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Surgical Technique


Pelosi minilaparotomy hysterectomy: Effective alternative to laparoscopy and laparotomy

This new modality—useful for normal, large, and fibroid-ridden uteri—combines the technical benefits of standard laparotomy with the convalescent advantages of laparoscopic surgery.

April 2003 · Vol. 15, No. 4

Although laparoscopic hysterectomy offers a minimally invasive alternative to laparotomy when vaginal hysterectomy is contraindicated, it has its drawbacks. Among them: the cost of expensive equipment, the long learning curve, and prolonged operating time.

We describe another alternative to open surgery that is comparable to laparoscopic hysterectomy in postoperative pain, cosmetic results, and time to return to normal activities. Our procedure—a redesigned minilaparotomy hysterectomy—relies on traditional open techniques and inexpensive novel instrumentation, making it significantly faster than laparoscopy and easy to perform and teach.

For patients who cannot undergo vaginal hysterectomy, this new modality offers an expeditious, minimal-access option. Gynecologists reluctant to relinquish the routine use of standard laparotomy may find this approach an appealing, less-invasive alternative.

Position, incision, and retraction are crucial to success

Our minilaparotomy hysterectomy is a systemized approach with elements derived from both open and laparoscopic surgery. Three preparatory components are involved:

  • position
  • incision
  • retraction

All are critical to a successful hysterectomy, ensuring that the procedure never becomes a haphazard struggle through an improvised, scaled-down, conventional Pfannenstiel or vertical incision. Our approach also avoids cumbersome traditional laparotomy exposure maneuvers and positioning.

Position: Modified lithotomy. After regional or general anesthesia is given, position the patient in a modified lithotomy with both arms tucked as for laparoscopic surgery. Place the legs in boot-type stirrups, with no hip flexion and sufficient thigh abduction to expose the vagina.

Next, perform a thorough pelvic examination and place an indwelling, transurethral catheter. A sturdy, hinged uterine manipulator is of paramount importance for the hysterectomy, as it facilitates exposure of the adnexa as well as elevation/rotation of the uterus and the uterine attachments. We recommend the Pelosi Uterine Manipulator (Apple Medical Corporation, Marlboro, Mass) or its equivalent (FIGURE 1).

Development of the Pelosi minilaparotomy hysterectomy technique

Standard minilaparotomy

The use of standard minilaparotomy—which is nothing more than a conventional laparotomy of limited length (3 cm to 6 cm), performed either transversely or vertically—has been confined to the surgical treatment of benign pelvic pathology of limited extent.

To generate sufficient exposure to work effectively, surgeons using the standard minilaparotomy have relied on the length of the abdominal incision and, secondarily, bowel packing and metal handheld or self-retaining fixed retraction systems. When exposure is difficult to achieve or maintain, however, routine surgical maneuvers become frustrating and time-consuming—unless the clinician uses extensive traction force, extends the incision length, or performs muscle-splitting. These alternatives often result in an uncomfortable, slow recovery typical of most laparotomies, thereby negating the primary goal of minimally invasive surgery.

Use of traditional minilaparotomy for hysterectomy has been reported only rarely. Hoffman et al1 found the procedure safe and effective in nonobese women in whom a vaginal approach was precluded. Benedetti Panicci et al2,3 also have used minilaparotomy successfully in benign gynecologic disease and hysterectomy.

The Kustner incision

Originally reported in 1896,4 this incision is avoided by most surgeons in favor of complete transverse or complete vertical incisions—largely due to difficulties with exposure, troublesome seroma formation, and wound complications secondary to increased fluid accumulation in the large dead space that results from wide dissection of the subcutaneous flap.

In the early 1990s, we realized the potential benefits of a scaled-down Kustner’s incision (2 cm to 5 cm) when assistance was needed via minilaparotomy during such laparoscopic-assisted procedures as uterine morcellation, tubal reanastomosis, and extensive uterine suture and reconstruction following complex laparoscopic myomectomy. 5 As a substitute for laparoscopy and laparotomy, we then tried a minilaparotomy Kustner’s incision (3 cm to 5 cm) as the sole means of surgical access, assessment, and treatment for benign pelvic conditions.

