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Textbook & Atlas of Laparoscopic Hysterectomy
B Ramesh, Pooja Sharma Dimri
SECTION 1: BASICS
CHAPTER 1:
Hysterectomy—Then and Now
INTRODUCTION
VAGINAL HYSTERECTOMY
ABDOMINAL HYSTERECTOMY
RADICAL HYSTERECTOMY
Laparoscopy
CHAPTER 2:
Laparoscopic Pelvic Anatomy—An Overview
INTRODUCTION
THE UMBILICUS, PERITONEAL FOLDS AND POSTERIOR PERITONEUM
STRUCTURES AT THE PELVIC BRIM
PELVIC SIDEWALL
BROAD LIGAMENT, ROUND AND OVARIAN LIGAMENTS
PELVIC CELLULAR TISSUES, FASCIA AND LIGAMENTS
The Cardinal or Mackenrodt's Ligament
The Uterosacral Ligament (USL)
VESICOUTERINE/VESICOCERVICAL LIGAMENTS
PUBOCERVICAL AND RECTOVAGINAL FASCIA
AVASCULAR SPACES OF PELVIS
RETROPUBIC SPACE (SPACE OF RETZIUS)
PARAVESICAL SPACE
PARARECTAL SPACE
VESICOVAGINAL SPACE
RECTOVAGINAL SPACE
PRESACRAL SPACE
PARA-AORTIC AREA
PELVIC LYMPH NODES
VASCULAR RELATIONSHIPS
VENOUS DRAINAGE
NERVOUS ELEMENTS
Somatic Innervation
Autonomic Innervation
AFFERENT INNERVATION
THE URETER
URINARY BLADDER
Surgical Anatomy and Relations (Figs 2.26A to C)
SIGMOID AND RECTUM
CONCLUSION
CHAPTER 3:
Indications of Hysterectomy
INTRODUCTION
BENIGN DISEASES
Leiomyoma
Adenomyosis
Abnormal Uterine Bleeding
Endometriosis
Chronic Pelvic Pain
Pelvic Organ Prolapse
PREINVASIVE DISEASES
MALIGNANT CONDITIONS
Cervical Cancer
Endometrial Cancer
Laparoscopic Radical Hysterectomy
LAPAROSCOPIC HYSTERECTOMY IN SPECIAL CONDITIONS
Nulliparous Women
Previous Abdominal/Pelvic Surgery
Women with Obesity
HYSTERECTOMY TRENDS
CONTRAINDICATIONS
ANATOMIC/DISEASE RELATED
Long Road Ahead!
CHAPTER 4:
Preoperative Preparation
INTRODUCTION
INITIAL VISIT
HISTORY
EXAMINATION AND ASSESSMENT
PATIENT INFORMATION
INFORMED CONSENT
PREOPERATIVE ASSESSMENT
PREOPERATIVE INVESTIGATIONS
WARD MANAGEMENT
Preoperative Discussion
Hair Removal
Thromboprophylaxis
Mechanical Prophylaxis
Pharmacological Prophylaxis
Bowel Preparation
OPERATING THEATER MANAGEMENT
Prophylactic Antibiotics
Bladder Catheterization
Skin Preparation
Draping
Operative Notes
CHAPTER 5:
Anesthetic Implications in Total Laparoscopic Hysterectomies
INTRODUCTION
HISTORY
PHYSIOLOGY OF INSUFFLATION
Choice of Insufflation Gas
PHYSIOLOGICAL TRESPASS CREATED BY THE PNEUMOPERITONEUM
RAISED INTRA-ABDOMINAL PRESSURE (IAP)
NEUROHUMORAL RESPONSE ASSOCIATED WITH RAISED IAP
GASEOUS INTERCHANGE
OTHER PHYSIOLOGICAL EFFECTS
Hypoxia
Hypothermia
The Stress Response
RESPIRATORY COMPLICATIONS OF PNEUMOPERITONEUM
CO2 Subcutaneous Emphysema
Pneumothorax, Pneumomediastinum and Pneumopericardium
Endobronchial Intubation
GAS EMBOLISM
RISK OF ASPIRATION OF GASTRIC CONTENTS
CARDIAC ARRHYTHMIAS DURING LAPAROSCOPY
EFFECT OF PNEUMOPERITONEUM ON REGIONAL HEMODYNAMICS
