Laparoscopic Radical Hysterectomy Task Analysis
Laparoscopic radical hysterectomy in Gynecologic cancer. task analysis
Dr Maliheh Arab, MD
1- Select the patient : Early stage cervical cancer- endometrial cancer with cervical involvement.
2- Put the patient in lithotomy position.
3- Telescope port position: 4cm above umbilicus ( supra umblical).
4- Working port position : Two 5mm right: ipslateral, and two 5mm left: ipslateral.
5- Open Peritoneum between round lig and infundibulopelvic ligament (IP) and cut downward towards iliac vessels .
6- Use harmonic for cutting ( metal part is open and cut with upward hanging and cutting of Peritoneum) or monopolar.
7- Find int iliac vessel by opening the peritoneum lateral to ureter just in junction of ureter and iliac vessels. cut uterine artery in its origin.
8- Dissect pararectal space lateral: to ureter and IP ligament :
- Anterior: uterine artery and lateral parametrium
- Lateral: posterior division of hypogastric artery
- Posterior: lateral surface of the sacrum
- Medial: rectum
9- Dissect paravesical passa by cutting peritoneum downwards:
- Lateral: ext. iliac and obturator fossa
- Posterior: uterine artery and lateral parametrium
- Anterior: obturator muscle
- Medial: bladder and vagina
10- Cut the uterine vein below ureter tp prevent bleeding in parametrial resection.
11- Cut parametrium which is located in front of pararectal space, near pevic.
12- Medial to ureter and IP ligament, cut the peritoneum towards down and medial to posterior cul de sac.
13- Expose rectovaginal space by dissecting denonvilie ligament and going down between uterosacral ligaments into the space.
14- Cut uterosacral ligaments in half of its length.
15- Open vagina circular by removing at least 2 centimeters of vagina.
16- Cut infundibulopelvic or utero. Ovarian ligament ( this step is postponed for better traction).
17- Vaginal cuff is closed by 3 extra corporal knots.
18- Ovaries might remain in young women
19- Ophoropexis is considered in young women for protection of ovarian function if irradiation is needed ( probably not very effective)
20- Do pelvic lymphadenectomy at first part or second part of the surgery.
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