Benefits of this incision. When a sturdy uterine manipulator was used to facilitate exposure of the adnexa and uterine elevation/rotation, we found this technique more effective than similar procedures using a scaled-down Pfannenstiel or Maylard incision. In addition, because the incision was small and the extent of subcutaneous dissection required to expose the rectus fascia in a vertical fashion was limited, there was no need for incision drainage. Nor was the procedure associated with seroma formation, as the full-sized Kustner’s incision had been.3 However, the minilaparotomy Kustner’s incision still suffered from limited surgical exposure.

Adding the retractor

It became clear that a soft, self-retaining abdominal retractor that is capable of creating a rapid, effective, nontraumatic, and predictable circular area of abdominal retraction would be helpful, particularly one that could be placed through the minilaparotomy Kustner’s incision.6 Once this retractor system was developed, using technology borrowed from hand-assisted laparoscopy,7-10 the minilaparotomy hysterectomy became a much simpler, more useful surgical option.

REFERENCES

1. Hoffman MS, Lynch CM. Minilaparotomy hysterectomy. Am J Obstet Gynecol. 1998;179:316-320.

2. Benedetti Panicci P, Maneschi F, Cutillo G, et al. Surgery by minilaparotomy in benign gynecologic disease. Obstet Gynecol. 1996;87:456-459.

3. Benedetti Panicci P, Zullo MA, Casalino B, et al. Subcutaneous drainage versus no drainage after minilaparotomy in gynecologic benign conditions. Am J Obstet Gynecol. 2003;188:71-75.

4. Kustner O. Der suprasymphysare kruzschnitt, eine methode der coeliotomie bei wening umfanglichen affektionen der weiblichen beckenorgane. Monatsschr Geburtshilfe Gynakol. 1896;4:197-206.

5. Pelosi MA, II, Pelosi MA, III. The suprapubic cruciate incision for laparoscopic assisted microceliotomy. J Soc Laparoendosc Surg. 1997;1:269-272.

6. Pelosi MA, II, Pelosi MA, III. Self-retaining abdominal retractor for minilaparotomy. Obstet Gynecol. 2000;96:775-778.

7. Pelosi MA, II, Pelosi MA, III. Hand-assisted laparoscopy for complex hysterectomy. J Am Assoc Gynecol Laparosc. 1999;6:183-188.

8. Pelosi MA, II, Pelosi MA, III. Hand-assisted laparoscopic cholecystectomy at cesarean section. J Am Assoc Gynecol Laparosc. 1999;6:491-495.

9. Pelosi MA, II, Pelosi MA, III. Hand-assisted laparoscopy (handoscopy) for megamyomectomy: A case study. J Reprod Med. 2000;45:519-525.

10. Pelosi MA, II, Pelosi MA, III, Eim J. Hand-assisted laparoscopy for pelvic malignancy. J Laparoendosc Adv Surg Tech. 2000;10:143-150.

Incision: Modified Kustner’s. Open the abdomen with a cruciate incision. Using a conventional scalpel and the Bovie device, make a 2.5-cm to 5-cm transverse incision through the skin and subcutaneous fat until you reach the anterior rectus fascia (FIGURE 2A). Clear the fat from the midline superiorly and inferiorly to expose approximately 5 cm to 6 cm of fascia in the vertical axis. Then incise the anterior rectus fascia in a vertical direction through the full length of the cleared area (FIGURE 2B).

Retract the rectus muscles from the midline, exposing the transversalis fascia and the underlying peritoneum. Enter the peritoneum digitally or with scissors above the level of the bladder dome, incising vertically until the entrance extends the full length of the fascial incision (FIGURE 2C).

This modified Kustner’s incision is essentially a vertical midline incision in its deeper layers. 1 The rapid surgical dissection of the fascia and rectus muscles and the intraperitoneal entry are relatively bloodless. This approach yields a surgical exposure superior to that of a small Pfannenstiel or Maylard incision.

Note that, in some patients, a vertical incision can be selected if there is a prior vertical incision or if the perioperative workup suggests a malignancy that may require a later extension of the original minilaparotomy incision.

Retraction: Soft, sleeve-type, self-retaining abdominal retractor. This device consists of a flexible plastic inner ring and a firmer outer ring connected by a soft plastic sleeve (FIGURE 3A). Two models are available: the Mobius (Apple Medical Corporation) and the Protractor (Weck Closure Systems, Research Triangle Park, NC).

