Podcast Transcript: Laparoscopic Hysterectomy Tips & Tricks

[Dr. Amy Park]
Walk me through, what's your usual steps, because I assume you have the same steps over and over again? I know when I was training, it was like, restore normal anatomy. Take these pedicles first, and do it the same way every time. What are your steps every time?

[Dr. Mark Hoffman]
Typically, assume we can see the uterus and if there's bowel and things like that like you said, restore normal anatomy. If they have anterior adhesions, C-section scar stuff, I save that for last, because in some ways it holds it up. I think a lot of times you start digging in there and it's bleeding, you can't see very well. Getting your blood supply number one is important to do early. Start with the fallopian tubes, now that we know these tubes need to come out, I get the tubes out of the way. I know a lot of people just leave them.

If you're doing a HYST without BSO, I think if you wait, get your tubes till later, there's an opportunity to forget. If you take the fallopian tubes from distal to proximal and on the mesencephalics and let them dangle in the way, and just take them with uterus, it's going to be in your way. I always take the fallopian tubes first, just as if you're doing a self-injecting sterilization, and do that first.

[Dr. Amy Park]
Are you using Ligature, or what's your bipolar?

[Dr. Mark Hoffman]
Ligature, that's what we have, Ligature, yes. I can never get on the harmonic train. I want to know that I've sealed my vessels before I transect them.

[Dr. Amy Park]
Which one do you use, the Maryland-tip or the blunt-tip?

[Dr. Mark Hoffman]
I do, yes, Maryland-tip.

[Dr. Amy Park]
Maryland tip, okay.

[Dr. Mark Hoffman]
I like the blunt-tip, it was fine. I didn't notice a huge difference.

[Dr. Amy Park]
For me, the ergonomics is more difficult with the Maryland, because you have to really have your hands wide in order to close it.

[Dr. Mark Hoffman]
Right, and I think there's two steps with the blunt. You clip it, and then you hit the button, and then you do this, versus it's a lot faster. I have larger hands, so ergonomically, it's fine. It was designed, fortunately for me, for hands like mine, but I can just zip, zip, zip right along because it's all fluid motion like that. The Maryland-tip, depending on the size. If it's a normal-sized uterus, I typically get my uterovarians first. Actually, I think it's a little easier to have the contralateral person take the uterovarians, so the person on the patient's right to get the left uterovarians, just an easy angle and very natural.

Seal three wide pedicles or three wide bites, and then go right in the middle, so you've got a bit of a pedicle on each side, and then sort of carry it along the round ligament, like the round ligament is a clothesline. You're just sealing along to about the midpoint of the round ligament, and that'll lateralize those ovaries and get them out of your way. It's that triangle of the infundibular pelvic to the uterovarian to the round, and the external iliac is that triangle, and there's pretty safe. Once you get your uterovarians, you can just pretty easily scoot along under the round to drop your ovaries laterally.

For larger pathology, where you can't get that angle and come across the uterus and get your uterovarians, starting with the rounds, either way is fine. I also have the resident's practice starting with the round, because they're going to be operating potentially independently in private practice, and they won't have the same level of assistance. The alternative is to start with the rounds, open up a window through the broad, and then take your uterovarians on your side from lateral to medial across in the same way, and that still drops the ovaries out. Then get the rounds. If you have significant anterior pathology, I'll just wait on getting my anterior broad, I'll just go posteriorly.

That's another important step that I think can really save your blood loss and keep you out of trouble. Carrying that posterior peritoneum down to the level of the co-ring posteriorly, and then finding your uterines, skeletonizing them posteriorly, and forget what's happening anteriorly. You can see your uterines, you can just bluntly, just anterior, just open up the space, just put your instrument in, open up the tips, just slowly open it up. Almost every time, you can find that white pubocervical fascia that's being pushed up by the co-cup, with having done zero anterior dissection on the bladder or the anterior leaf of the broad, and push that bladder up and out. Because in any C-section, ideally you're not putting any stitches through the uterines, you're somewhere medial to that. There should be a space, even if it's small, to where you can push that bladder anteriorly, get your uterines, and now we've gotten our entire blood supply, and we haven't even done the anterior broad, we haven't even started with the bladder.

[Dr. Amy Park]
Question. I agree about skeletonizing the posterior peritoneum, I think it's a nice trick. Do you look for the ureter while you're doing that? It usually drops it down when you pull down that peritoneum, but do you specifically take a look while you're doing that, or you just know where it is?

[Dr. Mark Hoffman]
I always look initially, they're always just so far lateral from unless we're doing a USO or BSO, I want to see that in the sidewall when I'm taking my IP, obviously. If I've got my ovary out and I've got my round, I'll want to peek at it, but unless there's disease, like endo and things like that, it's going to be way away. If I've got the manipulator pushed way up, and--

[Dr. Amy Park]
I agree about the pushing it up and so that the cup is just pushing the ureters down.

