Laparoscopic total hysterectomy and unilateral adnexectomy with resection of urinary bladder nodule for endometriosis

This video demonstrates the technique of a total laparoscopic hysterectomy with unilateral adnexectomy and the excision of a vesical endometriotic nodule. This patient is a 46-year-old lady with a previous surgical history of one laparotomy for a hemoperitoneum (endometriotic ovarian cyst rupture) and 6 laparoscopies because of endometriosis, the last one 3 years ago with a segmental sigmoid resection. After this last surgery, the patient starts to complain of dysmenorrhea, chronic pelvic pain and dysuria. She has never had any urinary infection. Because of urinary stress incontinence, she had botulinic toxin injection and underwent a cystoscopy, which revealed a bladder nodule.

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Laparoscopic total hysterectomy and unilateral adnexectomy with resection of urinary bladder nodule for endometriosis

Authors

A Wattiez, S Barata, AM Furtado Lima, P Trompoukis, B Gabriel, J Nassif

Abstract

This video demonstrates the technique of a total laparoscopic hysterectomy with unilateral adnexectomy and the excision of a vesical endometriotic nodule.
This patient is a 46-year-old lady with a previous surgical history of one laparotomy for a hemoperitoneum (endometriotic ovarian cyst rupture) and 6 laparoscopies because of endometriosis, the last one 3 years ago with a segmental sigmoid resection. After this last surgery, the patient starts to complain of dysmenorrhea, chronic pelvic pain and dysuria. She has never had any urinary infection.
Because of urinary stress incontinence, she had botulinic toxin injection and underwent a cystoscopy, which revealed a bladder nodule.

Keywords

Laparoscopic total hysterectomy, unilateral adnexectomy, resection of urinary bladder nodule, endometriosis

Media type

Surgical video

Duration

09'00''

Publication

2010-06

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E-publication

WeBSurg.com, Jun 2010;10(06).
URL: http://www.websurg.com/doi-vd01en2991.htm

Laparoscopic total hysterectomy and unilateral adnexectomy with resection of urinary bladder nodule for endometriosis

1. Introduction 00'09''

This video demonstrates the technique of a total laparoscopic hysterectomy with unilateral adnexectomy and the excision of a vesical endometriotic nodule. The patient underwent a pelvic MRI, which revealed a 4cm endometriotic bladder nodule and a 3.6cm left ovary endometrioma.

2. Beginning of total hysterectomy with left adnexectomy 00'34''

The procedure is begun by coagulating and cutting the round ligament on the left side and opening the broad ligament. The broad ligament is opened parallel to the infundibulopelvic ligament for the left adnexectomy and towards the vesicouterine space by dissecting, coagulating and cutting its anterior leaf. A window is created over the grey area of the posterior leaf of the broad ligament. The dissection is continued until the uterine artery is reached. The left infundibulopelvic ligament is coagulated and divided using bipolar cautery and scissors in order to remove the left adnexa with an endometrioma.

3. Hysterectomy without right adnexectomy 02'06''

On the right side, the round ligament is divided and a dissection plane is found towards the bladder in the right broad ligament whose anterior leaf is incised until reaching the level of the vesicouterine space. The broad ligament is opened parallel to the utero-ovarian ligament in order to coagulate it and cut it.

4. Bladder dissection 03'09''

The bladder dissection is performed with the help of the assistant holding up the bladder. In this case, the bladder dissection is one of the hysterectomy steps and can also help further in the endometriotic nodule excision.

5. Vesical nodule excision 03'24''

Once the bladder nodule has been clearly exposed, it is excised using monopolar scissors. A partial cystectomy to excise the nodule is undertaken bearing in mind the recent data published in the literature; indeed, better results are reported when the nodule is excised.

6. Left ureter dissection 04'52''

Before suturing the bladder, the ureteral orifices are localized by direct vision inside the bladder. Because the left ureteral orifice is very near the suture line, an extensive dissection of the left ureter is carried out until reaching the ostium into the bladder, in order to perform the bladder closure more safely. In this case, we did not place any double-J ureteral stents, but we usually recommend their insertion in case of bladder endometriosis, especially if the nodule location is at the vesical base, which is not the current case.

7. Bladder suture 05'52''

For the suture, a 3/0 monofilament thread Monocryl® is used. Two extracorporeal stitches are placed at both angles of the bladder’s opening in order to suspend it. The suspension stitches help to better view and expose the bladder. The bladder is then closed with a running suture. This is the final aspect of the bladder nodule excision.

8. Ligation of uterine arteries 08'21''

The hysterectomy is then continued from the left uterine side by coagulating and dividing the left uterine artery, then coagulating and dividing the left uterosacral ligament. The same steps are carried out on the right side: coagulation and division of the uterine vessels followed by coagulation and division of the uterosacral ligament.

9. Opening the vagina 08'48''

The vagina is now opened; this allows to identify the ceramic valve of the uterine manipulator. Colpotomy is then carried out using a monopolar hook. Hemostasis of the vaginal edges is achieved using bipolar cautery if needed.

10. Vaginal closure 09'33''

The vagina is sutured in two layers using intracorporeal knots with a polyfilament thread (Vicryl® 2/0): the first with two figure of eight knots within the mucosal layer and the second with one figure of eight knot within the vaginal fascia, including both uterosacral ligaments. The procedure is now complete and the final hemostasis is achieved.