The camera (a flexible-tip camera in this case) is inserted into the port, and the tip flexed, to assess the abdomen and pelvis. One can achieve the best, unobstructed views of the pelvis—and avoid instrument clashing—when the camera tip is placed toward the anterior abdominal wall and deviated downward toward the pelvis. As the surgery proceeds, one can obtain excellent views by simply adjusting the flexible-tip camera.
In a total laparoscopic hysterectomy, I have found that it is easier to begin with the primary surgeon standing near the patient's left shoulder to address the left side first. The uterine manipulator will deflect the uterus cephalad and toward the operator, placing the right utero-ovarian ligaments under tension.
With use of the reticulating grasper, the utero-ovarian ligament is elevated, which provides easy access for a straight vessel-sealing device. At this point the camera is best positioned providing views from the right lower quadrant looking anteriorly. (This is accomplished by lowering the camera toward the patient's chest and deflecting the camera tip inferiorly and medially.)
A vessel-sealing device of your choice can then be used to cross-clamp, seal, and transect the utero-ovarian, round, and broad ligaments. The bladder flap can be developed with either a hook cautery, scissors, or a vessel-sealing device. Often, the small vaginal branches of the uterine vessels will become compressed across the top of the manipulator cuff—be sure to use the vessel-sealing device to control this.
For the colpotomy, I generally use the monopolar hook with 40- to 50-W pure cutting. The disposable hook electrode is advantageous for LESS because it can be bent. By moving the flexible-tip camera, one can adequately visualize the entire colpotomy. I also use the uterine manipulator to advantage—applying upward pressure usually provides adequate views of all the cervical-vaginal attachments.
Once the uterus is detached, it generally can be delivered vaginally. When necessary, morcellation can be accomplished either vaginally (with or without a mechanical morcellator) or with a morcellator placed through the port in the umbilicus.
Suturing presents the biggest challenges. Even those who have mastered suturing in conventional laparoscopy will face a learning curve. The vaginal cuff can be closed intracorporeally using one conventional needle driver and one reticulating grasper, but it can also be facilitated with a commercial suturing device and extracorporeal knot tying. (This latter option may be advisable during the learning curve.)
When extracorporeal knot tying is used, be careful to prevent the suture from getting wrapped around the other instruments, especially if using the TriPort.
A few more tips to shorten the learning curve with single-incision laparoscopic hysterectomy:
▸ Don't hesitate to “pexy” the ovaries, epiploica, uterus, etc., when necessary.
▸ Lubricate instruments frequently.
▸ Complete one side before moving on to the other side. Anything you can do to minimize instrument changes will improve efficiency and eliminate the need to reposition the camera and instruments. When switching sides, maintain the same instrument configuration.
▸ The camera in the vertical position with upward flexion at the tip provides an excellent view of the posterior uterus and cul de sac.
▸ The camera in the horizontal position with downward flexion at the tip provides excellent views of the anterior uterus and bladder flap, and is preferable for viewing the broad ligaments.
Experience and Outcomes
Since June 2008, I have done more than 90 hysterectomies and 20 other surgeries using the LESS technique. Data from a 5-month period in 2008, involving 22 patients who had LESS surgery (19 of whom had a hysterectomy), show that patients used narcotic pain medications for an average of 2.5 days and any analgesic medication for an average of 5 days. Their length of stay averaged approximately 11.5 hours, and they returned to work after an average of 3.5 days. The average uterine weight was 324 g, and weight was as high as 1,600 g.
Blood loss averaged 50 mL, and the median operative time was 171 minutes. Surgical time was directly related to body mass index and uterine weight, and estimated blood loss increased with increasing uterine weight. Prior laparotomy and the presence of severe adhesions did not affect the length of surgery.
I encountered no intraoperative complications or conversions, although in one patient, morcellation of the 1,600-g uterus was carried out through an additional 15-mm suprapubic incision.
The complications I encountered in this initial group of 22 patients were vaginal bleeding on day 6 in one patient and a suture granuloma 3 weeks postop in another. A third patient had a tubo-ovarian abscess 11 days after surgery; she had a history of sexually transmitted diseases and substance abuse.