ANESTHESIA FOR LAPAROSCOPIC HYSTERECTOMY
Preoperative Evaluation of the Patient and Premedication
ANESTHETIC TECHNIQUE
POSITIONING OF THE PATIENT DURING THE SURGERY
Intravenous Fluids
EXTUBATION OF THE PATIENT
Postoperative Pain
POSTOPERATIVE NAUSEA AND VOMITING
MONITORING OF THE PATIENT
USE OF LARYNGEAL MASK AIRWAY
REGIONAL ANESTHESIA
ALTERNATIVES TO CO2 PNEUMOPERITONEUM
INERT GASES
GASLESS LAPAROSCOPY
SUMMARY
KEY POINTS
CHAPTER 6:
Instrumentation in Total Laparoscopic Hysterectomy
INTRODUCTION
ENDOSCOPY OPERATING ROOM (FIG. 6.1)
EQUIPMENT
Insufflator (Fig. 6.2)
Video Camera Unit
Light Source
Suction Irrigation System (Fig. 6.7)
Monitor and Documentation System
TELESCOPE
INSTRUMENTS FOR ENTRY(FIG. 6.10)
Veress Needle
Trocars (One 10 mm, Three 5 mm)
HAND INSTRUMENTS
Grasping Forceps—Available in 3–10 mm Sizes
ADDITIONAL INSTRUMENTS/EQUIPMENT
Uterine Manipulator
Reusable
Partially Disposable
Completely Disposable
KOH Colpotomizer (CooperSurgical)
V-Care Device
Pelosi Uterine Manipulator
Hulka Uterine Elevator
Valtchev Uterine Mobilizer
ENERGY SOURCES
MORCELLATORS
STERILIZATION
KEY POINTS
TEAM WORK!
CHAPTER 7:
Energy Sources in Total Laparoscopic Hysterectomy
INTRODUCTION
CONVENTIONAL ELECTROSURGICAL DEVICES
Basic Principles of Electrosurgery
Tissue Effects of Electrosurgery (Fig. 7.7)
CONVENTIONAL ELECTROSURGERY IN TLH
ADVANCED BIPOLAR VESSEL SEALERS
LigaSureTM (Figs 7.10 to 7.12)
EnSealTM
ULTRASONIC ENERGY
Harmonic Scalpel (Figs 7.13 to 7.15)
Sonicison (Fig. 7.16)
Thunderbeat
PRACTICAL TIPS FOR ELECTROSURGERY
SECTION 2: ROUTES AND TYPES OF HYSTERECTOMY
CHAPTER 8:
Total Abdominal Hysterectomy
INTRODUCTION
HISTORY
INDICATIONS
ADVANTAGES/DISADVANTAGES OVER VAGINAL HYSTERECTOMY OR LAPAROSCOPIC HYSTERECTOMY
PREOPERATIVE PREPARATION
OPERATIVE STEPS
Closure
POSTOPERATIVE MANAGEMENT
COMPLICATIONS
SPECIAL CIRCUMSTANCES
CONCLUSION
CHAPTER 9:
Vaginal Hysterectomy—The Signature of a Gynecologist
INTRODUCTION
THE SCOPE OF VAGINAL HYSTERECTOMY
REASONS COMMONLY REPORTED FOR AVOIDING VAGINAL HYSTERECTOMY AND CLINICAL EVIDENCE
Large Uterine Size
Nulliparity and Lack of Uterine Descent
Previous Cesarean Sections
Previous Pelvic Surgeries and Extrauterine Pathology
Need for Removal of the Ovaries
TRIAL OF VAGINAL HYSTERECTOMY
METHOD OF VAGINAL HYSTERECTOMY
Incision of the Vaginal Mucosa
Mobilization of the Bladder from the Uterus
Opening the Posterior Peritoneum
Division of the Lower Supports of the Uterus
Opening the Anterior Peritoneum and Ligation of the Uterine Arteries
Division of the Upper Part of the Uterus and Appendages
Reconstruction of the Pelvic Floor
Repair of the Anterior Compartment
Closing the Vaginal Wall
CONCLUSION
CHAPTER 10:
Laparoscopic Hysterectomy—The Game Changer
