Mini-Laparoscopy for Removal (Partial) of Adnexae at the Time of Hysterectomy

Abstract

Study ObjectiveTo demonstrate our technique of mini-laparoscopic adnexectomy or salpingectomy at the time of total laparoscopic hysterectomy (TLH). DesignStep-by-step video demonstration of our technique. SettingThe advantages of laparoscopic surgery have been widely recognized, including improved visualization and exposure, reduced operative trauma owing to smaller incisions and gentler tissue handling, and faster postoperative recovery. Continuing technological developments have allowed the use of smaller-caliber instruments while maintaining a high standard of surgical performance. Mini-laparoscopy requires the use of 3-mm or smaller ports. The main advantage of mini-laparoscopy is the reduced incision size, which can translate into a lower incidence of incision-related complications such as postoperative pain, infection, and trocar site herniation, along with superior cosmetic results. Today, in younger patients, prophylactic salpingectomy can be considered instead of adnexectomy, taking into account the well-known benefits of ovarian conservation. Prophylactic salpingectomy involves Fallopian tube removal for primary prevention of epithelial carcinoma of the fallopian tubes, ovaries, and peritoneum in women undergoing pelvic surgery for another indication. Other advantages of this intervention are the avoidance of hydrosalpinx (which affects ∼30% women after hysterectomy), the 7.8% lifetime risk of revision surgery [1], tubal infection, and benign and malignant Fallopian tube tumors. Finally, salpingectomy has no known physiological side effects, is safe and feasible, does not worsen surgical outcomes, does not significantly increase the operative time, and is not related to increased rates of intraoperative and postoperative complications or readmission. InterventionsThe patient is a 44-year-old woman with a history of 2 previous cesarean sections with adenomyosis and endometriosis infiltration of the uterosacral ligaments. After discussion about the risks and benefits of ovarian conservation with prophylactic salpingectomy versus adnexectomy, the patient opted to preserve her ovaries. A TLH with partial removal of the uterosacral ligaments nodules and prophylactic bilateral salpingectomy was performed. To begin, the patient was placed in lithotomy position with Allen stirrups at an angle of approximately 100 degrees. Standard trocar placement was used. A 5- or 10-mm 0° scope was placed at the level of the umbilicus and three 3-mm skin incisions were made for accessory lower quadrant trocar placement: 2 lateral, approximately 3 cm medial to the anterior superior iliac spine, and 1 suprapubic, slightly higher than the line made by the lateral trocars, ensuring that the distance between this port and the camera trocar exceeded 8 cm. This triangulation of the accessory ports allowed for good ergonomics for the surgeon. The procedure continued with abdominopelvic cavity inspection and bilateral transperitoneal ureter identification and eventual adhesiolysis, and then the following steps:1.Coagulation and section of the round ligament bilaterally.2.Opening of the anterior leaf of the broad ligament.3.Fenestration of the posterior leaf of broad ligaments to displace the ureter laterally.4.Bilateral salpingectomy. The tuba-ovarian ligament was first divided at the fimbriae, and then the tube was completely removed from its fimbriated end up to the uterotubal junction, preserving the vascularization of the mesosalpinx as much as possible. The tubes were left attached to the uterus to allow en bloc removal.5.Coagulation and sectioning of the uteroovarian ligaments bilaterally.6.Vesicouterine and posterior dissection.7.Uterine vessel dissection, coagulation, and sectioning.8.Opening of the vagina.9.Uterus extraction by the vaginal route.10.Vaginal closure with laparoscopic figure-eight sutures.The instruments used were a 10-mm scope, a 3-mm bipolar forceps, 3-mm cold scissors, a 3-mm suction-irrigation device and 3-mm grasping forceps. ConclusionMini-laparoscopy is an alternative to classic laparoscopy associated with greater patient satisfaction. Prophylactic salpingectomy has proven to reduce the risk of ovary, peritoneal, and tubal epithelial carcinomas as well as benign tubal diseases, and does not significantly increase the operative time or the incidence of postoperative complications.