Gale-Butto:
TAH:
- Creating colpotomy in TAH: Kocher clamp was placed on the lower anterior cervix. A second Kocher was placed just above it, and Mayo scissors were used to cut down through and enter the superior end of the vagina. This incision was carried around the cervix with Kocher clamps placed laterally, anteriorly and posteriorly to mark the vaginal cuff. At completion of this incision with Mayo scissors, the cervix, uterus, tubes and right ovary were removed from the abdomen.
- Closing the cuff: figure-of-eight suture was placed with 0 Vicryl at the right corner of the cuff and was carried across the vaginal cuff using a running locked fashion. Upon reaching the left end of the cuff, the suture was placed in a running fashion through the posterior peritoneum and then tied to the loose end of the suture that remained at the right cuff in a pursestring fashion ensuring that uterosacrals had good support of the superior vagina.
TVH:
- Leahy on anterior lip of the cervix. Inject local with epi anteriorly and posteriorly (Small amount, mostly for analgesia, not for hydrodissection). Lift cervix anteriorly and pull down on midline of posterior fornix with debakey pickups. Cut with mayos to enter the posterior cul-de-sac, sharply and bluntly dissect to the uterosacral ligaments. Place Heaney clamp with one arm in posterior cup-de-sac and one arm of clamp across lateral anterior edge of cervix to create uterosacral pedicle. Cut and ligate with 0 vicryl, repeat on opposite side. Place next clamp to ligate uterine artery/cardinal ligament, cut and ligate - repeat on opposite side. Cut circumference incision with scalpel across anterior surface, once in dissection plane, push back bluntly to enter anterior cup-de-sac. Continue to clamp, cut and ligate bilaterally, making sure to include serosa/peritoneum in clamp. Feel around uterus as you go to orient. Doubly clamp across utero-ovarian/round/fallopian tube, cut and ligate doubly - then remove uterus/cervix. Use sponge-stick to pull adnexa into view.
- Closure: figure of eight through bilateral uterosacral ligaments. Then continue simple interrupted 0 vicryl suture including both anterior and posterior peritoneum with vaginal epithelium.
**Bivalve of large uterus: place long weighted speculum and clamp lahey clamp on lateral sides of cervix. Use long handle scalpel to cut through midline up to fundus. As soon as able to reach adnexal pedicle, place clamp over utero-ovarian ligament, round ligament and tube. Once near fundus, concerns switching to long handle scissors to complete bivalve. Push one semi-uterus into pelvis to allow for cutting and ligating the other adnexal to remove one side of uterus. Then pull the first hemi-uterus into vaginal for removal.
Barkett:
ABDOMINAL:
- Place double toothed tenaculum on fundus. Clamp across round ligament, then suture round b/l rounds close to the side wall. Bovie down through anterior and posterior broad ligament until it opens. Slide finger into broad toward the midline and start bladder flap. Repeat bilaterally. Then place Kelly's across Fallopian tubes/utero-ovarian ligaments and begin to clamp, cut, ligate down to the cardinals/level of vagino-cervical junction.
- Creating colpotomy in TAH: Zeppelin clamps across upper vagina, just below cervix. Then use Mayos or sclapel to remove uterus and cervix. He also uses the same technique as Gale-Butto.
Or: With constant upward traction on the uterus with a towel clamp, use the bovie to incise circumferentially around the cervico-vaginal junction. As you enter the cuff corners, place kocher clamps at the corners.
-Closing the cuff: Suture (0 vicryl) from inside posterior vagina out through the posterior peritoneum then place the suture across the uterosacral ligaments, through the uterine artery/cardinal ligament pedicle, and loop suture through anterior vaginal cuff to come out in the vagina near the other end of the suture. Repeat on other side. Then place one or two interrupted "U" stitches to close the middle of the cuff. Close peritoneum over the cuff (2-0 vicryl), starting laterally near tubes/ovaries and running to other side.
- BS during TAH: Doubly clamp and cut the utero-ovarian ligament and fallopian tube. Use an 0 vicryl free tie to ligate the pedicle (with flash), then loop the tails of the suture around the pedicle again, and tie down. Next, Hold up the fallopian tube with a pickup or babcock, and use the tails from the utero-ovarian ligament ligation to ligate the base of the fallopian tube, and excise the tube with scissors. *If needed, use bovie to cauterize and cut through distal mesosalpingx to ensure fimbriated end is removed with the tube.
VAGINAL:
- Inject local with epi: 1-2ml in cervical tissue at uterosacral ligaments. Then inject 5ml anteriorly.
