INTRODUCTION

Hysterectomy refers to the surgical procedure aimed at removing a uterus, usually because it is affected by pathology (either malignant or benign). There are two types of hysterectomy: total, which involves complete removal of the uterine organ, and subtotal, which entails removal of the uterine body only, while preserving the cervix. Currently, fewer subtotal hysterectomies are performed, as total hysterectomy is considered the standard practice. Subtotal hysterectomy tends to be reserved for cases in which removal of the cervix may pose high intraoperative morbidity risk for the patient, or for selected cases of genital prolapse that are to be treated with prosthetic surgery.^1,2 Additionally, two aspects favor removal of the cervical tissue: prophylaxis against malignant cervical cancer and the fact that removal of the cervix does not affect pelvic floor stability. In this chapter, we will address total hysterectomy.

Indications for total hysterectomy

The indications for total hysterectomy are symptomatic uterine pathology that compromises metabolic function at either the systemic or locoregional level, including both benign and malignant pathologies. In terms of the latter, this chapter primarily focuses on malignant tumors of the endometrium, cervix and uterine body at stages at which surgical treatment is indicated, as well as atypical endometrial hyperplasia and endometrial intraepithelial neoplasia. We also consider early stages of ovarian cancer in the context of abdominopelvic cytoreduction with diagnostic and therapeutic purposes.^2,3 Regarding benign pathologies, these include symptomatic uterine fibromatosis, adenomyosis and uterine prolapse. It is important to note that symptomatic uterine fibromatosis encompasses all conditions in which the presence of large uterine fibroids causes mechanical compression of nearby organs or structures, thereby compromising their regular metabolic function, or resulting in uterine bleeding that is unresponsive to pharmacological treatments and is associated with severe anemia.⁴

Techniques

There are various approaches to this type of surgical intervention. The optimal technique is not always the same, and should be chosen based on the patient’s diagnosis, the clinical conditions of the patient, and the technical skills of the surgeon. The techniques currently available for performing a total hysterectomy include the following:

• vaginal (colpohysterectomy)
• laparotomic (with a transverse suprapubic incision or longitudinal umbilical–suprapubic incision)
• laparoscopic
• combined vaginal/laparoscopic (laparoscopically assisted colpohysterectomy)
• robotically assisted laparoscopic
• vaginal laparoscopic using the v‑NOTES system.⁵

In this chapter, we focus on the laparoscopic technique for performing total hysterectomy, and highlight certain ergonomic principles that are essential for achieving high-quality surgical performance when utilizing a technology-based technique such as laparoscopy. The term ‘ergonomics’ refers to the optimal integration of human work, machinery and the work environment to maximize work efficiency.

SURGICAL PROCEDURE

The standard surgical steps for laparoscopic hysterectomy are:⁶

• positioning of the uterine manipulator
• establishment of four access ports (one optical port and three ancillary operating ports)
• sectioning of the round ligament and opening of the posterior aspect of the broad ligament bilaterally
• identification of the ureteral course
• anterior incision of the vesicouterine fold and detachment of the bladder from the cervix downwards until the anterior vaginal fornix is reached
• sectioning on each side of the infundibulopelvic ligament in the case of adnexectomy, or the tubo-ovarian ligament, the mesosalpinx and the uterine–ovarian ligament in the case of ovarian preservation
• sectioning of the medial aspect of the broad ligament until the insertion of the uterosacral ligament is reached at the level of the cervix on both sides
• posteriorly, incision of the uterosacral ligament bilaterally and opening of the rectovaginal space until the posterior vaginal fornix is reached
• laterally, sectioning the cardinal ligament with the intervening uterine vessels until the lateral vaginal fornix is reached on both sides
• circular colpotomy at the fornices
• removal of the surgical specimen via the vaginal route
• suturing of the vaginal incision, and anchoring it to the residual stumps of the uterosacral ligaments
• control of hemostasis and the integrity of the pelvic viscera
• deflation of the abdominal cavity and removal of the laparoscopic trocars
• closure of the abdominal access incisions

The technique that we describe differs from the traditional method in that we do not use a uterine manipulator and isolate the uterine artery at its origin to clamp it (Figures 1 and 2), thus reducing the risk of bleeding and allowing direct visualization of the critical structures present in the surgical field.

