Access and trocar insertion
Safe surgical access is a fundamental step in any laparoscopic procedure. The choice of the insertion site for the Veress needle and the first (optical) trocar requires a strictly individualized approach. The standard access through the umbilical ring margin is not advisable if the patient has a history of previous abdominal surgeries. In such cases, to prevent the telescope from entering an area of dense adhesions, the optimal approach is to insert the instrument to the left and superior to the umbilicus.
Non-standard access points are also chosen in the following conditions:
- Severe patient obesity.
- Presence of a giant uterine myoma distorting the anatomy.
- Presence of a scar from a prior laparotomy (e.g., a transverse suprapubic Pfannenstiel incision).
To ensure comfortable and safe working conditions for the surgeon, three additional ports (working ports) are established:
| Port site | Location on the anterior abdominal wall | Anatomical landmarks |
|---|---|---|
| First and second | Right and left iliac regions | In the avascular zone, medial to the anterior superior iliac spine (spina iliaca anterior superior) |
| Third | Strictly midline | On the midline directly below the pubic symphysis |
Preparatory stage and exploration
Following the successful introduction of the laparoscopic optics and working instruments, a thorough visual exploration of the pelvic and abdominal organs is performed. To create adequate working space, the operating table is adjusted to place the patient in the Trendelenburg position (with the head down).
Due to this gravitational tilt, the mobile intestinal loops and the greater omentum shift into the upper abdomen. This provides the surgeon with an unobstructed panoramic view and creates optimal conditions for safe manipulation of the uterus and its adnexa.
Technique of laparoscopic salpingectomy
Removal of the uterine tube requires meticulous and reliable hemostasis. Initially, the tube is grasped with endoscopic forceps, put under appropriate tension, and clamped with the blades of a dissector. Electric current (monopolar or bipolar) is then applied to the instrument in coagulation mode.
Tissue transection is performed strictly along the upper margin of the mesosalpinx (mesosalpinx), ensuring simultaneous cessation of bleeding. The excised surgical specimen is extracted using an atraumatic grasper through a slightly enlarged left port site.
Specifics of laparoscopic adnexectomy
Removal of the uterine adnexa begins with a step entirely analogous to an isolated salpingectomy. After transecting the tube, the surgeon proceeds to sequential manipulation of the ovarian ligamentous apparatus:
- Ovarian proper ligament (ligamentum ovarii proprium): the tissue is securely grasped with forceps as close to the ligament as possible, then thoroughly coagulated and transected.
- Suspensory ligament of the ovary and mesovarium: the ovary is grasped near the suspensory ligament. Kept under continuous tension, the organ is finally detached from the mesovarium (mesoovarium).
The choice of instrument directly dictates the surgical technique:
- Monopolar coagulator allows simultaneous coagulation and cutting of tissues.
- When using bipolar forceps, complete vascular coagulation is achieved first, and the mechanical tissue division itself is performed using endoscopic scissors.
The specimen (ovary along with the uterine tube) is evacuated from the abdominal cavity through an enlarged puncture site. The surgical procedure concludes with mandatory peritoneal lavage—thorough rinsing of the abdominal cavity with isotonic sodium chloride solution to remove blood clots and verify hemostasis.
Briefly: answers to topical questions
Which blood vessels run within the suspensory ligament of the ovary (ligamentum suspensorium ovarii)?
The suspensory ligament of the ovary (ligamentum suspensorium ovarii, or ligamentum infundibulopelvicum) contains blood vessels that supply blood to the ovary and uterine tube:
- Ovarian artery (a. ovarica) — descends into the pelvis from the aorta or renal artery.
- Ovarian vein (v. ovarica) — accompanies the artery as part of a well-developed venous plexus.
Branches of the ascending branch of the uterine artery may also be located within the ligament, forming prominent anastomoses with the ovarian artery for combined blood supply.
What anatomical structures are removed during total hysterectomy with adnexectomy?
During total hysterectomy with adnexectomy, the following are removed:
- Uterine body and cervix — the uterus is removed entirely.
- Uterine tubes.
- Ovaries.
In malignant ovarian neoplasms, the standard scope of surgery also includes greater omentectomy.
How to prevent ureteral injury during coagulation and transection of the suspensory ligament of the ovary?
To prevent iatrogenic ureteral injury, mandatory visual tracking of its course must be maintained throughout the entire surgical procedure.
This is critically important because the ovarian artery descends into the pelvis alongside the ureter and runs within the thickness of the suspensory ligament of the ovary (ligamentum infundibulopelvicum). Additionally, when working with uterine vessels, clamps should be applied strictly parallel to the lateral margin of the uterus and as close to it as possible to avoid accidentally catching the ureter.
How is the uterus itself extracted from the abdominal cavity during laparoscopic hysterectomy?
According to the cited sources for laparoscopic supracervical hysterectomy, two methods for extracting the uterine body are indicated:
- using a morcellator;
- through a colpotomy incision.
When using colpotomy, the vaginal wall is sutured laparoscopically or via a vaginal approach. During morcellation, the use of a special retrieval bag is recommended to prevent tissue dissemination.
For quick recall of additional trocar placements, use the 'Inverted Triangle' rule: two ports are located laterally (medial to the anterior superior iliac spine), and the third is positioned inferiorly on the midline (suprapubically).
Class and exam questions
Why is the primary trocar insertion near the umbilicus contraindicated in the presence of adhesions?
In this area, there is a high risk of injuring intestinal loops adhered to the scar. Shifting the access point to the left and superior to the umbilicus allows for safe insertion of the optics outside the adhesion conglomerate.
What is the main purpose of transferring the patient to the Trendelenburg position?
Tilting the operating table into the head-down position causes the intestines and omentum to shift into the upper abdomen, freeing up the necessary workspace for pelvic surgery.
What is the difference between monopolar and bipolar instrument operation during ovarian detachment?
A monopolar instrument allows the surgeon to coagulate and cut tissue simultaneously. A bipolar instrument is intended solely for coagulation, after which the tissue must be transected separately using endoscopic scissors.
How are resected tissues extracted from the abdominal cavity?
The severed uterine tube and ovary are extracted using an atraumatic grasper through one of the lateral port sites (usually the left), which is slightly enlarged beforehand.
What else to study on this topic
- Anatomy of avascular zones of the anterior abdominal wall and prevention of bleeding
- Operation modes of electrosurgical generators: monopolar and bipolar coagulation
- Topographic anatomy of the ligamentous apparatus of the ovary and uterine tube
- Safety procedures for the insertion of the Veress needle and the primary trocar
- Management of patients with giant myomas and severe obesity
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