Proper case selection is necessary. When starting to perform this technique it is best to select simple cases first. A good case to start is a small uterus with no previous surgery.
No special diet is necessary The patient is ask to dissolve 2 bottles of Fleet Phosphosoda and drink it about 8 hours before surgery
Position of Patient
Patient is placed in a low modified lithotomy position on stirrups. Yellow Fin stirrups are good because the position of the leg can be adjusted during surgery. In single incision surgery, the surgeon (right handed) will be standing on the left of the patient holding 2 instruments close to the laparoscope at the umbilicus (see Figure 13). This may be tiring. So tilting the patient slightly to the left (towards the surgeon) can reduce stress on the back of the surgeon.
- One 10 mm trocar (Choose a trocar that does not have a large “head”)
- Two 5 mm trocars
- 2 rubber bands
- 1 30 degrees 10mm laparoscope
- 1 right angle connector (Figure 1)
- 1 vessel sealer which can coagulate and cut (eg Ligasure, Enseal, Bicision, Harmonics)
- 1 bipolar forceps (Choose a bipolar which has the cable parallel to the shaft)
- Monopolar hook
- Uterine manipulator
- Needle holders
- Graspers (1 Maryland grasper for suturing)
- Myoma screw
Uterine manipulator used will depend on the surgery performed. For single incision total laparoscopic hysterectomy, a RUMI with a KOH cup and occluder is ideal.
Skin Preparation and Port placement
- Make a mark using a sterile ruler, 2.5mm across the umbilicus. (Fig 3)
- Make a midline incision connecting these 2 marks (Do not go beyond this marks). (Fig 4)
- Detach the skin of the umbilicus from its attachment in the midline. Be careful not to enter into the peritoneal cavity. (Fig. 5)
- Create a space of about 1.5 cm under the skin and above the rectus sheath all around the incision. (Fig 6)
- Use a Verres needle to insufflate the abdomen in the centre of the incision. (Fig 7)
- Take a 10 mm trocar and tie 2 rubber bands about 1.5 cm from the tip. This is to prevent it from slipping into the abdomen during surgery. Insert the trocar into the abdomen in the usual way. (Fig 8)
- If you have accidentally made a large opening in the rectus sheath, enter the 10 mm trocar directly into the abdomen and place a purse string around it to prevent leakage of gas. (Fig 9)
- Place the laparoscope with the right angle light connector attached and visualize the abdomen and pelvis for adhesions.
- Place the 5mm trocar on the right side as laterally as possible stretching the skin.
- Choose a 5mm trocar with an extension for gas input. (Fig 10)
- Place a grasper to see that the trocar is well placed in the abdomen.
- Remove the grasper.
- Place the second 5mm trocar on the left side as laterally a possible stretching the skin and then place a grasper to ensure that it is properly placed. (Fig 11)
- You are now ready to perform the surgery
STEPS OR PERFORMING SINGLE INCISION LAPAROSCOPIC HYSTERECTOMY
- Inspect the pelvis for suitability to perform the hysterectomy by single incision.
- Place a vessel sealing instrument in the right port and a grasper in the left port.
- Begin by coagulating and cutting the right tube and right ovarian ligament. (even when you plan to do a salpingoophrectomy, leave the ovaries and tubes in the pelvis first and come back and remove them after the hysterectomy. In this way the presence of the tubes and ovaries attached to the uterus will not obstruct your view when dealing with the ascending branches of the uterine arteries.) ( Fig. 13 – 15)
- Coagulate and cut the broad ligament until the uterine vessels is reached.
- Release the peritoneum overlying the bladder and cut it and separated the bladder from the cervix. (Fig 16 – 17)
- Coagulate and cut the left ovarian ligament and tube. Usually it is possible to do it with the vessel sealant in your right hand. This will involve crossing your instruments. If this is awkward, change so that the vessel sealant is in your left hand and the grasper is in your right hand (Fig 18 -19).
- Once both uterine vessels are seen, bring a needle into the abdomen through the skin. (Use a large needle so that it is easy to pass through the skin) (Fig 20)
- With the needle holder in the right hand, suture the left uterine artery first. Then use the Maryland grasper in your right hand for it makes tying the knot easier. Use the cinch knot. (Fig 21 -22)
- Suture the right uterine artery next. It is preferable to suture both the uterine arteries from top to the bottom so for the left uterine artery, hold the needle holder with your left hand in the left port.
