Approach to a Total Laparoscopic Hysterectomy with Anterior Abdominal Wall Adhesions

Abstract

<h3>Study Objective</h3> The objective of this video presentation is to describe a laparoscopic approach to a hysterectomy where there are anterior abdominal wall adhesions present. <h3>Design</h3> A total laparoscopic hysterectomy where anterior abdominal wall adhesions were noted was recorded in the OR for review. <h3>Setting</h3> This video took place in the OR with the patient in dorsal lithotomy position in Trendelenburg. An umbilical port, suprapubic port, and 2 lateral ports were used for this procedure. A uterine manipulator with a colpotomy cup was in place. <h3>Patients or Participants</h3> This case was selected due to the presence of anterior abdominal wall adhesions found upon entry to the abdomen. <h3>Interventions</h3> A TLH was completed while reviewing multiple approaches in the setting of anterior abdominal wall adhesions Different techniques to complete the hysterectomy depending on the extensiveness of adhesive disease were reviewed including taking down adhesions before placing all ports, potentially taking the uterine artery at its origin, backfilling the bladder, and tunneling through the adhesions. <h3>Measurements and Main Results</h3> The main result of this video presentation was that a review of multiple methods of approaching anterior abdominal wall adhesions while performing a total laparoscopic hysterectomy was done while addressing ways to overcome obstacles that could be encountered. <h3>Conclusion</h3> When approaching a laparoscopic hysterectomy where there are anterior abdominal wall adhesions, there are several different obstacles that can be encountered, and this video presents different approaches to these challenges. One should consider alternate modes of uterine manipulation should a routine manipulator be unsafe to place. Suprapubic ports can be safely placed once adhesions that prevent placement are taken down, but also consider alternative port placement such as a LUQ or subxiphoid port depending on the location of the adhesions. Be prepared for ligation of the uterine artery at its origin. Ensure that there is no bladder involvement by backfilling the bladder to delineate planes.