The rationale for not using the uterine manipulator is based on the following indications:

• economic: related to lack of availability of the instrument in centers with limited resources
• oncological: pertaining to the treatment of malignant pathology originating from the cervix
• anatomical: due to cervical anomalies that make it impossible to insert the manipulator through the cervix (severe stenosis of the external uterine os, previous cervical conization/amputation, non-habitable vagina)
• personnel shortages: associated with surgical teams in which a lack of staff does not allow for a third operator to use the uterine manipulator

SET-UP AND INSTRUMENTS

The operating room should be equipped with a single laparoscopic tower with one monitor (instead of the traditional two monitors), equipped with an insufflation system, a lighting system, and a video system with a camera; the tower should be placed at the foot of the patient so that the visual screen is easily visible to both operators, the circulating nurse and the anesthetist. The tower should also be equipped with an operating table that has an adjustable action system (automatic/manual) to allow for movement up or down or into the Trendelenburg or anti-Trendelenburg positions; it should also be fitted with adjustable leg holders suitable for positioning the patient in a lithotomy position. There should also be the option to have two platforms on which the operators can stand to be elevated above the operating table to ensure better ergonomics during the procedure.^7,8,9 The tower also requires:

• four trocars based on the type of optics used (one 10 mm and three or four 5 mm)
• a 0° 10-mm laparoscope, or, alternatively, a 5-mm laparoscope equipped with a light cable and camera
• an irrigation and suction system
• a coagulation and cutting system comprising bipolar electric energy forceps and cold-blade scissors or advanced bipolar electric energy forceps that combine coagulation and cutting in the same device
• a laparoscopic clip applicator for blood vessels
• two atraumatic fenestrated Johann forceps, one traumatic Manhès forceps, and one 25-cm Foerster ring forceps,
• a laparoscopic needle holder (Figure 3) and a long resorbable braided suture (e.g. Vicryl no. 0 CR1 with a 25-mm half-circle needle or self-locking Vicryl no. 0 with a 23-cm half-circle needle) (Figure 4).

In terms of the operating room set-up (Figure 5), the anesthetist’s workstation should be located behind the patient’s head area, the nurse’s station should be positioned along the patient’s left flank at the level of the pelvis and lower limbs, and the operating table should be positioned at the lowest possible height. The monitor is positioned to allow clear visibility for both operators, the circulating nurse, and the anesthetist. The surgical table is centrally located. The operators (surgeons) are positioned on either side of the surgical table to allow for seamless teamwork and instrument access. The nurse is stationed nearby to assist with instrument management and support as needed. The instrument table holds all necessary surgical instruments within easy reach during the procedure. The anesthetic apparatus is situated at the head of the surgical table, providing the anesthetist with direct access to the patient for anesthesia administration and monitoring. The aspiration system is located to facilitate easy access for managing fluids during surgery, and the electrosurgical unit is positioned to allow operators to access electrical surgical tools for coagulation and dissection.

This configuration emphasizes ergonomic efficiency, ease of communication among the surgical team, and streamlined access to necessary equipment and instruments.

ERGONOMIC CONSIDERATIONS

The patient should be positioned supine on the operating table, with both arms extended alongside the body and the legs separated, with the calves placed on the appropriate leg holders in the lithotomy position. The legs should also be positioned so that the level of the thighs creates a plane that is level with that of the abdomen. The cables connecting the laparoscopic tower and the irrigation and suction system should be run along the right flank and lower limb of the patient to prevent tangling in the operative field during the surgical procedure. The two operators should position themselves alongside the patient’s flanks at shoulder height, and should keep their sides free from instruments and/or anything else, to allow unrestricted movement throughout the surgical phases. The position of the operators should be elevated relative to the patient’s abdominal plane to facilitate ease and freedom of arm movement in all spatial planes through which they need to rotate (anterior, posterior, lateral, medial, superior and inferior). This movement is facilitated by having the elbow level significantly lower than that of the shoulders, which is achieved either by raising the operator and lowering the surgical table, or, if the surgical table cannot be lowered, significantly raising the operating level of the surgeon.¹⁰

TROCAR POSITIONING

Before proceeding with insertion of the trocars, it is crucial to personally check that all necessary instruments have been prepared and connected and are functional. The first trocar should never be inserted without first confirming that everything needed for performance of the surgery is connected and fully operational. For convenience, we refer to the primary operator as the one performing the operation, who is normally positioned on the patient’s left flank, and the secondary operator as the one assisting, typically positioned on the patient’s right flank. In the case of a left-handed primary operator, their positions will be reversed.