[Dr. Mark Hoffman]
I'm always looking for this, I call it my golden view, my critical view. It's like, you've been to London where they have like the subway signs, it's the red circle with like the blue little rectangle with the station name in it. That to me is the view. I want to see the anterior cup, I want to see the posterior cup, I want to see the ring and I want to see the vessels on either side. If I've got that ring, it's like, okay, I'm good. I now feel like I've got everything I need to see. I don't care how big the uterus is, I don't care what pathology I've got. When I get that view, it's just like, okay, we know where we are, we know where our vessels are, we know our uterines are lateral. If I've got the cup pushed up enough, I can take my vessels medial to the cup. You never need to be lateral to the cup, that's sort of your lateral margin for operating. I think you get into trouble when you start chasing, when things are being pushed up and elevated way up at the cup, everything else that you want to stay away from should be low and lateral.

If you don't have a good assistant and you're not having them really push up, you're sort of pushing everything in and down and you're putting your instruments towards those things you want to avoid, like the uterus. I think really elevating the vaginal cuff, the cervicovaginal junction, you want that up and elevated as much as possible, and I think that's going to be one of the things you'll really get in trouble.

[Dr. Amy Park]
So meaning cephalad and flexed.

[Dr. Mark Hoffman]
Correct. Away from them--

[Dr. Amy Park]
Antiflex.

[Dr. Mark Hoffman]
Towards me. If I'm operating on my side, I'll say, point the uterus at my assistant and like you want to stab them with the uterus. Then I'll say, okay, now stab me with the uterus and my resident can work on the left side. That allows them to understand, and sometimes, like I said, well, I'll put my hand on there on the manipulator and say, okay, you can feel how hard I'm pushing up here. We don't want to traumatize anybody, but you can push up pretty hard and by pushing up hard, it really allows us, not necessarily to keep everything bad away, but it allows us to see our anatomy on tension to help differentiate where we want to be and where we don't want to be.

[Dr. Amy Park]
Where do you take the uterines?

[Dr. Mark Hoffman]
Just at the level of the Koh cup.

[Dr. Amy Park]
That corresponds to internal os basically, right?

[Dr. Mark Hoffman]
Yes. I know that if the uterines are coming up over the rim of the Koh, that cup is the cervical vaginal junction, so I'm taking them at that level and I'm using the Koh cup as my sort of lateral border. I'm not going out lateral if I can help it. The number of times I've had to open the pelvic sidewall and get the uterine at the origin, I can count on one hand where I felt like I had to do that. It's just something even in the biggest pathology, once you get down to the cervix, I feel like I can see the uterines, it's fine.

[Dr. Amy Park]
When you take the uterines, do you go at a right angle once you skeletonize the uterines, and then do you transect it like perpendicular and then make that into a pedicle, like make it--

[Dr. Mark Hoffman]
Yes, sort of. I'll come because where our ports are coming in from lateral, that's your first bite. I just sort of work my way in more medially, and then I'll actually rotate if it's the Maryland tip because it's a bit of an angle, that'll be more of a vertical bite. Then I'll take it. You don't want to take it too medially because then you get the bleeding from the uterus. You want to give yourself a wide enough pedicle.

Sometimes, once I've got control of the blood supply and it's sealed and I cut it and there's still that part of the uterine that's like right on the Koh cup and I can't quite get to it. Again, that's a great angle to come from the opposite side, from the contralateral side. If my resident on the left side has gotten most of the uterine, but there's still a little bit of that base of it right on the Koh cup I can come from my side and I've got a much better angle to undermine it. That lateralizes the vessel just off the Koh and they can do the same thing from my side.

[Dr. Amy Park]
You go to vertical, like--

[Dr. Mark Hoffman]
I almost come underneath it. If the ring is like--

[Dr. Amy Park]
Parallel to the cup.

[Dr. Mark Hoffman]
Right.

[Dr. Amy Park]
You make that perpendicular for the uterine and then you go vertical just to like skeletonize that.

[Dr. Mark Hoffman]
Just to lateralize it, just to make sure I get every little bit of it. Yes. Because it'll retract and that's why you want to get it more medially. When it retracts, if there's a little oozing, I've got a pedicle that I can grab and seal without digging laterally. I've got a vessel, I've identified it, there's still normal anatomy lateral to that I can then pick up and seal. I'm staying out of that area because I know the uterine is coming in underneath that somewhere. I want to know that whatever I'm sealing is going to be right where I want to be.

[Dr. Amy Park]
Then tell me about the anterior leaf.

[Dr. Mark Hoffman]
Normally, again, it's just using, as Dr. Lengyel, who is the chair now at Chicago's [unintelligible 00:44:16], "Use what God has given you." I think Ted Lee calls it tissue interrogation, and like you're just pushing in different areas and opening and seeing what gives and what opens. If they haven't had a C-section anteriorly for the broad, you can just go in bluntly with your ligature and open the whole space up.

If they've had prior C-section and there's a lot of anterior adhesive disease, I think again, leaving that anterior scar tissue for last, most of the time, you can get using the Koh cup, that ridge, you can identify the bladder and push it down and almost tunnel across over the Koh and like all the way to the other side and push the bladder down. Then you can sort of address those anterior adhesions last. Sometimes it's just concrete and you've got to get your monopolar scissors and just shave away at it.

