Total Laparoscopic Hysterectomy

• Identify UV Fold by rotating the Funnel

Edge anteriorly.
• Mark dissection lines on peritoneum with
Bipolar Forceps or gently with Monopolar
Scissors.
• Dissect on the medial edge of your
dissection line, as the lateral edge will be
displaced by the CO2 pressure.
UV FOLD LIFTED BY FUNNEL EDGE.

THIS CAN BE USEFUL IN

ABDOMINAL OPERATIONS
U / V FOLD
MARK DISSECTION LINES ON
ANTERIOR FOLD OF BROAD
LIGT FROM UV FOLD UP TO
ROUND LIGAMENT WITH
MONOPOLAR SCISSORS.
START DISSECTION WITH OVARIAN
LIGAMENT AND THEN THE TUBE,
WORKING UP TO THE ROUND
LIGAMENT AS VESSELS ARE
POSTERIORLY PLACED IN THESE
STRUCTURES.
DISSECT BROAD LIGAMENT DOWN
TO LEVEL OF UTERINE VESSELS.
I DO NOT SEPARATE THE LEAVES OF
THE BROAD LIGAMENT AS THIS
TENDS TO DISTORT THE DISSECTION
LINES.
YOU WILL COME ACROSS THE UPPER
BRANCH OF THE UTERINE ARTERY IN
THE BROAD LIGAMENT BEFORE YOU
ENCOUNTER THE UTERINE PEDICLE.
COAGULATE THIS BRANCH WITH
BIPOLAR ENERGY AND DIVIDE IT.
USE THE HOOK DISSECTOR TO PULL
THE LARGE UTERUS TO EXPOSE THE
LATERAL PELVIS.
UTERINE HOOK DISSECTOR
DO THE SAME ON THE OTHER SIDE
DOWN TO THE LEVEL OF THE UTERINE
VESSELS PEDICLE.
WITH MONOPOLAR ENERGY,
COMPLETE THE UV FOLD DISSECTION
ON THE FUNNEL EDGE. PUSH THE
FOLD DOWNWARDS UNTIL THE
VAGINA IS APPARENT.
YOU DO NOT HAVE TO UNDERMINE
THE BLADDER BASE UNLESS
PREVIOUS LSCS.THE FUNNEL EDGE
WILL ELEVATE THE VAGINA.
THE UTERINE PEDICLE IS
DISPLAYED FROM THE
LATERAL EDGE OF THE
FUNNEL AS SHOWN.
THE UTERINE PEDICLE IS SECURED
WITH A CURVED NEEDLE I VICRYL
SUTURE.
MAKE SURE THE FUNNEL EDGE IS
ANTERIOR.
INSERT NEEDLE FROM LATERAL SIDE
OF THE FUNNEL EDGE DOWNWARDS.
CURVE NEEDLE AROUND THE
UTERINE PEDICLE.
USING SINGH UTERINE ARTERY
NEEDLE TO SECURE PEDICLES,
INTRODUCED AT SUPRAPUBIS.
NEEDLE PLACEMENT
FOR LEFT PEDICLE.
RETROVERT UTERUS
AND PUSH NEEDLE
DOWN TO BLACK MARK.

BLACK MARK
NEEDLE PLACEMENT FOR
RIGHT PEDICLE
ANTEVERT UTERUS. NEEDLE TIP
SHOULD APPEAR AS SHOWN
WITH KNOT ON SUTURE.
PULL ON SUTURE
END
SUTURE AROUND LEFT
PEDICLE
INTRA CORPORAL TIE.
EXTRA CORPORAL SLIDING
KNOT.
After tieing the uterine pedicles, I bipolar medially before dividing the uterine pedicles. If you do not wish to tie
your uterine pedicles,you can bipolar them using the edge of the Funnel as your lateral margin.

Rotate the funnel edge anteriorly and cauterise the vagina on the funnel edge until the funnel is nearly visible.

Rotate the funnel edge laterally to the Right fornix and dissect the Makenrodt ligament on the funnel edge,
displacing the uterine pedicle. Cauterise the vagina on the funnel edge until the funnel is visible.

Insert bipolar forceps medial to the funnel edge and then cut the vagina with scissors. By using bipolar first
before cutting the vagina, you minimise bleeding and bowel damage. I used to use monopolar cautery but find
the bipolar and scissors method just as quick. Keep rotating the funnel shaft posteriorly and repeat bipolar and
scissors to the uterosacrals and enter the posterior edge. Keep dissecting on the funnel edge and you are well
clear of the ureters.

Rotate the funnel to the other uterine pedicle and repeat the procedure so the lateral and posterior vaginal
vaults are divided.

FOR CO2 LEAKAGE, INSERT THE VAGINAL PLUG ONTO THE FUNNEL AS
SHOWN IN THE EARLIER SLIDES. INSERTING A WET PACK INTO THE
VAGINA OR LOOSEN THE ORING ON THE SUC AND PULL THE FUNNEL INTO
THE VAGINA CAN ALSO HELP.
I used to enter the anterior fornix first, but I now find it easier and quicker to enter laterally as soon as
the uterine pedicles are displayed laterally. Divide the Macenrodt ligaments down to the vagina and then
work posteriorly. The anterior fornix is then divided to free the cervix from the vagina.
Remove the funnel shaft by releasing the black or white O Ring.
The suture on the cervix will enable extraction of the uterus when you pull out the uterine cannula.

Insert the largest Vaginal Probe to maintain pneumoperitoneum so you can suture the vaginal vault. You can
leave the uterus in the vaginal vault if you do not want to use a probe.