Mastering the Anterior Approach of Laparoscopic Hysterectomy for the Huge Uterus

Abstract

Video Objective To expand laparoscopic surgical skills, we need to strategies to cope with the very large uterus.Traditionally, there are three techniques to detect and mobilize the ureter and uterine artery: the anterior, lateral and posterior approach. Generally, the lateral approach is most common as one can easily detect the ureters transperitoneally at the rim of psoas muscle. But, in the case of a large and bulky uterus, advanced techniques are required. Design Laparoscopic demonstration of fascial planes and surgical techniques used to cope with the huge uterus. Setting Kurashiki medical center, private hospital, in Japan. Patients Total laparoscopic hysterectomy for uterus greater than 800 grams. Interventions In anterior approach, by making a bladder flap one can firstly detect and ligate uterine arteries to reduce bleeding. Measurements and Main Results In the case of adenomyosis and endometriosis, bleeding from severe fibrosis may be encountered in the parametrium. Ligation of the uterine arteries first will help to avoid bleeding. Open the bladder flap wide and lifting it sufficiently and cutting the loose connective tissue caudally will expose the palpable ascending and inward vessel. That is the uterine artery. The separation between the uterine artery and the ureter opens Latzko's pararectal space. In the case of fibroid, we find the ureter first as the broad ligament is more elastic allowing for stretching. By making the broad ligament tense, you can elevate the posterior leaf of broad ligament to separate the mesoureter. This procedure allows entry into Okabayashi's pararectal space. The entry point is at about 1cm medially to the root of the lateral umbilical ligament. This space is avascular and stretches to easily find the mesoureter containing the ureter above it. Conclusion Mastering an anterior approach and recognizing fascial layers contributes to our surgical toolbox in coping with more complicated hysterectomies.