INTRODUCTION
HISTORY
TYPES
INDICATIONS
CONTRAINDICATIONS
ADVANTAGES/DISADVANTAGES OVER ABDOMINAL HYSTERECTOMY
ADVANTAGES/DISADVANTAGES OVER VAGINAL HYSTERECTOMY
COMPARISON OF TOTAL LAPAROSCOPIC HYSTERECTOMY WITH SUBTOTAL HYSTERECTOMY
OPERATIVE STEPS OF TOTAL LAPAROSCOPIC HYSTERECTOMY
Special Circumstances
CONCLUSION
CHAPTER 11:
Choosing the Route of Hysterectomy
INTRODUCTION
HYSTERECTOMY: EVOLUTION FROM THE ANNALS OF HISTORY
THE PASSAGE: VAGINAL PASSAGEWAY
THE PASSENGER: UTERINE SIZE
PLACE OF THE PASSENGER: PELVIC CAVITY
CHOOSING A ROUTE FOR HYSTERECTOMY: QUALITY OF CARE
VAGINAL SURGERY: SIGNATURE OF A GYNECOLOGIST
SECTION 3: THE PROCEDURE
CHAPTER 12:
Ports and Positioning
INTRODUCTION
BASICS OF PORT POSITIONING
PORT PLACEMENT
UTERINE MANIPULATION DURING TOTAL LAPAROSCOPIC HYSTERECTOMY
CONCLUSION
KEY POINTS
CHAPTER 13:
The Upper Pedicle
INTRODUCTION
SURGICAL ANATOMY
INSTRUMENTATION
PROCEDURE
REMOVAL OF OVARIES IN HYSTERECTOMY
REMOVAL OF FALLOPIAN TUBES IN HYSTERECTOMY
CONCLUSION
KEY POINTS
CHAPTER 14:
Bladder Dissection in Total Laparoscopic Hysterectomy
INTRODUCTION
SURGICAL ANATOMY
GENERAL CONSIDERATIONS
BLADDER DISSECTION TECHNIQUES
Normal Uterus (Unscarred) (Figs 14.2 to 14.4)
Previous Cesarian Section (LSCS) (Scarred Uterus)
Lateral Approach (Figs 14.5 to 14.8)
OTHER APPROACHES TO FACILITATE BLADDER DISSECTION IN DIFFICULT CASES
Combined Vaginal and Laparoscopic Approach
Cystosufflation
Saline Infiltration of Uterovesical Fold
Bladder Injuries During Total Laparoscopic Hysterectomy
CONCLUSION
KEY POINTS
CHAPTER 15:
Uterine Artery and Total Laparoscopic Hysterectomy
INTRODUCTION
CONSIDERATIONS
Anatomical
Surgical
The Principle: Skeletonization of the Uterine Vessels
Our Technique: “The Twin Triangles of Safety” Technique
OUR EXPERIENCE AND CONCLUSION
SPECIAL CONSIDERATIONS
ILLUSTRATIVE DIFFICULT CASE SCENARIOS
Case 1
Approach
Case 2
Approach
DISCUSSION: CONTROVERSIES AND DILEMMA
CONCLUSION
CHAPTER 16:
Cardinal Uterosacral Ligament Complex, Opening of the Vaginal Vault and Specimen Retrieval
CARDINAL UTEROSACRAL LIGAMENT COMPLEX
Surgical Anatomy
Relationship of Cardinal-USL Ligament Complex with Ureter
DISSECTION OF THE CARDINAL UTEROSACRAL LIGAMENT COMPLEX IN LAPAROSCOPIC HYSTERECTOMY
OPENING OF THE VAGINAL VAULT (FIGS 16.3 AND 16.4A TO C)
SPECIMEN RETRIEVAL
Vaginal Morcellation (Mechanical) (Figs 16.5A to D)
Abdominal Morcellation (Electromechanical) (Figs 16.6A to E)
LAPAROSCOPIC SUPRACERVICAL HYSTERECTOMY
ELECTROMECHANICAL MORCELLATION IN HYSTERECTOMY—CURRENT STATUS
Current Status
CONCLUSION
KEY POINTS
CHAPTER 17:
Suturing of Vault in Total Laparoscopic Hysterectomy
INTRODUCTION
QUESTIONS AND CONTROVERSIES
Suture or Not to Suture?
Vaginal or Laparoscopic?
