(1)
Service de Gynécologie et Obstétrique, Centre d’Études Périnatales de l’Océan Indien (CEPOI) – EA7388, CHU Réunion, Hôpital Félix Guyon, Saint Denis de la Réunion, France
4.1 Surgical Setting
- (a)
Uterine mobilization and cul de sac presentation
When the uterus is in place and if you target a conservative surgery, it’s crucial to expose correctly the posterior cul de sac of the vagina and to be able to antevert and retroflex the uterine body. Several manipulators and cul de sac presenter are available on the market. We have chosen the Tintara (Pictures 1 and 2) one because it’s cheap, reusable, easy to use and efficient. If not available in your OR, you can replace it with a Leriche retractor (Picture 3) or an equivalent, to present the posterior cul de sac. Then uterine mobilization can be performed by using the disposable and cheap T Lift devices as shown on Pictures 4 and 5.
When the uterus is absent or if you remove it partially or totally during the first step of your procedure, the Leriche retractor (or equivalent) is better than a vaginal tampon because there’s no risk to pass a suture or a staple through it.
Picture 1 Tintara uterine manipulator (Storz) or Pelosi uterine manipulator (Apple medical). 1 is anteversion of the uterus with presentation of the posterior cul de sac (2). 3 is lateral mobilization of the uterus and 4 is retroversion of the uterus
Picture 2 Tintara uterine manipulator (Storz) or Pelosi uterine manipulator (Apple medical)
Picture 3 Leriche retractor
Picture 4 TLift
Picture 5 TLift in place to mobilize the uterine body
- (b)
Trocar setting
Picture 1 Trocar positioning—1 is upper limit of pubis bone, 2 is umbilical arteries, 3 is epigastric vessels. Trocar A is in the umbilicus, trocar B is lateral to the left epigastric vessels, trocar C is medial to the right umbilical artery and trocar D is lateral to the right epigastric vessels.
- (c)
The instruments
No special instruments are required: two atraumatic forceps, two grasping forceps, one scissor, eventually, one needle holder and a suction-irrigation device. Ideally, harmonic scalpel could be used for quick dissection but if not available, a bipolar cautery device can do the job.
4.2 LSCP for Vault Prolapse or After Subtotal Hysterectomy
Step 1: Grasp the peritoneum in front of the promontory (1) and lift it strongly. The blood vessels (common right iliac artery and vein: 2) are not adhesive to the peritoneum and your full thickness incision will be safe. Remember: there are two layers to incise; the peritoneum itself and the underlying sheet of fascia. Usually, it is performed in two times. Ureter (3) is very distant.
Step 2: The peritoneum is open (two layers) and you can see the extra peritoneal space (1) looking like some spider web. You have direct visual access to the promontory (2) with the medial sacral vessels that should not be injured (3).
Step 3: The peritoneal opening progresses from the promontory (1) towards the Douglas pouch (arrow), along the right side of the rectum (2), close to the rectum, far from the right ureter (3).
Step 4: The dissection (arrow) must stay medial to the uterosacral ligament (1). Thus, the extra peritoneal dissection will lead automatically to the rectovaginal wall and stay far from the right ureter (2). Always stay close to the rectum.
Step 5: Open (arrow) the peritoneum between the rectum (1) and the vault (2) exposing the pararectal fat. The vault is presented well with the vaginal device. In the pararectal fat, you can frequently see the correct dissection plane to the elevator muscles as a soft spider web area (3).