- Make "heart-shaped" incision down to cervical stromal tissue (V shape on the anterior and posterior surface, with the point directed toward the os. Then connect the tops of the V's around the sides of the cervix. Use scissors to carry the incision down the cervical stroma tissue, and use blunt dissection to push back the vaginal epithelium.
- Once the posterior peritoneum is visualized, enter sharply. Place clamps with bottom arm in posterior peritoneum and top arm over anterior cervix, rotate clamp perpendicular to the direction of the cervix and clamp down sliding just off cervix, but over the uterosacral ligament. Cut and haney suture.
- Continue up in this fashion over the cardinal ligament, uterine artery and broad ligament.
- Once only utero-ovarian remains, place two clamps over ligament, cut and doubly ligate with free ties.
- Closing the cuff: Place corner sutures through uterosacral ligament, then through anterior and posterior peritoneum on you way through anterior and posterior vaginal epithelium. Then throw interrupted sutures, including peritoneum across middle of cuff. (Going through uterosacrals should elevate cuff to level of ischial spines, or "0" station).
Sikkenga:
TLH with Harmonic:
Max for broad ligament, bladder flap, colpotomy. For bladder flap, hold down max and pull tissue up to cut through quickly.
Min for thicker tissues such as round ligament, cardinal ligament, utero-ovarian ligament.
Advanced hemostasis for IP and uterine arteries.
For coag without cut, Click closed and slightly release and hold down Min for 5-6 beats.
TLH Closure:
- Endostitch (with Quill suture in running closure of cuff): Use grasper to pull cranially on posterior cuff, then use hold endostitch open across cuff near grasper, with needle in posterior jaw, then slide laterally to place first stitch at corner, as close to uterosacral ligament as possible. Squeeze to close endostitch jaws, making sure you go through vaginal mucosa. Then, toggle switch 3 times to pass needle to the anterior jaw. Open jaws completely and pull anteriorly and cranially to pull needle through tissue. Once needle is through, close jaws before you pull cranially to pull suture through tissue, leaving a tail with the loop on the end. In the same fashion, pass needle through anterior cuff, and pull suture through. Then pass the needle through the loop at the end of the suture and pull tight. Continue in running fashion across cuff. Once you have reach the opposite side, you have to come back at least one throw to secure suture. Cut suture with no tail to avoid quills causing injury. *Always toggle the needle 3 times every time you pass it through thicker tissue, and use anterior, then cranial force to pull needle through tissue. http://www.medtronic.com/covidien/products/hand-instruments-ligation/endoscopic-suturing-devices
- Laparoscopic Suturing: (0 quill suture with loop at end), one self-righting needle driver and one grasper. Start on the corner of the cuff closest to the person suturing. Grasp anterior cuff, pass needle through anterior, then posterior cuff, including uterosacral ligament in posterior pass. Thread needle through loop at end of suture, and tighten suture down by pulling across abdomen to tightening first loop. Continue in running fashion to opposite corner, then suture back 1-2 bites to lock into place. Cut suture with no tail.
Holzgen:
Davinci closure: Running quill (two layer if needed)
Cree:
Uses Vessel Sealer instead of PK and scissors.
Davinci Colpotomy:
Does not ligate uterine arteries until creating colpotomy. Start midline posterior, move laterally along VCare cup to near uterine artery. Place vessel sealer with one arm in vagina, other outside, clamping across the uterine artery. On the first side twist/slide arm to cauterize laterally, then medially of the line of colpotomy. Then use monopolar scissors to cut/cauterize between burns. Then, on the second uterine artery, place vessel sealer across uterine artery in a similar fashion to cauterize uterine artery. Use monopolar scissors to cut/cauterize to continue colpotomy medial to the burn.
Davinci closure: running "double-locked" method.
Vandermark:
Robotic: place camera port approx. 2cm above umbilicus, transverse incision. Uses sharp trocars, so apply pressure, then back off and allow pneumoperitoneum to re-establish, then push trocar in again. Push in perpendicular to fascia until the tip of the trocar is seen, then aim toward pelvis to push it in the rest of the way.
- Always scan directly below where camera port was inserted to check for injury/bleeding.
- Cuff closure: 0 vicryl suture, first place around uterosacral ligament, then through uterosacral ligament. With the same suture, start closure by going through uterosacral ligament into vagina laterally near corner, then continue through the anterior vagina. Then tie suture to the end that went around the uterosacral ligament. Next, do the same at the other corner to complete uterosacral involvement in bilateral corners. Then complete closure of cuff through the middle using either U-stitches (to evert the edges and decrease chance of granulation tissue) or figure of 8's.