Laparoscopic Suturing
Transvaginal Suturing of the Vaginal Vault (Fig. 17.10)
Evidence (Laparoscopic Vs Vaginal Suturing in TLH)
Single or Double Layers?
Which Suture?
Barbed Suture
Advantages
Disadvantages
CONCLUSION
KEY POINTS
SECTION 4: SPECIAL CONSIDERATIONS
CHAPTER 18:
Laparoscopic Uterine Artery Occlusion in Hysterectomy—Practical Tips and Tricks
INTRODUCTION
DIFFERENT APPROACHES TO OCCLUDE THE UTERINE ARTERIES
Different Methods to Occlude the Uterine Arteries
Lateral Approach (Figs 18.1 to 18.7)
Steps
Salient Points
Posterior Approach (Figs 18.8 to 18.16)
Salient Points
Anterior Approach (Figs 18.17 to 18.21)
Steps
Salient Features
Key Points
CONCLUSION
CHAPTER 19:
Total Laparoscopic Hysterectomy in a Large Uterus and Multiple Surgeries—Difficulties and Modifications
INTRODUCTION
ENTRY AND PORT PLACEMENT
MANIPULATION
ADHESIONS AND ADHESIOLYSIS
Omental and Bowel Adhesiolysis
Use of Minilaparoscope
Bladder Adhesiolysis
Lateral Window Technique
Cystosufflation
SECURING THE UTERINE ARTERY
Technique of Uterine Artery Ligation at Origin
SPECIMEN RETRIEVAL: A CHALLENGE IN A BIG UTERUS
Vaginal Retrieval Methods
Abdominal Specimen Retrieval
In situ Morcellation
Morcellation in Endobag
Minilaparotomy
BLOOD LOSS
KEY POINTS
CHAPTER 20:
Total Laparoscopic Hysterectomy in Severe Endometriosis
INTRODUCTION
PREOPERATIVE EVALUATION
PREOPERATIVE PREPARATION
INSTRUMENTS AND EQUIPMENT
PROCEDURE
ABDOMINAL ENTRY AND PORT POSITIONS
ANATOMICAL CORRECTION
UPPER PEDICLES
BLADDER MOBILIZATION AND DIVISION OF UTERINE VESSELS
DIVISION OF CERVICOVAGINAL ATTACHMENTS
EXCISION OF RECTOVAGINAL NODULES AND ADNEXAL REMOVAL/REPAIR
VAULT CLOSURE
CHECKING THE RECTUM AND CYSTOSCOPY
POSTOPERATIVE MANAGEMENT
DIFFICULTIES
KEY POINTS
CHAPTER 21:
Laparoscopic Radical Hysterectomy
INTRODUCTION
INDICATIONS
INVESTIGATIONS
Examination under Anesthesia
Preoperative Preparations
Anesthesia
Patient Position
Port Positions
Types of Radical Hysterectomy7
Procedure8
Step 1: Posterior ‘U-cut’ (Figs 21.4A and B)
Step 2: Pararectal Space Dissection and the Clipping of Uterine Arteries (Fig. 21.6)
Step 3: Anterior ‘U-cut’ (Fig. 21.7)
Step 4: The Dissection of Ureteric Tunnel (Figs 21.8A and B)
Step 5: Colpotomy (Fig. 21.9)
Ileo-obturator Lymph Node Dissection
The Specimen
Our Results
COMPLICATIONS
CONCLUSION
KEY POINTS
CHAPTER 22:
Concomitant Stress Urinary Incontinence Surgery with Laparoscopic Hysterectomy
MAGNITUDE OF THE PROBLEM
CONCOMITANT STRESS URINARY INCONTINENCE REPAIR WITH TOTAL LAPAROSCOPIC HYSTERECTOMY
Choice of Procedure
Sequence of Procedure
LAPAROSCOPIC BURCH COLPOSUSPENSION6
TENSION FREE VAGINAL TAPE
TSUIT9
TrOT/TOT/MONARC
MINIARC/MINISLINGS
COMPLICATIONS IN CONCOMITANT TOTAL LAPAROSCOPIC HYSTERECTOMY AND STRESS URINARY INCONTINENCE REPAIR SURGERIES—OUR EXPERIENCE
Laparoscopic Burch (Figs 22.1A to F)
TSUIT/TVT/Stratassis (Figs 22.2 and 22.3)
TrOT/TOT/Monarc (Figs 22.4A to F)
Miniarc (Figs 22.5A and B)
KEY POINTS
CONCLUSION
CHAPTER 23:
Laparoendoscopic Single-site Hysterectomy