For the most part, the bladder is lower than most of the adhesions most of the time. If you're ever not sure, back to the setup, retrograde fill your bladder. If you're not sure where the bladder is, if you can't really see, in almost every instance, coming in more laterals than you think, where the tissue is abnormal with the adhesive disease and scarring is the hardest time to figure out where you are or the toughest place to figure out where you are. Start where the anatomy is normal, laterally. Identify your bladder laterally, push your way up, if you can't really tell what's what, retrograde fill it with some saline, and then you can really push it off, worrying about the abnormal anatomy last once you've sort of figured out where everything else is.

[Dr. Amy Park]
Do you take down the anterior leaf with the ligature or do you use the cautery or do you use--

[Dr. Mark Hoffman]
Ligature. I use ligature for basically everything with the exception of, unless there's bladder, like it's just the last little bit is just a big fat band of scar tissue and it's probably not bladder, but if I get in, I want to do it cold, I'll just get cold scissors and sometimes use monopolar. I know a lot of places do a lot more monopolar scissors, like Bovie stuff, but I don't use it for the bladder. I'd rather get a bladder injury with a monopolar scissors than a ligature for sure. Also, bladder injuries are just so rare. It's usually pretty easy to figure out where the bladder is.

[Dr. Amy Park]
That's a question because I have heard of several cases of delayed cautery injury to the ureters or to the bladder from using the ligature and--

[Dr. Mark Hoffman]
Where's the ureteral injury occurring? Is it at the cervicovaginal junction? Is it at the uterovarian or rather IP, I mean?

[Dr. Amy Park]
Yes, I don't really remember, but the thought was that it was from the burning part. I use blunt, so the blunt ligature, so I'll just cut down or I'll use a monopolar cautery to sharp.

[Dr. Mark Hoffman]
Again, I think giving yourself bigger margins. Again, when I've got my uterines, like I'm on that Koh, I'm pushing all that other stuff anteriorly. When I see my uterines, like there is nothing else in my bite but uterine arteries when I can help it. Clearly, there's some times with endo, it's just the anatomy is not the same. When I've given talks on this, when I've given lectures on TLH and stuff, like showing that critical view where I've just, that bladder is off, that posterior leaf of the posterior part of the Koh is like naked. It's just white pubocervical fascia. It's just uterines in my bite if I can help it, and it's above the Koh, so there shouldn't be anything in that bite but vessel.

Clearly, there's always a risk of injury with surgery, and doesn't always mean it's bad technique, but that's, I think, really just getting things as clean as you can before you take that bite.

[Dr. Amy Park]
I agree about going lateral to medial though, and there's like a million AAGL videos about the lateral approach to the difficult anterior dissection. Then I agree, sharp, if you can help it. The other thing I do, on a sacral colpopexy, sometimes I'll just use, well, a lot of times I'll just use the manipulator, like the Deaver for the posterior wall, and then an anterior wall, use a malleable just to spread out the anterior.

[Dr. Mark Hoffman]
You guys dissect so much more too. I think one of the things is like--

[Dr. Amy Park]
We dissect a lot.

[Dr. Mark Hoffman]
Because I operate with urogynecologists, I watch them do a few typical pexies, and you go, okay, so whatever I think I'm pushing the bladder off and clearing it off the anterior vaginal wall, you can go about five times further than we're going. Obviously, you don't need to do that for a traditional TLH, give yourself a good bite to the closure, which is the other thing.

[Dr. Amy Park]
I agree. Because you know what, I've seen a couple of fistulas from not taking the bladder far enough down, and then they incorporate the bladder into the Vicryl sutures for the cuff, and it's easy to do from the--

[Dr. Mark Hoffman]
Not recommended.

[Dr. Amy Park]
Yes. Do not recommend. That is something to avoid easily if you just give yourself a margin and just go down a couple of centimeters. Yes. Obviously, you have to use your landmarks with the Koh and everything. How do you know how far down to take the bladder, just going past the cup or how do you figure that out?

[Dr. Mark Hoffman]
I think it's always going to be when it's on tension, it's going to look like you've got more vagina to sew than when you're done. Usually, a couple of centimeters at least, because it's going to end up being about half that I think once the uterus is off. Colpotomy, I always just use monopolar cutting. We use a hook. I think it's a small instrument. I think the scissor is fine. It's just more active energy source out there in the world. The hook is a very small little instrument, small little tip that I can feel more confident. I personally, I control the pedal. I let the residents do the colpotomy cup, but I'll control the pedal cutting and then just make it around. Then if you can pull pathology out, great. If not, we can morcellate in a bag vaginally, or if we have to through a fan steel.

[Dr. Amy Park]
How do where to make colpotomy?

[Dr. Mark Hoffman]
It's just right on that ridge. Again, having that critical view, having that ring right on that, you can sort of see in the VCare, there's a little divot, like a little ridge, I think not like the Koh cups and things like that, it's more like a corner, but pretty close to the cervix is we would only [unintelligible 00:49:59] as much vagina as possible. Once you see green on the VCare, that's like we're home. Once I see that green plastic, we can chill out because we know we're there. Start anteriorly, work my way posteriorly, and do the same on the other side. Then just cuff closure after that.