OBJECTIVE
The objective of this study was to demonstrate a technique for safe and easy laparoscopic hysterectomy for patients with a history of cesarean section using narrated video footage.
DESIGN
Step-by-step video demonstration of the surgical technique.
SETTING
Laparoscopic hysterectomy for patients with a history of cesarean section.
INTERVENTIONS
The surgical technique is shown in a step-by-step manner to facilitate viewer comprehension, to improve the performance of the procedure in a simple and safe manner, and to minimize bleeding and bladder injury.[1,2] The steps of the procedure are as follows [Figure 1]:
Figure 1.
To reach the vesicouterine pouch from a more caudal and dorsal direction, a dissection under the layer of the uterine artery and superior vesical artery was performed. http://www.apagemit.com/page/video/show.aspx?num=295; http://www.apagemit.com/page/video/show.aspx?num=296
Dissecting the ureter, ligating the cut round ligament, posterior layer of the broad ligament, uterosacral ligament, and infundibulopelvic ligament/ligamentum ovarii proprium
Dissection under the bladder pillar bilaterally, followed by dissection under the bladder caudal to the adhesion from the cesarean section
If we could not dissect the bladder using step 2, it implied that the adhesions were widespread and we thus would perform dissection more caudally. Therefore, we ligated the uterine artery and the ureteric branches of the uterine artery and dissected the ureter laterally. To reach the vesicouterine pouch from a more caudal and dorsal direction, a dissection under the layer of the uterine artery and superior vesical artery was performed.[3,4] In other words, we reached the vesicouterine pouch under the ureteric tunnel, as is the case during uterine cancer surgery.[5] Thereafter, we approached an area which was more caudal to the adhesion area. This area is usually dissected in a modified radical hysterectomy.
RESULTS
We were able to dissect below the bladder caudally to the adhesion from the cesarean section.
CONCLUSIONS
Our technique includes dissection of the area more caudal to the adhesion than usual. Currently, the order of dissection is not fixed and is left up to each facility. We dissected the area without touching the previous cesarean section because it minimizes the risk of bladder injury. This is helpful for laparoscopic hysterectomy, which has weaker traction than open laparotomy.
Ethical statement
Institutional Review Board approval was obtained before the experiment was started (approval number: S20-219).
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that hername and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
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