- After suturing both the uterine arteries, the needle can be hooked on the anterior abdominal wall and removed from the vagina later or brought out through the skin. (Fig 23)
- Coagulate and cut the uterine arteries and the cardinal ligaments. One can use the vessel sealant or just a normal bipolar followed by the scissors (Fig 24 -25)
- Use a monopolar hook to cut on the on the Koh cup and make a circumferential incision to detach the uterus from the vagina. Use the 30 degrees lens to look at the various angles when performing this. To do the posterior part one can rotate the laparoscope 180 degrees (Fig 26 – 27)
- Remove the uterus from the vagina.
- Remove the tubes or the ovaries at this juncture (Fig 28)
- Bring a needle through the vagina using a vaginal tube.
- If the bladder is obstructing the view of the vault, bring in unabsorbable suture on the straight needle through the skin the hitch up the peritoneum of the bladder.
- Suture the angles of the vaginal vault (Fig. 29 -30)
- Place two more interrupted sutures in the middle to close the vault. (Fig 31 -32)
- Inspect the vault for bleeding and attain haemostasis.
- Remove the 2, 5 mm trocars, then release the carbon dioxide and remove the 10mm trocar.
Reconstruction of the umbilicus.
- Suture the 10mm port opening carefully using a 1 PDS suture (Fig. 33).
- Using a 3-0 PDS suture, reattach the skin to the rectus sheath in the midline. This is crucial for a good cosmetic result. (Fig 34 – 35)
- Close the midline incision using interrupted suture. 5-0 quick absorbing sutures (eg: RapidVicryl or SafilQuick) should be used (Fig 36 -37)
- Close the wound with a small gauze and a waterproof dressing (Fig 38 -39)
- Use a syringe is to create a vacuum in the dressing so that pressure is applied to the wound (Fig 40)
There is no need for Foley’s catheter post operation unless there is excessive bladder dissection.
Clear fluids an be given after 6 hours and nourishing fluid and soft diet can be commenced after the patient has passed flatus. She could be discharged 24 hours to 48 hours later.
Other procedures that can be performed by this technique
Choose cases with an single anterior subserous fibroid, for suturing of the wound is easier. Use a midline incision on the fibroid for due to the location of the needle holder at the umbilicus , suturing will be easier. The fibroid can be removed via a colpotomy or by converting to a 5 mm laparoscope and morcellating from the umbilicus.
Laparoscopic salpingoophrectomy or salpingectomy
This can easily be performed using this technique. The difficulty will be placing the cyst in a bag. A bag can be passed into the abdomen from the 10 mm port and 2 graspers can be used to open up the bag to place the cyst/tube in the bag. This can sometimes be technically difficult. One can use fluid to open up the bag and then place the cyst in the bag.
Tips and tricks in performing single incision laparoscopic surgery in gynaecology using common laparoscopic instruments
- If you are unsure whether you can perform SILS surgery, make a small incision in the umbilicus, insufflate with Verres needle and use a 5mm scope to look into the abdomen first and then decide whether the case is suitable for single incision surgery.
- If there is a worry of umbilical adhesions, Verres needle can be placed at the Palmar point and a needle scope can be inserted from here to view the umbilicus before deciding on single incision surgery. Choose 10 mm and 5 mm trocars with a small “head”.
- Choose hand instruments with no side projections (eg. diathermy attachments) Cable should come parallel to the hand instruments.
- Use instruments with multifunction to reduce operating time.
- Long bariatic instruments especially needle holder can bring the handle of the needle holder far away from the head of the 10mm trocar so that there will not be clashing of instruments.
- When instruments are clashing at the site of the camera head, zoom in.
- Sutures can be used as retractors. Bring the sutures through he skin and use them as retractors.
- Rescue a difficult surgery with an accessory 5mm or 3mm trocar.
- Fogging of the laparoscope may occur. This can be reduces by changing the carbon dioxide input to the right 5 mm trocar.
Single incision laparoscopic surgery can be performed using common laparoscopic instruments available in most operating theatres. The only accessory required is a right angle light connector. Choose simple cases to start of with. A small uterus will be ideal of SIL TLH. Choose a 10mm trocar and 2, 5mm trocars with small “head” to prevent clashing of instruments. Choose instruments with multifunction and with no side or perpendicular projections. Pay particular attention to skin preparation because leakage of gas will cause difficulty during surgery. Tilt the patient to your side if you suffer from back pain