C*I*S*H*

4. Surgical Technique

A. Safety Steps - Trocar Insertion

After general anesthesia with endotracheal intubation, the patient is placed in a modified lithotomy position. She is prepared vaginally and abdominally, and sterile drapes are placed. We then proceed as follows.

1. Palpation of the aorta: The aorta and its bifurcation are palpated through the umbilicus. The location and distance from the abdominal wall are appreciated.
2. Needle flow test: Patency, functionability of the snap mechanism, and the flow resistance of the inflow tube and needle system are determined, with the CO₂ gas flow set at 1 L/min. The gas flow resistance should not exceed 6-8 mm Hg. This pressure must be the same after the needle has perforated the parietal peritoneum.
3. Snap test: While inserting the Veress needle vertically into the umbilicus, one can observe the snap mechanism three times: at the skin, the fascia, and the parietal peritoneum. If the needle is introduced at 45°, the snap mechanism cannot function optimally and the needle tip works like a scalpel.
4. Hiss test: If the needle is placed correctly and the abdominal wall is elevated, air is brought through the needle, causing a hissing sound. The insufflator then indicates negative abdominal pressure.
5. Aspiration test: Saline solution 5 ml is injected through the needle and aspirated. If fluid is not aspirated, the surgeon may be sure that the needle lies properly (otherwise blood or bowel content is immediately visible). With the needle safely in place, CO₂ gas is insufflated until an intraabdominal pressure of 12 mm Hg is reached and the insufflator shuts off.
6. Sounding test: Once the pneumoperitoneum has been established, a sounding needle (120 mm long and 0.8 mm thick) can be inserted 2-3 cm below the umbilicus and slowly advanced. When aspirating gas through a small column of saline in a syringe, gas bubbles through the fluid if the needle tip is free, otherwise bubbling stops, indicating the interference of underlying structures, such as bowel or adhesions. The needle is advanced in different directions, looking for a free space above the contents of the abdomen into which a trocar is to be inserted.
7. Trocar insertion: Having established an adequate pneumoperitoneum, a small vertical intraumbilical incision is made through the skin. A 5 mm conical trocar is inserted in a Z fashion through the rectus muscle avoiding the linea alba. Care is taken to not damage the fascia, thereby avoiding possible hernia formation at the end of the procedure. The incision closes in different layers to prevent omental or intestinal prolapse.

A complete 360° abdominopelvic inspection is carried out. The diagnosis and indication for surgery are confirmed. Dilation is accomplished with trocars of 5 mm to 11 mm and a 10 mm laparoscope inserted. Three 5 mm ancillary trocars are inserted suprapubically in Z fashion under direct visualization: two lateral to the deep epigastric vessels and one off-center through the left or right rectus muscles.
The patient is placed in a 15° Trendelenburg position. The bowel is displaced cephalad out of the pelvic cavity. The C*I*S*H* can now be safely started. The uterus and adnexa are isolated from adhesions by adhesiolysis, as indicated.

B. Abdominal Portion of C*I*S*H*

• The round ligament is grasped with a biopsy forceps close to the fundus and endocoagulated with a crocodile clamp at 110°C for 20 seconds.
• Vasopressin with chlorobutanol (Pitressin; Parke-Davis, Morris Plains, NJ) 5 units in 100 ml of saline solution, is injected into the ligament and under the anterior and posterior leaf of the broad ligament (hemostasis and aquadissection).
• The ligament is divided with hook scissors. Roeder loops are placed over the pedicles for security.
• The posterior leaf of the broad ligament is identified and widely incised with blunt dissection. Large uterine vessels and the ureter are clearly visible at the caudal and lateral border of the peritoneal window. An endoligature is passed through the window in the broad ligament with 3- and 5-mm needle holders. An extracorporeal sliding knot is tied, and the ligature is placed over the infundibulopelvic ligament. A second ligature is placed over the proximal portion of the adnexa.
• The infundibulopelvic ligament is divided with hook scissors and the pedicle secured with two additional Roeder Loops.

If the adnexa are to be left in situ, ligatures are placed around the uteroovarian ligament and a cut is made beween them. The pedicles are secured with additional Roeder loops. The last loop is always a 0 catgut loop (catgut swells when wet!). The uterus is now freed to the level of the large vessels.

• The bladder peritoneum and posterior broad ligament are injected with a dilute solution of vasopressin with chlorobutanol (5 U/100 ml saline solution.
• Blunt and sharp dissection exposes the bladder, uterine vessels and ureters.
• With the isthmus portion of the cervix exposed, a Roeder loop or endoligature is placed over the cervicocorporeal junction, at the level of the uterosacral ligaments.

C. Vaginal Portion of C*I*S*H*

• The cervix is infiltrated with dilute vasopressin with chlorobutanol solution (5 U/100 ml saline solution).
• A Schiller test is performed to demonstrate the squamocolumnar junction. If the morcellator does not include the squamocolumnar junction, cold knife conization or loop electrosurgical excision should be performed.
• The guide rod of the calibrated uterine resection tool (C*U*R*T) is inserted through the cervical canal, and the fundus is perforated under laparoscopic guidance to create a straight cervicocorporeal axis.
• The morcellator of the C*U*R*T is placed over the stabilizer and is used to core out a tissue cylinder from the squamocolumnar junction of the exocervix to the fundus. This step can be performed manually or with the aid of the WISAP®Moto-Drive.
• As the tissue cylinder is removed, the preplaced Roeder loop or endoligature is quickly and securely tied. This maneuver prevents loss of the pneumoperitoneum and possible CO₂ embolization. Both ascending branches of the uterine artery are safely occluded.

The cervical wound is surprisingly dry. A tampon of SURGICEL is inserted into the cervical defect to prevent oozing and infection. SURGICEL is bactericidal.
The larger the diameter of the C*U*R*T used, the larger the caliber of the cervical vessels from which bleeding can occur. In this and in cases of a very congested cervix a cerclage suture of 0-Vicryl placed high around the cervical remnant together with a SURGICEL tampon is sufficient to stop all bleeding. Coagulation, cauterization, fulgeration, and additional sutures are not recommended. It only leads to delayed healing.

The use of prophylactic antibiotics is debatable. In hundreds of cases with or without antibiotics prophylaxis a difference in morbidity has not been observed. In difficult and prolonged cases prophylaxis my be advisable.

D. Removal of Surgical Specimen

• After two additional Roeder loops are placed around the cervical isthmus, the corpus is amputated with hook scissors, and a fourth catgut loopis tied for enhanced hemostasis.
• The middle suprapubic 5mm trocar is dilated to 15 or 20 mm. The amputated uterus with or without adnexa are morcellated and removed using the serrated-edge macromorcellator (S.E.M.M.) with or without employing the WISAP®Moto-Drive.
• The remaining cervical stump and pedicles are treated with the point coagulator at 120°C to minimize postoperative adhesions, sterilize the cervical remnant, and ensure that all remaining endometrium is destroyed.
• Incidental pelvic floor repair can now be done.
• The remaining raw surface is peritonealized by bringing the anterior bladder flap to the posterior aspect of the cervical stump in the midline with an endosuture.
• The pelvis is thoroughly irrigated with Ringer's solution.
• After complete hemostasis is confirmed, all trocars are removed under direct visualization. The trocar sites need not be sutures because of the Z type placement of the trocars. The skin is approximated with clips and covered with small bandaids.

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September 1997