INTRODUCTION
PATIENT SELECTION
PATIENT COUNSELING
PREOPERATIVE PREPARATION
ACCESS
PORT AND INSTRUMENT SELECTION
Instrument Selection
Laparoscopes
TYPES OF HYSTERECTOMY
LESS-LAVH
LESS-TLH
Steps of LESS-TLH
The Upper Pedicle (Figs 23.2 to 23.4)
Development of Bladder Flap (Figs 23.5A to E)
The Uterine Pedicles (Figs 23.6 and 23.7)
Cardinal-Uterosacral Ligament Complex
Opening of the Vault (Figs 23.8 and 23.9)
Specimen Retrieval
Vault Closure (Figs 23.10 and 23.11)
SPECIAL SITUATIONS
LESS-TLH for Previous LSCS
Bladder Dissection Technique in Cases with Previous LSCS
LESS-TLH for Large Uterus
LESS-SCH (Supracervical Hysterectomy)
COMPARISON WITH 4 PORT CONVENTIONAL TLH/LAVH
COMPLICATIONS
Complications of Laparoscopy
LEARNING CURVE
CONCLUSION
KEY POINTS
CHAPTER 24:
Robot-assisted Laparoscopic Hysterectomy
INTRODUCTION
da VINCI ROBOTIC SYSTEM
da VINCI SURGICAL SYSTEM COMPONENTS
Surgeon's Console (Fig. 24.1)
Patient-side Cart (Fig. 24.2)
EndoWrist Instruments
Vision System (Fig. 24.6)
Safety Features
Procedures
Port Placement
Steps of Robotic Hysterectomy
ROBOTIC HYSTERECTOMY— SPECIAL CONSIDERATIONS
Endometriosis (Fig. 24.27)
Multiple Fibroids and Large Uterus (Fig. 24.28)
Robotic Hysterectomy5 in Previous Surgeries (Fig. 24.29)
Postoperative Recovery
Cost
CHAPTER 25:
Day Care Total Laparoscopic Hysterectomy
INTRODUCTION
Day Care Laparoscopic Hysterectomy
PREOPERATIVE PREPARATION
THE ANESTHESIA PROTOCOL
TECHNIQUE
POSTOPERATIVE RECOVERY
DISCUSSION
SECTION 5: COMPLICATIONS OF TLH
CHAPTER 26:
General Complications of Laparoscopic Surgeries
CLASSIFICATION OF COMPLICATIONS (ORGAN SPECIFIC)
CLASSIFICATION OF COMPLICATIONS (MECHANISM)
ANESTHESIA-RELATED COMPLICATIONS
Extraperitoneal Gas Insufflations
PATIENT POSITIONING
ENTRY COMPLICATIONS: ACCESS-RELATED
Vascular Injury
Inferior Epigastric Vessel Injury
Diagnosis
Management
Intraperitoneal Vessel Injury
Great Vessel Injury
GAS EMBOLISM
BOWEL INJURY
INJURY TO THE URINARY TRACT
ELECTROSURGICAL INJURIES
Insulation Failure
Direct Coupling
Capacitive Coupling
POSTOPERATIVE SHOULDER PAIN
PORT SITE INFECTIONS
PORT SITE HERNIA
PORT SITE METASTASIS
VENOUS THROMBOSIS
PREVENTION OF COMPLICATIONS: KEY POINTS
Anesthesia
Position (Figs 26.8 and 26.9)
Thermal Injury
Access
Primary Port
Secondary Ports
Adhesiolysis
CONCLUSIONS
CHAPTER 27:
Bladder Injuries in Total Laparoscopic Hysterectomy
INTRODUCTION
ANATOMY OF THE URINARY BLADDER
ETIOLOGY
MECHANISM OF BLADDER INJURY IN HYSTERECTOMY
PREVENTION TECHNIQUES
RECOGNITION OF BLADDER INJURY
Intraoperative Signs
Postoperative Signs
SCREENING FOR BLADDER INJURY
Intraoperative Identification
Postoperative Identification
MANAGEMENT (FIGS 27.3A TO D)
POST-OPERATIVE CONSIDERATIONS
ROLE OF ROUTINE CYSTOSCOPY IN TOTAL LAPAROSCOPIC HYSTERECTOMY (TLH)
KEY POINTS
CONCLUSION
CHAPTER 28:
Ureteric Injuries in Total Laparoscopic Hysterectomy
INTRODUCTION
RISK FACTORS FOR URETERIC INJURY
SITES OF URETERAL INJURY
DIAGNOSIS
Intraoperative Diagnosis
Postoperative/Late Diagnosis
MANAGEMENT
When to Operate?
