Robotic Assisted Total Laparoscopic Hysterectomy for Complex Uteri with Cervical Fibroids: Tips and Tricks with an ABC Approach

Abstract

<h3>Study Objective</h3> Leiomyomatous uteri present as a complex pathology for those women requiring a hysterectomy. Specifically, cervical leiomyomas complicate typically straightforward hysterectomies by anatomically distorting the ureter, uterine arteries, and bladder pillars. A systematic approach is necessary in order to ensure the safety of patients undergoing robotic surgery for benign indications. <h3>Design</h3> N/A. <h3>Setting</h3> N/A. <h3>Patients or Participants</h3> This patient is a 40-year-old, African American woman who presents with a 4.6 centimeter cervical fibroid adjacent to the right uterine artery and parametrium on transvaginal ultrasonography. <h3>Interventions</h3> This video proposes the following ABC approach in order to safely perform a robotic-assisted total laparoscopic hysterectomy (RA-TLH) in the setting of known cervical fibroids by imaging: A - Anatomical identification: specifically, the ureters, uterine artery, and colpotomy demarcation B - Build a plane to delineate cervical fibroids: find a tissue plan with judicious use of blunt dissection and short bursts of energy C - Consistent traction/counter traction: push the fibroids up and away from the eventual colpotomy site <h3>Measurements and Main Results</h3> Following the ABC approach ensures patient safety by identifying critical anatomical landmarks within the pelvis. Planes that delineate cervical fibroids help peel and shell these bulky tumors off and away from the eventual colpotomy site, while at the same time minimizing blood loss. Traction and counter traction allows for the cervix and colpotomy site to be set apart and distanced from the transection site, thus avoiding complications. <h3>Conclusion</h3> Cervical fibroids present as a uniquely complex pathology for surgeons attempting a total laparoscopic hysterectomy, whether robotic or via straight stick. This video proposes surgeons to follow the ABC approach for safely performing a hysterectomy with a leiomyomatous cervix. Further ongoing pre- and peri-operative planning will ultimately optimize patient outcomes.