Squeeze the inner ring into the peritoneal cavity through the minilaparotomy incision, allowing it to spring open against the parietal peritoneum. Conduct a digital assessment to ensure that no viscera are trapped by elevating the outer ring. Next, roll the outer ring onto the sleeve, collecting excess length, until it sits firmly against the skin (FIGURES 3B and 3C). The result, when there is adequate tension within the sleeve, is a circular area of retraction offering excellent exposure of the pelvis. Note that during surgery you may need to adjust the outer ring if the sleeve loosens.

The soft, self-retaining abdominal retractor offers several advantages over traditional abdominal retraction:

  • Atraumatic retraction. This device distributes retraction force evenly around the entire incision. Because standard retractors concentrate retraction force at only a few points, they often lead to tissue trauma, nerve damage, bruising, and postoperative pain.
  • Incision protection. The retractor’s flexible material lines the incision, protecting the wound’s edges from contamination and potential implantation of malignant cells.
  • Improved access. Because the continuous retraction force is delivered more effectively to the incision, exposure is maximized. As a result, the need for intensive surgical assistance is dramatically reduced.
  • Adjustable height. The retractor’s design lets it adapt to wounds of varying depth—a feature that makes it ideal for obese patients. The device compresses the patient’s skin and peritoneum between the external and internal rings, keeping the full thickness of the abdominal incision constant throughout the surgery.
  • Cost-effectiveness. The device, which costs under $100, is simple and fast to set up. In our experience, placement takes approximately 2 minutes; this compares favorably with table-mounted or self-retaining rigid retraction systems, which may require significant capital expenditures (cost may run in the thousands), repair costs, and complicated set-ups.

FIGURE 1 Hinged uterine manipulator


A sturdy hinged uterine manipulator facilitates exposure of the adnexa as well as elevation/rotation of the uterus.

FIGURE 2 Cruciate incision


A. Make a transverse incision suprapubically through the skin and the subcutaneous fat to reach the anterior rectus fascia.

FIGURE 2 Cruciate incision


B. Clear the fat from the midline to expose the rectus fascia in the vertical axis, then incise the fascia in a vertical direction through the full length of the previously cleared area. The rectus muscles are retracted, thereby exposing the peritoneum.

FIGURE 2 Cruciate incision


C. Incise the peritoneum vertically until it extends the full length of the fascial incision.

FIGURE 3 Soft, sleeve-type, self-retaining abdominal retractor


A. At left, the Protractor (Weck Closure Systems); at right, the Mobius (Apple Medical Corporation).

FIGURE 3 Soft, sleeve-type, self-retaining abdominal retractor


B. After inserting the inner ring into the peritoneal cavity, twist the outer ring downward until it inverts and rests snuggly against the skin.

FIGURE 3 Soft, sleeve-type, self-retaining abdominal retractor


C. An atraumatic, circular, self-retaining area of retraction is created.

Standard technique: Exteriorize the uterus; divide uterine attachments, vessels

Assess the anatomy. Using your index finger and the uterine manipulator to rotate and flex the uterus, carefully assess the uterus, adnexa, and pelvis, noting the location of the ureters. Determine the extent of any unexpected pelvic pathology or adhesions, using traditional small retractors or gentle packing to gain additional exposure. Perform any adhesiolysis that is necessary.

Exteriorize the uterus. Next, bring the uterus and the adnexa above the abdominal wall in order to perform as much of the hysterectomy extracorporeally as possible. Pass the uterus or adnexa through the incision with the upward assistance of the uterine manipulator, then divide the upper uterine attachments (FIGURE 4A).

Increase exposure. You can achieve additional uterine elevation and targeted exposure in several ways. For example, a strong traction suture can be placed in the uterine fundus, left long, and secured with a clamp. To achieve uterine elevation, place long clamps lateral to the corpus. Another effective approach is to place a heavy tenaculum on the uterine fundus.

When lateral exposure is limited, divide the proximal adnexal pedicles and round ligaments to begin the operation, and remove the adnexa separately following the completion of the hysterectomy.

Divide the uterine vessels through the small incision using clamping, division, and ligation. Unless you intend to preserve the cervix, mobilize the bladder to the level of the anterior vaginal fornix. Inward pressure on the uterine manipulator provides additional elevation of the lower uterine vasculature and the cardinal and uterosacral ligaments as these structures are ligated and divided. Amputate the uterine specimen from the vaginal cuff using the uterine manipulator to guide the vaginal circumcision (FIGURE 4B). Close the vaginal cuff using standard closure.

Continued...
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