Academic OB/GYN

There are days when laparoscopic surgery is a breeze.  The anatomy is perfect.  The view is beautiful.  Your assistants are thinking three steps ahead of you.  In other words, the way surgery happens in your dreams

And then there are days when it isn’t going that way.  The anatomy is distorted and confusing.  There is bleeding that continuously distort your view.  Your assistants are struggling.  You are quickly becoming unhappy and want nothing more than for the surgery to be over and the patient to be well.

I have had many of both kinds of days.  Over the years I have been operating, I have identified a few things that tend to have happened on the latter kind of days, and hope to pass a few of those things on.   So if you find yourself struggling with laparoscopy, consider whether one of these things is going on.

1) If there is one key to a laparoscopic hysterectomy, it is proper placement of the uterine manipulator and associated obturator ring.  Whether you use the KOH or V-Care to do your TLHs, it is absolutely imperative that it is placed correctly and the ring is pushed all the way up against the cervix.   If you are struggling with the anatomy, there is a good chance the problems is that the ring is not where it should be.   When it is in correctly, it should bulge up between the insertions of the uterosacral ligaments posteriorly, and should be prominent anteriorly.  If it isn’t, it probably isn’t in right.

There are many ways the ring can be in wrong, or come out of position during the case.  With a KOH, the uterus can be pulled off the manipulator, leading the ring to no longer be up against the cervix.  This is particularly true if you are using the robot and your tenaculum is pulling up on the uterus.  It is very easy to pull so hard that you pull the uterus off the manipulator, particularly if the person on the manipulator is not careful to keep pushing.  With the new RUMI-KOH ARCH, it is possible for your assistant to push so hard than they push the slide off the arch, thus allowing the ring to become loose in the vagina and no longer surround the cervix.  One can also forget to remove the tenaculum from the cervix before pushing the manipulator in, which will keep the ring from seating correctly in the upper vagina.

If your assistant pushes hard enough on a V-Care and doesn’t have the white thumbscrew down hard, the shaft will come loose and perforate the uterus.  While this isn’t the worst thing, as you are taking out the uterus anyway, it now means that the ring is no longer pushed hard against the cervix.  So if this happens, make sure your assistant pulls the shaft back, secures the ring against the cervix, then screws that thumbscrew down hard this time.

Bottom line – if you are struggling, check that manipulator.  There’s a good chance it isn’t in right.

2) If the anatomy is confusing, make sure your camera is not rotated.  Cameras can rotate very slowly, so much so that may not notice it happening.  Over time your camera may be 90 degrees off horizon without you even noticing.  The only thing you notice is that everything seems wrong, and you can’t figure out why.   This can really happen when using a zero degree scope on the robot, which tends to rotate as you move the camera laterally.  I even tell my assistant to watch for rotation and point out to me if the horizon is getting off.  Its easy to tell from the assistant screen, but for the surgeon it can be very difficult to tell that rotation has occurred, despite the horizon indicator right in front of you.   Personally I think that the ability for a zero degree scope on the robot to rotate is a design flaw.  There is really no reason why you would want to rotate a zero degree scope, as it doesn’t change what is seen, it just rotates the screen, which just disorients the surgeon.  No upside, all downside.  The robot shouldn’t even allow it.  Or sound an alarm maybe.  Just sayin, Intuitive….

3) The robot gives you an incredible range of motion, far greater than you have via traditional laparoscopy – but don’t overestimate its abilities.  There are some angles you still will not be able to reach, either because of port placement or because the uterus is just getting in the way of your arms.   For example,if you are doing a robotic TLH and the uterus is huge, you may not be able to pronate the bipolar left hand enough to get the uterine artery right at the internal os where you should.  You may be tempted to push the uterus over with the arm and pronate the hand over as much as you can, burning the vessel out a little wider than you usually would.  Don’t do this.  You are asking for a thermal injury to the right ureter.  You will get away with it most of the time, but occasionally you won’t.  In this situation, just switch arms and bring the bipolar if from the right.  You will be able to get the uterine exactly where you want to.

4) When doing a robot hysterectomy on a big uterus, you have to be mellow with the third arm tenaculum.  It can really help you, but if you overuse it it can be hurt you more than it helps.  On one hand, it moves the uterus and improves exposure.  On the other hand, every time you move it you make more holes in the uterus, each one of which is going to bleed and obscure your visualization.   The bleeding is not clinically significant, but if you have enough of it you won’t be able to see well enough.  You will then be unhappy for the rest of the case, and may even end up needing to open because you can’t see.  So use the person on the manipulator first.  Or use the prograsp on the third arm instead of the tenaculum.   It doesn’t work as well, but it doesn’t tear up the uterus as much.

5) Maybe your ports are not placed well.  Bad port placement can ruin your day.  Do your best to optimize port placement from the beginning… but if you are struggling because your ports are not optimal, remember you can always place another port or move a port.  It is way better to have another 5 mm skin incision than to operate through ports that aren’t allowing you to operate efficiently or safely.

On the robot, make sure accessory ports are lateral enough.  A right sided accessory port has to be at least 5 and preferably 10 cm lateral to the rightmost robot port.  Preferably it is also inferior to the robot port.  If your accessory port is too superior relative to the right arm port, your assistant will be unable to access the right side of the pelvis because the handle of their instrument will clash with the robot arm.

One trick – you can actually put the robot arm ports far more medial than you would think.  The robot specs says they should be 10 cm lateral to the camera port, but since the camera doesn’t move laterally very much and the arms will always lean outwards instead of inwards, ports placed more medially will actually work fine.   The upside of this placement is that the accessory ports will have more room to move without being blocked by the robot arm, both internally and externally.  The only exception would be if you are doing a lymph node dissection, as medial arm placement may prevent the arms from reaching lateral enough to get obturator nodes.

6) If you are feeling really bad about a case as it is going on, you should consider opening.  That really bad feeling is your brain telling you something is going wrong.  It is your Spidey Sense.  Don’t ignore it.  Figure out what is wrong.  If you can’t, open.  Proceeding laparoscopically without being clear about the anatomy is a recipe for a complication.  There are far worse things than converting to laparotomy.  Your patient will be much more forgiving of an unexpected scar than an unexpected ureteral stent.

If you are a surgeon, let me know your tips!  If you aren’t, you probably have no idea what I am talking about.  That’s OK.   Its just doctors talking shop.

Dr. Fogelson is a gynecologic surgeon and endometriosis specialist who practices at Northwest Endometriosis and Pelvic Surgery in Portland, OR.  Call 503-715-1377 for clinical consultation or email nfogelson@nwendometriosis.com. http://www.nwendometriosis.com