The first optical laparoscopic trocar (5 mm/10 mm) should be positioned by the primary operator above the umbilical scar along the xiphoid–umbilical line, approximately 3–4 cm above the transverse umbilical line. This trocar can be accessed directly or by guiding the laparoscopic optics inserted through the trocar’s head. The trocar should be handled by placing the upper end of its head against the hypothenar eminence of the hand, gripping the underside of the head with the index and ring fingers around the trocar’s axis, and extending the middle finger along the axis of the trocar.

The ancillary trocars (all 5 mm) should be inserted in a clockwise sequence, starting from the left trocar (relative to the patient’s abdomen), then the central trocar, and proceeding to the right. In the case of a left-handed primary operator, the direction of trocar insertion should be reversed, from right to left. The second trocar should be inserted by the primary operator in the left parailiac region along the iliac–umbilical line, approximately 4–5 cm from the iliac crest, first verifying the course of the superficial epigastric vessels via endoperitoneal visualization using the laparoscopic optics. The third trocar should be inserted by the primary operator in the suprapubic region along the midline umbilicopubic line, approximately 4–5 cm below the umbilical scar. The fourth trocar should be inserted by the secondary operator in the right parailiac region along the iliac–umbilical line, approximately 4–5 cm from the iliac crest, first verifying the course of the superficial epigastric vessels via endoperitoneal visualization using the laparoscopic optics.¹¹ It is essential to maintain an ergonomic surgical position to minimize risks associated with laparoscopic access; therefore, the trocar should always be inserted by the operator on the side of the selected hemi-abdomen for entry. The exception is the central optical trocar, which should always be inserted by the primary operator at the start of the procedure.

SURGICAL STEPS

To make all steps of the surgical process clearer, we divide the surgical process into seven phases related to the anatomical regions, and also divide them by side when the anatomy is equal and symmetrical. Before initiating the surgical phases of the procedure, it is essential to perform an exploration of the upper and lower abdomen to verify the integrity of structures and organs.

1st phase: Approach to the retroperitoneal region of the iliac fossae

On the left side, the primary operator, inserting the operating instrument through the central suprapubic trocar and using an atraumatic Johann forceps inserted through the left parailiac trocar, grasps the lateral extremity of the round ligament laterally, while the secondary operator, inserting a second Johann forceps through the right parailiac trocar, grasps the left round ligament at its insertion on the uterine angle, pulling it medially, upwards and laterally deviating to the right to render the uterine body anteverted and laterally deviated to the right. The primary operator coagulates and resect the left round ligament at its lateral third. After this resection, the secondary operator shifts their hold from the uterine angle to the medial stump of the round ligament that has been formed. Subsequently, the primary operator coagulates and resect the lateral aspect of the left broad ligament in a caudocranial direction along a line connecting the resection point of the round ligament to the posterior angle, determined by the intersection of the iliopsoas muscle with the ovarian vessels of the infundibulopelvic ligament. This line of resection represents the bisector of the anatomical triangle with the vertex directed downwards, defined by the round ligament above (base), by the iliopsoas muscle laterally (first side) and by the infundibulopelvic ligament with the associated uterus medially (second side) (Figure 6).

After opening the broad ligament, the primary operator shifts their left forceps to the posterior apex of the resected peritoneum, exerting gentle longitudinal caudocranial traction on it. The secondary operator maintains their hold on the stump of the round ligament. The primary operator utilizes their central operating forceps to perform a dissection of the loose connective tissue at the junction between the iliopsoas muscle and the infundibulopelvic ligament until the ureteric course can be identified, following the utereric course with longitudinal craniocaudal movement until it crosses the uterine artery. Once the uterine artery is identified, it is isolated from its origin in the internal iliac artery, where it is hemostatically secured using endoclips introduced by the primary operator through the central suprapubic trocar, replacing the operational instrument. The endoclip should be applied as close as possible to the emergence of the uterine artery from the internal iliac artery to maintain distance from the ureteric course.