Lawrence:
VAGINAL:
- Inject local with epi: 10ml in cervical tissue across anterior surface and at uterosacral ligaments.
- Make circular incision through epithelium around cervix below the bladder reflection withdown to cervical stromal tissue. Use scissors (with tips perpendicular to cervix) to carry the incision down the cervical stroma tissue, and use blunt dissection to push back the vaginal epithelium.
- Once the posterior peritoneum is visualized, enter sharply, then tag posterior peritoneum to posterior vaginal epithelium with single interrupted 0 vicryl at midline - stat. Place heaney retractor posteriorly. Place clamps with bottom arm in posterior peritoneum and top arm over anterior cervix, rotate clamp perpendicular to the direction of the cervix and clamp down sliding just off cervix, but over the uterosacral ligament. Cut and heaney suture, tag uterosacral/vaginal cuff corners with figure of 8 0 vicryl - kocher's to tag.
- Enter the anterior peritoneum sharply with mayo scissors (consider clamp, cut and ligation of cardinal ligament before entering anteriorly).
- Continue up in this fashion over the cardinal ligament, uterine artery and broad ligament.
- Once only utero-ovarian ligament and tube are remaining, place finger posteriorly around pedicle and place heaney from superior to inferior down over the pedicle.
- Modified heaney: place suture through the middle of the pedicle and tie single throw, then carry suture around end of heaney clamp and tie off pedicle with suture completely around pedicle.
- If uterus is large, then core out uterus (use scalpel to remove all but fundus and utero-ovarian ligament and tube attachments).
- If removing tubes and/or ovaries, use spongestick to pull into view, grasp tube with babcock, then clamp across pedicle with Gupta-Frank clamp.
- Place figure 8 suture in corners of cuff, including uterosacral ligaments. Continue figure of 8 suture across cuff to complete closure, making sure to include anterior preitoneum in cuff.
ABDOMINAL:
- Place double toothed tenaculum on fundus. Clamp across round ligament, then suture round b/l. Use bovie to cut down to level of bladder flap. If taking ovaries, create window in the mesoovarian to allow for clamping and suture ligating of IP. Then place Kelly's or Heaney's across Fallopian tubes (right at uterus) and begin to clamp, cut, ligate down to the cardinals with clamps.
- Colpotomy - after cut down to the level of the cervix, use jorgenson's to cut amputate cervix/uterus from vagina. Then use 4 allis' to hold vaginal epithelium/fibromuscular layer/posterior peritoneum together and close with interrupted figure of 8 suture's.
Daudi:
TAH:
Colpotomy, place two right angle clamps nose-to-nose across vagina just under cervix. Use scalpel to cut across the top of the clamps to remove cervix and uterus.
Cuff Closure: Heaney suture with 0 vicryl under each right angle clamp. Figure 8 suture in midline to complete closure if needed.
Vertical Skin Closure: Loop PDS for peritoneum and fascia (going around rectus). 2-0 vicryl interrupted for dermal closure. Nylon (3-0 or 4-0?) vertical mattress of dermal/epidermal layer. Use alice clamps clamps across skin incision to approximate skin for staple placement.
- staple removal at 14 days (rarely she might remove at 10 days).
Brader:
Davinci TLH:
Oopherectomy: skeletonizes IP, then cauterizes, but does not cut IP. Then completes hysterectomy and cuts IP right before removing uterus vaginally to keep adnexa out of the way during TLH.
Cuff closure: 0 vicryl in unlocked running fashion. Passes needle through 10mm assist port and uses port for removal of needle (Or, place needle through colpotomy with ring forceps after removal of cervix/uterus, then after cuff closure, pass needle backwards through closed cuff and remove vaginally.
Bennett:
Davinci TLH: Uses as little bipolar as possible, especially at colpotomy to aid in healing and decrease risk of dehiscense.
Salpingectomy: removes tubes completely at the beginning of the case and takes them out assist port
Oopherectomy: same as Brader.
- After cauterizing and cutting through round ligament, use monopolar to dissect through anterior broad ligament down to bladder flap. Then monopolar down posteriorly to skeletonize uterine artery and bipolar artery x2, then cut medially.
(If you bipolar an area, then don't use monopolar when cutting, just cut to decrease effects of cautery).
Colpotomy: Posteriorly, makes incision with monopolar scissors above the v-care cup, to leave the uterosacral ligaments intact. Sides and anterior of colpotomy are completed following the cup. Cuff is closed with 0 vicryl in figure 8 sutures.