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this video is a typical example of a
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robotic assistant total laparoscopic
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hysterectomy due to large fibroids and
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mini Rajah the patient is a 44 year old
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african-american female with multiple
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uterine fibroids pelvic pain and mini
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Raja
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she had an 18 week gestational sized
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uterus on physical exam she was about to
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begin a new job and desired a minimally
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invasive laparoscopic hysterectomy at
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the initial survey the enlarged uterus
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and multiple fibroids can be seen the
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procedure is performed using the ACE
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harmonic scalpel the procedure has began
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with a soft injected me by cutting them
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as a sow pace with the harmonic scalpel
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a routinely perform ‘south injected me
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at the time of hysterectomy as leaving
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the tubes behind serves no purpose but
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they increase the chance of developing a
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Hydra sow things down the road the utero
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Varian and then round ligament is
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divided
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you
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you
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you
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as the broad ligament is open the and
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here bladder flap has created
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as the bra blinkman is open the uterine
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artery seen here is then skeletonized
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the harmonic is then used to coagulate
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the uterine artery in multiple places
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before transected
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you
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the descending branch of the uterine
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artery has then coagulated
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attention is then turned to the opposite
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side I have swap locations of the
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tenaculum in the harmonic scalpel
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with a laparoscopic hysterectomy and
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particularly with a large uterus it is
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important to transect the round ligament
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in its midpoint or just slightly lateral
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to this area this both facilitates
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approaching the uterine artery at the
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proper angle and stays away from the
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large vessel surrounding the uterus
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the anterior peritoneum dissection has
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continued to meet that of the other side
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again the uterine vessels are
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skeletonized
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Theatre and artery is located here with
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the uterine vein just behind it the
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uterine vein is coagulated first
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followed by the Maine
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the artery is then fully divided
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the Cardinal ligament is then divided
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aiming towards the edge of the coat
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called pata miser cup as the Cardinal
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ligament is divided the uterine artery
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begins to fall laterally
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the cervical fashio is thinned all the
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way around the cup as the bladder was
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not able to be dissected down at the
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initial steps is pushed down at this
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point the Kolkata me is then began with
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the harmonic scalpel the cocoa atomizer
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cup can be seen here the uterus has
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pushed inward with the uterine
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manipulator which places pressure on the
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vagina thinning out the tissue overlying
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that cope atomizer cup approximately 2/3
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of Kolkata me is performed from one side
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attention then turns back to the right
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side where the final dissection of the
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Cardinal ligament and thinning out is
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performed
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completion of the co pada we can then be
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performed
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once full disconnection is achieved the
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uterus is pulled into the vagina in this
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case vaginal Morse elation was performed
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as this patient had one large 8
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centimeter fibroid the uterus was turned
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with the body of the Rieu turrets
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removed from the fibroid and then the
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fibroid taken out separately
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the body of the large fibroid is kept in
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the vagina to maintain the
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pneumoperitoneum cuff closures that
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began using a 0 v lock barbed suture
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as the uterine vessels can be seen here
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care is taken to place the suture inside
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of their margin in particular care is
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taken to grab good bytes of the vaginal
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mucosa
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but once the initial corner bite is
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placed the 0v lock suture is looped back
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on itself the closure is then continued
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in a running fashion along the way
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ensuring that the bladder is
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appropriately dissected away from the
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vaginal cuff
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you
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this patient had a portion of deep
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infiltrating endometriosis and this
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posterior peritoneum that’s that it is
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not incorporated in this middle area in
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anticipation of coming back and
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dissecting out this area of
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endometriosis
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you
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as I close the cuff with a single
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running suture from right to left that
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take care not to fully tighten down the
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final sutures so that the vaginal mucosa
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corner can be clearly located prior to
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completion of the cuff closure
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you
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once I have placed the last few sutures
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I will then go back and tighten down the
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barb to be lock suture
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the case is now complete the small area
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of endometriosis was fully excised
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pathology revealed multiple uterine
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fibroids ranging from zero point seven
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to eight centimeters in significant
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areas of adenomyosis the total urine
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weight was 856 grand
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the estimated blood loss was 50 CCS
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surgical times were 35 minutes to
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removal the uterus 14 minutes for
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vaginal more sedation in 10 minutes for
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the cuff closure the patient went home
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the same day from the recovery here she
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was able to begin a new job only ten
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days later
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you