On the right side, the same steps are performed contralaterally, but, in this case, the use of atraumatic Johann forceps should be reversed, being inserted into the right and left parailiac access points by the two operators, while the primary operator continues to use the operational instrument and the endoclip-positioning forceps from the central suprapubic access. For clarity, the hold on the round ligament is maintained by the primary operator from the left parailiac access, while the posterior caudocranial traction on the resected peritoneum of the broad ligament is performed by the secondary operator from the right parailiac access.

2nd phase: Approach to the uterine adnexal regions

On the left side, in the case of adnexectomy, the primary operator lifts the ipsilateral adnexa, grasping it using the atraumatic Johann forceps introduced through the left parailiac ancillary trocar at the angle formed between the infundibulopelvic ligament and the ovarian pole. Meanwhile, the secondary operator lifts the uterus in an anteverted and laterally deviated direction to the right, grasping it at the round ligament at its origin from the uterine angle. The primary operator then uses the operational instrument introduced through the central suprapubic trocar to coagulate and suture the infundibulopelvic ligament and subsequently the medial aspect of the broad ligament longitudinally from cranial to caudal until the insertion of the ipsilateral uterosacral ligament on the posterior uterine isthmus is reached in a straight line.

On the left side, in the case of ovarian preservation, the two operators perform the steps in the same manner and using the same instruments introduced through the same access routes as indicated for adnexectomy. However, in this case, the primary operator grasps the ipsilateral Fallopian tube at the angle formed between the tubo-ovarian ligament and the tubal fimbria, coagulating and suturing the tubo-ovarian ligament, mesosalpinx and utero-ovarian ligament before moving downwards towards the insertion of the ipsilateral uterosacral ligament, resecting the medial aspect of the visceral uterine peritoneum.

On the right side, in the case of adnexectomy, the secondary operator lifts the ipsilateral adnexa, grasping it using the atraumatic Johann forceps introduced through the right parailiac ancillary trocar at the angle formed between the infundibulopelvic ligament and the ovarian pole, while the primary operator lifts the uterus in an anteverted and laterally deviated direction to the left, grasping it from the round ligament at its origin from the uterine angle. The primary operator, using the operational instrument introduced through the central suprapubic trocar, coagulates and sutures the infundibulopelvic ligament and subsequently the medial aspect of the broad ligament longitudinally from cranial to caudal until the insertion of the ipsilateral uterosacral ligament on the posterior uterine isthmus is reached in a straight line.

On the right side, in the case of ovarian preservation, the two operators perform the steps in the same manner and using the same instruments introduced through the same access routes as indicated for adnexectomy. However, in this case, the secondary operator grasps and lifts the ipsilateral Fallopian tube at the angle formed between the tubo-ovarian ligament and the tubal fimbria, while the primary operator coagulates and sutures the tubo-ovarian ligament, mesosalpinx and utero-ovarian ligament before moving down towards the insertion of the ipsilateral uterosacral ligament, resecting the medial aspect of the visceral uterine peritoneum.¹²

3rd phase: Approach to and development of the posterior uterine pelvic compartment

On the left side, the secondary operator lifts the uterus in an anteverted and median direction by grasping it at the insertion of the left round ligament using the atraumatic Johann forceps introduced through the right parailiac trocar, and applies gentle traction upwards to properly distend the uterosacral ligaments. Meanwhile, the primary operator, using atraumatic Johann forceps introduced through the left parailiac trocar, grasps the visceral peritoneum at the insertion of the uterosacral ligament, pulling it longitudinally and caudocranially to extend and displace the ligament from its position and subjects it to coagulation and suturing using the operational instrument introduced through the central suprapubic trocar. Subsequently, the ipsilateral cervico–vaginal–rectal anatomical hemispace is developed craniocaudally and lateromedially until the plane between the posterior vaginal fornix is reached.

