Fondazione Policlinico Universitario A. Gemelli IRCCS (Drs. Gueli Alletti, Restaino, Scambi, and Fanfani), UOC di Ginecologia Oncologica, Dipartimento per la Tutela della Salute della Donna e della Vita Nascente, Roma, Italia.
Fondazione Policlinico Universitario A. Gemelli IRCCS (Drs. Gueli Alletti, Restaino, Scambi, and Fanfani), UOC di Ginecologia Oncologica, Dipartimento per la Tutela della Salute della Donna e della Vita Nascente, Roma, Italia.
J Minim Invasive Gynecol. 2020 Jan;27(1):22-23. doi: 10.1016/j.jmig.2019.06.001. Epub 2019 Jun 12.
To reveal principles and the feasibility of a total laparoscopic hysterectomy (TLH) with uterine artery ligation at the origin.
Step-by-step demonstration and explanation of technique using videos from patients.
Gynecologic oncology unit at a university hospital.
A 54-year-old woman with uterine fibromatosis and metrorrhagia.
TLH has 7 common components. First, round ligaments are coagulated and cut to enter the retroperitoneum. The ureter is identified. Second, pararectal spaces are entered between the ureter and the internal iliac artery. This maneuver allows the identification of the uterine artery as it leaves its origin from the internal iliac artery. The uterine vessels are stapled with a vascular endoscopic stapler at their origin from the hypogastric vessels or sealed with a bipolar device. Third, adnexal structures are separated from the uterine corpus for subsequent preservation or removal. Fourth, the blood supply is dissected, occluded, and divided before extirpation of the uterine corpus. Fifth, the cardinal ligament complex is transected with colpotomy, and the cervix is amputated from the vaginal apex. Sixth, the specimen is removed. Finally, the vaginal cuff is closed [1].
Laparoscopic hysterectomy was first described by Reich et al. [2] in 1989 and has slowly gained popularity. Today, hysterectomy is the most common gynecologic procedure performed. TLH is where the entire operation (including suturing of the vaginal vault) is performed laparoscopically and there is no vaginal component except for the removal of the uterus. Currently, hysterectomies are performed by different approaches, and individual surgeons have different indications for the approach to hysterectomy based largely on their own array and patient characteristics. TLH requires the highest degree of laparoscopic surgical skills [3], and knowledge of pelvic anatomy defines a safe space for sharp entry into the retroperitoneum and safe identification of pelvic vasculature.
We present an educational video with step-by-step explanation of the technique to highlight the anatomic landmarks that guides the procedure.
揭示在子宫动脉起点处结扎子宫动脉的全腹腔镜子宫切除术（TLH）的原则和可行性。
使用来自患者的视频逐步演示和解释技术。
大学医院妇科肿瘤病房。
一位 54 岁的子宫肌瘤和月经过多患者。
TLH 有 7 个常见步骤。首先，结扎圆韧带并切断，进入后腹膜。识别输尿管。其次，在输尿管和髂内动脉之间进入旁正中间隙。这一操作可使子宫动脉在离开髂内动脉起点时得到识别。在子宫血管的起点处用血管内镜吻合器夹闭或用双极器械封闭子宫血管。第三，从子宫体分离附件结构，以备后续保留或切除。第四，在切除子宫体之前，解剖、阻断和分离血液供应。第五，经阴道切开切断主韧带复合体，从阴道顶点切除宫颈。第六，取出标本。最后，关闭阴道残端。
1989 年 Reich 等人首次描述了腹腔镜子宫切除术[2]，此后该技术逐渐普及。如今，子宫切除术是最常见的妇科手术。TLH 是指整个手术（包括阴道穹窿缝合）均在腹腔镜下进行，除了切除子宫外，没有阴道部分。目前，子宫切除术有不同的方法，个别外科医生根据自己的手术方法和患者特点，对子宫切除术的方法有不同的适应证。TLH 需要最高程度的腹腔镜手术技能[3]，对盆腔解剖学的了解定义了一个安全的空间，可用于锐性进入后腹膜和安全识别盆腔血管。
我们提供了一个教育视频，逐步解释技术，突出指导手术的解剖学标志。