Conservative Management
Surgical Management
Repair
Ureteroureterostomy (Fig. 28.5)
Ureteroneocystostomy (Fig. 28.6)
Psoas Bladder Hitch (Figs 28.7A to D)
Boari Flap (Fig. 28.8)
Transureteroureterostomy (Fig. 28.9)
Kidney Autotransplantation
Role of Laparoscopy and Robotics
PREVENTION AND EARLY RECOGNITION OF URETERAL INJURY
Anatomy and Dissection
Prevention of Thermal Injury
Intraoperative Cystoscopy in TLH
Delphi Technique
Preoperative Ureteric Stenting
Role of Ureteroscopy
CONCLUSION
CHAPTER 29:
Bowel-related Complications of Operative Gynecological Laparoscopy
INTRODUCTION
MECHANISM (BOX 29.1)
CASE SELECTION
OPERATIVE TECHNIQUE
RECOGNITION OF BOWEL INJURY (EARLY and LATE) (BOX 29.2)
PREVENTION OF BOWEL INJURY (BOX 29.3)
MANAGEMENT OF BOWEL INJURY
Management of Small Bowel Injuries
Management of Large Bowel Injuries
DEALING WITH AFTERMATH OF BOWEL INJURY
CONCLUSION
KEY POINTS
CHAPTER 30:
Vault Complications Following Total Laparoscopic Hysterectomy
INTRODUCTION
RISK FACTORS
VAULT HEMORRHAGE
Diagnosis
Prevention
Management
VAULT HEMATOMA
Diagnosis
Management
VAULT DEHISCENCE/EVISCERATION
Diagnosis
Prevention
Management
VAULT INFECTIONS/VAULT ABSCESS
Diagnosis
Prevention
Treatment
VAULT DISCHARGE
VAULT GRANULOMA
Diagnosis
Prevention
Management
LATE COMPLICATIONS
SEXUAL DYSFUNCTION
CHAPTER 31:
Post Hysterectomy Vault Prolapse and Management
INTRODUCTION
ANATOMY
ASSESSMENT OF POST-HYSTERECTOMY PROLAPSE
PREVENTION AND MANAGEMENT OF POST HYSTERECTOMY VAULT PROLAPSE
McCall Culdoplasty
Sacrospinous Fixation
Iliococcygeal Fixation
Uterosacral Suspension
Abdominal Sacrocolpopexy
Laparoscopic Sacrocolpopexy
Robotic Assisted Sacrocolpopexy
CONCLUSION
CHAPTER 32:
Conversion of Total Laparoscopic Hysterectomy
INTRODUCTION
FACTORS FOR CONVERSION IN LAPAROSCOPIC HYSTERECTOMY
Preventive/Pre-emptive/Strategic Conversion
Reactive Conversion
Conversion to Vaginal Hysterectomy
Conversion to Laparotomy
Vascular Injuries During Entry
Uncontrolled Hemorrhage During Total Laparoscopic Hysterectomy
Dense Adhesions
To Deal with Major Complications
Bladder Injury
Bowel and Rectal Injuries
SECTION 6: FOOD FOR THOUGHT
CHAPTER 33:
Vaginal Hysterectomy in the Era of TLH—The View from the Vaginal End
CHOICE OF ROUTE OF HYSTERECTOMY: WHAT DOES EVIDENCE SAY?