On the right side, the secondary operator lifts the uterus in an anteverted and median direction by grasping it at the insertion of the right round ligament using the atraumatic Johann forceps introduced through the right parailiac trocar, and applies gentle traction upwards to properly distend the right uterosacral ligament, which remains intact while expanding the previously developed left cervico–vaginal–rectal hemispace. Meanwhile, the primary operator, using atraumatic Johann forceps introduced through the left parailiac trocar, grasps the visceral peritoneum at the insertion of the right uterosacral ligament, pulling it longitudinally caudocranial to extend and dislocate the ligament from its position, and subjects it to coagulation and suturing using the operational instrument introduced through the central suprapubic trocar. Subsequently, the ipsilateral cervico–vaginal–rectal anatomical hemispace is developed craniocaudally and lateromedially until the plane passing through the posterior vaginal fornix is reached, thereby completing development of the anatomical area corresponding to the posterior uterine compartment.

4th phase: Approach to and development of the anterior uterine pelvic compartment

On the left side, the primary operator lifts and pulls the uterus longitudinally in the caudocranial direction with a slight lateral deviation to the right, holding it using the atraumatic Johann forceps at the insertion of the left round ligament from the uterine angle, after introducing the forceps through the left parailiac trocar. Simultaneously, using the operational instrument introduced through the central suprapubic trocar, access is gained to the vesicouterine space via the loose connective tissue present above the course of the cervical branches of the left uterine vessels at the junction between the cervix and uterine isthmus. Once that space is identified, it should be opened bluntly, and a first movement of the forceps should be made longitudinally in the craniocaudal direction until the level of the anterior vaginal fornix is reached, and subsequently, from that position, a second movement of the forceps should be executed to develop the ipsilateral retroperitoneal vesicouterine hemispace. During this surgical period, the secondary operator should frame the surgical field by placing the camera above the left forceps of the primary operator.

On the right side, the primary operator similarly lifts and pulls the uterus longitudinally in the caudocranial direction with a slight lateral deviation to the left, grasping it using the atraumatic Johann forceps at the insertion of the right round ligament from the uterine angle, after introducing the forceps through the left parailiac trocar. Simultaneously, using the operational instrument introduced through the central suprapubic trocar, access is gained to the vesicouterine space via the loose connective tissue present above the course of the cervical branches of the right uterine vessels at the junction between the cervix and the uterine isthmus. Once that space is identified, it should be opened bluntly, and a first movement should be performed longitudinally in the caudocranial direction until the level of the anterior vaginal fornix is reached. Subsequently, a second movement should be carried out to lateromedially shift the forceps to also develop the right retroperitoneal vesicouterine hemispace. At this point, the entire retroperitoneal vesicouterine space will be fully developed. Resection of the vesicouterine peritoneum is then performed transversely above the previously developed retroperitoneal space. The secondary operator then uses the atraumatic Johann forceps introduced through the right parailiac trocar to secure the mid-third margin of the resected vesicouterine peritoneum and lifts it upwards. During this surgical phase, the secondary operator should also frame the surgical field by placing the camera above the left forceps of the primary operator.

At this point, while the secondary operator maintains the lifted prevesical peritoneum in its lifted position, the primary operator, using the forceps introduced through the central trocar, proceeds to dissect the bladder from the cervix using blunt dissection, sliding the back of the forceps along the cervical course, thereby lowering and dissecting the bladder down from its mid-third and through the two lateral thirds until the level of the anterior vaginal fornix is reached.

5th phase: Approach to the uterine vascular pedicles

On the left side, while the secondary operator maintains upwards traction on the prevesical peritoneum, the primary operator retracts and anteverts the uterus while laterally deviating it to the right, holding it using the atraumatic Johann forceps at the insertion of the right round ligament from the uterine angle, introducing the forceps through the left parailiac trocar. At the same time, using the operational instrument introduced via the central suprapubic trocar, a first coagulation is performed upstream at the uterine isthmus on the cervical branches of the uterine vessels to prevent retrograde bleeding, subsequently coagulating and resecting the cardinal ligament with the interposed uterine vessels in multiple steps, following the lateral margin of the ipsilateral uterus, gradually moving downwards until the level of the left lateral vaginal fornix is reached.

