. You see that she has posterior adhesions of the rectum into the Douglas’ pouch, so what is this? here you have one ascension of the rectum so we are going to look at this situation. She is not known to have endometriosis. So you see here we have a big adhesion of the rectosigmoid junction here. Let’s start surgery. Here I am going to free a little bit the sigmoid colon first. You see the problem of obese patients is that we have less vision due to the fatty tissue. The needle is a little bit long and you have to manipulate it a little but this is ok. Joseph Nassif is pulling on the sigmoid colon, we are probably going to release it when we do this side, but at least it is ready and when we are going to do the other side, it will help. Push the uterus towards me. This is the occlusion of the tube, you see that already the manipulator did some adhesiolysis here just by manipulating so I am going to close the other tube. Let’s try to free this a little bit more. We are using a ForceTriad™ generator, which has a very good control of the bipolar waves. So here is the sigmoid colon, and I am going to see if we have to do something here, I am not sure. The uterus is quite fixed. Remember this patient’s BMI is 34. We start the opening for the lymphadenectomy. When we started lymphadenectomies in the 80’s, we were making very small peritoneal incisions. I try to get the first landmarks covered by fat, which is normally the psoas muscle is seen. We are going to go very slow, try to open here the paravesical fossa and get our anatomical landmarks; you have to go slow in order to avoid bleeding. I am going to open a little bit the bladder flap in order to get a little bit more space. I use bipolar and monopolar cautery at the same time. The paravesical fossa is divided in two by the umbilical artery. If we can’t see, I think it’s because I am too close to the bladder at this point. I can feel that here is the internal limit of the paravesical fossa. I will look for the umbilical here but I can make a mistake because she is very obese. I try to find the external limit of the paravesical fossa, here is the umbilicus. Now we have the internal limit of our lymphadenectomy. Normally I should find the Cooper’s ligament around here. Ok at least, we know where we are here, let’s go here and try to find the psoas muscle, I can probably open a little bit more; the only risk at this level is the psoic vessels and here we are going to be on the psoas muscle. The psoas is here, I am going to stay close to the iliac artery because it is safe, there is no branch anteriorly to the artery normally. If I could identify the internal limit of the vein, it would be better. This is the plane here normally. Let’s try if we go over the vein, this would be cut to give you more space. We are trying to get the posterior aspect of the muscle, so you see that here we passed through. For the moment, I can’t see any branches so let’s try to go back to our posterior plane. I don’t see the branch but let’s pay attention, here I have seen a bleeding but for the bleed as I am close to the artery I immediately put the suction on so that I am not overcome by the bleeding, in this way, I can act immediately and check, it is a safety measure. Ok it was nothing, just a branch but you never know, especially in these patients so it is better to look precisely and you see here, this is where we get the posterior plane. Let’s try to find our way down, we are right over the pubic branch, right here you see, the Cooper’s ligament starts here. This will take us up to the obturator vessels. This is the plane here. We have the nerve inside, we have to pay attention, obviously these are nodal tissues. We come to the upper limit. When we said that we have restrictions on exposure, this is a very good example. Let’s go down now, we have to free this. We are at the level of the bifurcation. Here we arrive at the gluteal level so we are under the nerve, the nerve is somewhere in this fat or tissue. Let’s go back to the posterior angle, now we have a lot of fat tissue, my impression is that all this is fat and all this is nodal tissue. We have to make a decision at some point. We are going to find the obturator hole so I can find the nerve and be ok. You see that normally we cut it here now, but on this patient I did not get the access because it is too large here you see and obviously most of the part here is fat. I just need one extra hand to help me so I decide to attach this to the wall in order not to lose time. Now I am going to try to go here and find my window here. I try to find the differences between tissues in order to get the nodal tissue and not the fat but it’s not always easy. Here is nodal tissue, and you see that even the iliac vessels are really over the psoas, so this is the obturator nerve. Normally we just pull this way but I am not going to do it today because I am afraid to injure some big veins. The obturator nerve should normally pass outside this at this point but here is probably inside so I have to pay attention. Here is the infundibulopelvic ligament so the ureter should be on the other part. Let’s see if by chance we see it, yes it is here. Here it is fat tissue so no problem, here as far as we break the fat, we have all this bleeding. We have to stop here, give me a global view. I should find a way here, the ureter should be here. Now I should identify what is here. If the ureter is here then this is the uterine artery right here. Now I hope that we will be able to find the nerve, I should turn this around and find exactly where the nerve passes before cutting. Obviously, I am a little blocked here, so let’s try to go back here and see what we can do. Here be very aware of the gluteal veins, the best is to cut them superficially and then come back. Obviously it is a cancer here. At least now that I have the nerve in my sight, if I am careful with the coagulation, it should be ok. As I told you by pulling too much I can injure a branch lower down. We are going to take those nodes and ask for frozen section.
3. Hysterectomy 15'30''
So we are going to dissect the bladder. I know that Joseph got the patient’s bladder. I go directly into the vesicovaginal space. Let me cut this part of what we can call the vesicovaginal ligament. We are under the pouch, now we push the ureter on this side and before I cut the suspension and I am going to prepare a little bit more here. You see it here so we are very safely away from the ureter and we don’t really understand this hole here; it could be that we are here in the Douglas’ pouch under the rectal adhesions, so here I cannot do the hemostasis of this vein, I tried with a Ligasure device and I couldn’t, with a normal bipolar I couldn’t, sometimes you have to be patient. I am going to take back this suture. It is smarter than to cut it for nothing. You start where you can get all the tissue, then you go up and you close. I don’t cut yet, I place a second shot, the ureter is here so we are safe and we can go down and we were right we are going into the pouch. Now we understand better, we clean the field a little. At this point, I am going to do the right adnexa. I release the tension on the sigmoid colon and we are going to dissect it. As I have dissected the ureter on the other side, I am going to look by taking my window, it is here. I can cut now. You see you have exactly the effect of the Endo-GIA. When you take the tissues, it always seems like you have it all but when you release, there is always some left, which is also safe because if you have bleeding you can also keep it and act on your internal site, if necessary. You see that we release the adhesions, the ureter is here, we feel better now. Can you make the valve now? Let me see where we are now, here I have a small bleeding. We have finished the right side now. I think that as we did the adhesions on the posterior part, we stay high like this here. This is the big vein that was bleeding on the other side, and now we stay here to cut, this is the lowest part. This should be enough. We are placing the disc inside the vagina, so the discs are going to be placed to avoid having the gas spill out. Now the uterus moves much better.