THE INCIDENCE OF DIFFERENT TYPES OF HYSTERECTOMY
INDICATIONS OF VAGINAL HYSTERECTOMY
NEW AQUA DISSECTION MODIFIED TECHNIQUE FOR NONDESCENT VAGINAL HYSTERECTOMY: A STUDY OF 11,007 CASES (FROM 1997–2007)
Introduction
Aims and Objectives
Indications for Hysterectomy
Abnormal Uterine Bleeding (Dysfunctional Uterine Bleeding)
Adenomyosis
Enlarged Uterus due to Fibroids
Cervical Fibroid/Cervical Submucous Myomatous Polyp
Uterine Prolapse
Carcinoma in situ of Cervix/Cancer Cervix
Endometrial Malignancy
Postmenopausal Bleeding
Hydatidiform Mole
Nullipara
Severe Mental Handicap
History of Abdominal Surgery
Previous Vaginal Surgeries
Need for Oophorectomy
Total or Subtotal Hysterectomy
Examination Under Anesthesia
Trial Vaginal Hysterectomy
Laparoscopic Evaluation
Recommendations
Uterine Volume
Contraindications to Vaginal Hysterectomy
Modified Surgical Technique (Study)
Saline Injection (Figs 33.5A to C)
Technique of Vaginal Hysterectomy
Results
DISCUSSION
CONCLUSION
SALIENT POINTS OF THIS STUDY
CHAPTER 34:
Are All Hysterectomies Indicated?
UTERINE LEIOMYOMAS
GnRH Agonists
Mifepristone
Danazol
Mirena
Magnetic Resonance Imaging Guided Focused Ultrasound Surgery (MRgFUS)
Uterine Artery Embolization (UAE)
Laparoscopic Uterine Artery Occlusion
Myolysis
Conservative Surgical Procedures
Vaginal Polypectomy or Myomectomy
Hysteroscopic Resection
Myomectomy
Hysterectomy
ABNORMAL UTERINE BLEEDING
Nd: YAG Laser Ablation
Hysteroscopic Transcervical Resection of the Endometrium with Resectoscope (TCRE)
Hysteroscopic Ablation of Endometrium with Resectoscope (Rollerball)
Thermal Uterine Balloon Therapy System for Endometrial Ablation
ENDOMETRIOSIS
ADENOMYOSIS
UTEROVAGINAL PROLAPSE
CHRONIC PELVIC PAIN
BENIGN ADNEXAL MASS
PREINVASIVE NEOPLASTIC DISEASES
Endometrial Hyperplasia
Cervical Squamous Intraepithelial Neoplasia
Adenocarcinoma in situ
Familial Ovarian Cancer
CONCLUSION
KEY POINTS
CHAPTER 35:
Alternatives to Hysterectomy in Dysfunctional Uterine Bleeding
INTRODUCTION
DIAGNOSIS
MEDICAL MANAGEMENT
Surgical Treatments
Hysteroscopy with Dilation and Curettage (D and C)
Uterine Artery Embolization (Fig. 35.3)
Endometrial Ablation
First-generation Endometrial Ablation: Laser/Roller Ball/Transcervical Resection of Endometrium with Loop (Figs 35.4 to 35.6)
Laser (Nd:YAG laser, Goldrath in 1981)
Roller Ball (DeCherney and Polan in 1983)
Loop (Hallez in 1985)(Fig. 35.6)
Thermal Balloon Endometrial Ablation (TBEA)
Microwave Endometrial Ablation (MEA) (Microsulis Medical Limited)(Fig. 35.11)
Hydrothermal Ablation (EnAbl; HTA Boston Scientific, USA)(Figs 35.12A and B)
Cryoablation-endometrial Cryotherapy; (Her Option; Soprano)(Figs 35.13 and 35.14)
Impedance-controlled Radiofrequency Ablation (Novasure TM Hologic Inc)(Fig. 35.15)
Endometrial Laser Intrauterine Thermal Therapy (ELITT GyneLase)
3rd Generation Endometrial Ablation: In Future
KEY POINTS
SECTION 7: OUR EXPERIENCE
CHAPTER 36:
Total Laparoscopic Hysterectomy—Practical Tips
GENERAL CONSIDERATIONS
Selection of Patients
Indications for TLH
Contraindications to Laparoscopic Route
Planning for Surgery
Learning Curve
Conversion during Hysterectomy
SURGICAL PROCEDURE
Upper Pedicles
Bladder Dissection
Uterine Vessels
Opening the Vault and Intrafascial Technique
Vault Closure
TLH in Big Uterus
TLH—OUR EXPERIENCE (2004–2014)
Technique
CONCLUSION
KEY POINTS
INDEX
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