On the right side, while the secondary operator continues to maintain upwards traction on the prevesical peritoneum, the primary operator retracts and anteverts the uterus while laterally deviating it to the left, holding it using the atraumatic Johann forceps at the insertion of the left round ligament from the uterine angle, introducing the forceps through the left parailiac trocar. Simultaneously, using the operational instrument introduced via the central suprapubic trocar, a first coagulation is performed upstream at the uterine isthmus on the cervical branches of the uterine vessels to prevent retrograde bleeding, subsequently coagulating and resecting the cardinal ligament with the interposed uterine vessels in multiple steps, following the lateral margin of the ipsilateral uterus, gradually moving downwards until the level of the right lateral vaginal fornix is reached.

6th phase: Colpotomy and removal of the surgical specimen

While the secondary operator maintains upwards traction on the prevesical peritoneum, the primary operator grasps the uterus at the level of the peritoneum remaining from the previous resection at the anterior uterine isthmus mid-third using atraumatic forceps introduced through the left parailiac trocar. The primary operator exerts longitudinal caudocranial traction on the uterus to completely distend the anterior vaginal fornix (Figure 7).

At this point, 25-cm Foerster ring forceps are introduced vaginally, sliding them along the mid-third of the anterior vaginal wall until the hollow represented by the anterior vaginal fornix is reached. While maintaining pressure on the forceps, the instrument is directed upwards at an angle of approximately 45°, and spread apart by a couple of cm to create a tent effect at the mid-third of the anterior vaginal fornix on the endoabdominal side. The primary operator, using cold-blade scissors introduced through the central suprapubic trocar, makes an incision in the vaginal wall at this level until the vaginal cavity is reached (Figure 8).

The secondary operator releases their hold on the prevesical peritoneum and grasps the anterior vaginal flap of the breach that has been created, while the ring forceps are withdrawn from the vagina, and a glove is introduced into the vaginal cavity for pneumostatic purposes. The primary operator replaces the atraumatic forceps from the left trocar with traumatic Manhès forceps, and grasps the anterior lip of the cervix longitudinally pulling it in a caudocranial direction while replacing the cold-blade scissors with the operational instrument in the central suprapubic trocar, executing a circular colpotomy along the entire course of the previously isolated vaginal fornices in the various described surgical phases. During this time, the two lateral portions of the vaginal fornices are brought together by shifting the uterine body contralaterally from the side to be resected, while the secondary operator relocates the camera by passing it under the plane created by the forceps used by the primary operator and introduced through the left parailiac trocar. This shift should be performed using the central operational instrument without changing the hold and traction on the anterior lip of the cervix maintained using the Manhès forceps introduced through the left parailiac trocar.

Once the colpotomy is complete, the uterus is removed from the pelvic cavity through the vagina. If available, it is advisable to use a laparoscopic bag of 15 mm introduced into the pelvic cavity via the vaginal route for this purpose.

7th phase: Vaginal suture with colpoplasty

Colporrhaphy is performed with a continuous longitudinal posteroanterior suture using a self-locking Vicryl no. 0 suture with a length not exceeding 25 cm. The primary operator introduces the needle holder through the central trocar, and the counter needle holder from the left parailiac trocar. The secondary operator grasps the anterior vaginal apex using atraumatic Johann forceps introduced through the right parailiac trocar and pulls it upwards, using cold scissors to make a vaginal incision comprising two parallel cuts that represent the two edges to be sutured (Figure 9a).

The suture should start from the bottom, and the first stitch should encompass, in a single needle rotation, the stump of the right uterosacral ligament, the right margin of the posterior vaginal apex, the left margin of the posterior vaginal apex, and the stump of the left uterosacral ligament. At the end of the needle rotation, the suture thread should be secured endoperitoneally (or tied if a self-locking suture is not available) beneath the region of the mid-third posterior vaginal fornix to restore the medial connection of the uterine ligaments and recreate the support pillar of the pelvic floor.

The suture should then proceed continuously upwards until the anterior apex of the vagina is reached (Figure 9b). The distance between each stitch should be kept constant at approximately 5 mm, ensuring that only the area represented by the groove formed by the vaginal fornices is transfixed laterally, without affecting the surrounding parametrial tissue, to avoid possible direct or indirect injuries to the ureters and bladder.

PRACTICE RECOMMENDATIONS