Description

Introduction Total Laparoscopic Hysterectomy (TLH) has become a widely accepted minimally invasive surgical approach for removing the uterus due to benign and selected malignant conditions. The evolution of surgical technology has further refined this technique. The introduction of the Uterine Manipulation, Knowledge-Integrated Technology (UKIT) system has significantly improved intraoperative visualization, safety, and operative efficiency. This guide provides a detailed step-by-step operative technique for performing a UKIT-enhanced TLH. Preoperative Preparation Patient Selection and Evaluation • Indications: Symptomatic fibroids, abnormal uterine bleeding, adenomyosis, early-stage endometrial cancer. • Pre-op Workup: Imaging (TVUS/MRI), lab tests, cervical screening, and anesthesia clearance. • Informed Consent: Discussion about risks, benefits, and alternatives. Equipment Setup • UKIT System: Includes enhanced uterine manipulator with integrated illumination and articulation capabilities. • Laparoscopic Tower: High-definition camera, insufflator, electrosurgical unit. • Standard Instruments: Trocars, graspers, monopolar/bipolar energy sources, suction-irrigation system. Operative Technique 1. Patient Positioning and Port Placement • Position: Dorsal lithotomy with steep Trendelenburg. • Port Configuration: o 10mm umbilical port (camera) o 5mm ports in bilateral lower quadrants (working) o Optional suprapubic port (assistant or retraction) 2. Establishing Pneumoperitoneum • Technique: Veress needle or open (Hasson) method. • Intra-abdominal Pressure: Maintained at 12–15 mmHg. 3. Insertion and Positioning of the UKIT Manipulator • Insertion: Introduced transvaginally after cervical dilation. • Advantages: o Illuminated tip for enhanced visualization. o Articulation for optimal uterine mobility. o Real-time data feedback to monitor manipulation force. 4. Inspection and Lysis of Adhesions (if needed) • Survey pelvis and abdomen. • Mobilize bowel or omentum if adherent to uterus or adnexa. 5. Skeletonization of the Uterine Vessels • Round Ligament: Coagulated and transected bilaterally. • Broad Ligament: Opened anteriorly and posteriorly. • Bladder Flap: Developed by dissecting vesicouterine peritoneum. 6. Uterine Vessel Ligation • With the uterus manipulated for optimal exposure, the uterine vessels are: o Coagulated using bipolar or advanced energy devices. o Transected close to the uterus to preserve ureteral integrity. 7. Cornual and Adnexal Management • Adnexa Preservation or Removal: o If preserving: transect utero-ovarian ligaments. o If removing: transect infundibulopelvic ligaments after identifying ureters. 8. Colpotomy • Circumferential colpotomy using monopolar hook or harmonic scalpel. • Performed under direct visualization with uterine manipulation for exposure. 9. Uterine Extraction • Delivered vaginally or morcellated if enlarged. • UKIT system aids in delineating vaginal fornices for safe dissection. 10. Vaginal Cuff Closure • Closed laparoscopically or vaginally using absorbable suture. • Barbed sutures may be used for efficient and secure closure. 11. Final Inspection and Hemostasis • Irrigate pelvic cavity and inspect for bleeding. • Confirm integrity of bladder, bowel, ureters. 12. Port Closure and Recovery • Remove instruments under vision. • Close fascia of ≥10mm ports. • Skin closure with subcuticular sutures or skin adhesive. Postoperative Care • Monitoring: Vital signs, urine output, pain control. • Ambulation: Encouraged early to reduce thromboembolism risk. • Diet: Advanced as tolerated. • Discharge: Often within 24 hours if stable. Advantages of UKIT Integration • Improved Uterine Mobilization: Facilitates exposure and access. • Enhanced Safety: Better visualization of anatomical landmarks. • Operative Efficiency: Shortens procedure time and reduces blood loss. • Surgeon Ergonomics: Less instrument clashing and fatigue. Conclusion The UKIT-enhanced TLH represents a significant advancement in minimally invasive gynecologic surgery. By integrating intelligent design with advanced maneuverability and illumination, it allows for precise dissection and improved surgical outcomes. Mastery of this technique requires understanding both traditional TLH steps and the optimized use of UKIT technology.