Challenges in total laparoscopic hysterectomy: Severe adhesions

Technique. After emptying the stomach of its contents using suction, insert the Veress needle into the peritoneal cavity at a point midway between the midclavicular line and the anterior axillary line, 3 cm below the costal margin (FIGURE). Advance it slowly until you hear three pops, signifying entry into the peritoneal cavity. Only minimal insertion is needed; insufflation pressure of less than 10 mm Hg indicates intraperitoneal placement of the needle tip.⁵

Once pneumoperitoneum pressure of 20 mm Hg is established, insert a 5-mm trocar perpendicular to the abdominal wall, 3 cm below the ribs, midway between the midclavicular line and the anterior axillary line.³ (There is a risk of colon injury at the splenic flexure if the entry point is further lateral.)

Inspect the abdominal cavity with the laparoscope from this access port to determine the best placement of remaining trocars under direct vision; lyse adhesions, if necessary, to perform the procedure.

FIGURE Enter the abdomen at Palmer’s point

This entry site (red dot) lies midway between the midclavicular line and the anterior axillary line, 3 cm below the costal margin. The other port sites (black dots) are described in Figure 2 in Part 1 of this article.

Success depends on careful lysis and minimal tissue injury

Adhesions in the abdomen may involve:

• omentum to peritoneum
• omentum to pelvic structures
• intestine to peritoneum
• intestine to pelvic structures.

Adhesions may be filmy and thin or dense and thick, avascular or vascular. They can be minimal, or a veritable curtain that prevents adequate visualization of the primary surgical site. When they are present, they must be managed successfully if the primary procedure is to be accomplished laparoscopically.

Successful management requires techniques to maximize adhesiolysis and minimize new adhesions or tissue injury:

• Use traction and countertraction to define the line of attachment; this is essential to separate two tissues bound by adhesions.
• Use atraumatic graspers to reduce the risk of tissue laceration.
• Avoid sharp dissection with scissors. Although this is the traditional method of lysis, it is often associated with bleeding that stains and obscures the line of dissection.
• Choose tools wisely. Electrosurgery and lasers use obliterative coagulation, working at temperatures of 150°C to 400°C to burn tissue. Blood and tissue are desiccated and oxidized, forming an eschar that covers and seals the bleeding area. Rebleeding during electrosurgery may occur when the instrument sticks to tissue and disrupts the eschar. In addition, monopolar instruments may cause undetected remote thermal injury, causing late complications.⁶ Both monopolar and bipolar techniques can also leave carbon particles during the oxidation process that become foci for future adhesions.⁷
• Consider ultrasonic energy. Unlike electrosurgery, ultrasonic energy is mechanical and works at much lower temperatures (50°C to 100°C), controlling bleeding by coaptive coagulation. The ultrasonic blade, vibrating at 55,500 Hz, disrupts and denatures protein to form a coagulum that seals small coapted vessels. When the effect is prolonged, secondary heat seals larger vessels. Ultrasonic energy involves minimal thermal spread, minimal carbon particle formation, and a cavitation effect similar to hydrodissection that helps expose the adhesive line. It creates minimal smoke, improving visibility. Because ultrasonic energy operates at a lower temperature, less char and necrotic tissue—important causes of adhesions—occur than with bipolar or monopolar electrical energy.⁷

Although different energy sources interact with human tissue using different mechanisms, clinical outcomes appear to be much the same and depend more on the skill of the individual surgeon than on the power source used. Data on this topic are limited.

Thawing the frozen pelvis

Many patients have adhesions that involve omentum or intestine that can be managed using simple laparoscopic techniques, but some have organs that are fixed in the pelvis by adhesions. In these cases, traction and countertraction techniques can be tedious and may cause inadvertent injury to critical structures or excessive bleeding that necessitates conversion to laparotomy.

A better way to approach the obliterated, or “frozen,” pelvis is to open the retroperitoneal space and identify critical structures:

• Enter the retroperitoneal space at the pelvic brim in an area free of adhesions. Identify the ureter and follow it to the bladder. This can be accomplished using hydrodissection techniques or cavitation techniques with ultrasonic energy.
• Skeletonize, coagulate, and cut the vessels once you reach the cardinal ligament and identify the ascending uterine blood supply.
• Dissect the structures of the obliterated cul de sac using standard techniques.
• Use sharp dissection for adhesiolysis. Laparoscopic blunt dissection of adhesions can lead to serosal tears and inadvertent enterotomy. Sharp dissection or mechanical energy devices are preferred to divide the tissue along the line of demarcation—but remember that monopolar and bipolar devices can cause remote thermal damage that goes undetected at the time of use.