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Surgical Techniques SURGICAL TECHNIQUES ■ BY MARCO A. PELOSI II, MD, and MARCO A. PELOSI III, MD 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. lthough laparoscopic hysterectomy Position, incision, and retraction offers a minimally invasive alternative are crucial to success Ato laparotomy when vaginal hysterec- ur minilaparotomy hysterectomy is a sys- tomy is contraindicated, it has its drawbacks. Otemized approach with elements derived Among them: the cost of expensive equip- from both open and laparoscopic surgery. ment, the long learning curve, and prolonged Three preparatory components are involved: operating time. • position We describe another alternative to open • incision surgery that is comparable to laparoscopic • retraction hysterectomy in postoperative pain, cosmetic All are critical to a successful hysterectomy, results, and time to return to normal activi- ensuring that the procedure never becomes a ties. Our procedure—a redesigned minila- haphazard struggle through an improvised, parotomy hysterectomy—relies on tradition- scaled-down, conventional Pfannenstiel or al open techniques and inexpensive novel vertical incision. Our approach also avoids instrumentation, making it significantly cumbersome traditional laparotomy exposure faster than laparoscopy and easy to perform maneuvers and positioning. and teach. Position: Modified lithotomy. After For patients who cannot undergo vaginal regional or general anesthesia is given, posi- hysterectomy, this new modality offers tion the patient in a modified lithotomy with an expeditious, minimal-access option. both arms tucked as for laparoscopic surgery. Gynecologists reluctant to relinquish the rou- Place the legs in boot-type stirrups, with no tine use of standard laparotomy may hip flexion and sufficient thigh abduction to find this approach an appealing, less-invasive expose the vagina. alternative. Next, perform a thorough pelvic exami- ■ Dr. Pelosi II is director and Dr. Pelosi III is associate director, nation and place an indwelling, transurethral Pelosi Women’s Medical Center, Bayonne, NJ. catheter. A sturdy, hinged uterine manipula- CONTINUED 16 OBG MANAGEMENT • April 2003 Development of the Pelosi minilaparotomy hysterectomy technique Standard minilaparotomy tried a minilaparotomy Kustner’s incision (3 cm to 5 The use of standard minilaparotomy—which is noth- cm) as the sole means of surgical access, assess- ing more than a conventional laparotomy of limited ment, and treatment for benign pelvic conditions. length (3 cm to 6 cm), performed either transversely or Benefits of this incision. When a sturdy uterine vertically—has been confined to the surgical treat- manipulator was used to facilitate exposure of the ment of benign pelvic pathology of limited extent. adnexa and uterine elevation/rotation, we found this To generate sufficient exposure to work effec- technique more effective than similar procedures tively, surgeons using the standard minilaparotomy using a scaled-down Pfannenstiel or Maylard inci- have relied on the length of the abdominal incision sion. In addition, because the incision was small and, secondarily, bowel packing and metal handheld and the extent of subcutaneous dissection required or self-retaining fixed retraction systems. When to expose the rectus fascia in a vertical fashion was exposure is difficult to achieve or maintain, howev- limited, there was no need for incision drainage. er, routine surgical maneuvers become frustrating Nor was the procedure associated with seroma for- and time-consuming—unless the clinician uses mation, as the full-sized Kustner’s incision had extensive traction force, extends the incision been.3 However, the minilaparotomy Kustner’s inci- length, or performs muscle-splitting. These alterna- sion still suffered from limited surgical exposure. tives often result in an uncomfortable, slow recov- Adding the retractor ery typical of most laparotomies, thereby negating It became clear that a soft, self-retaining abdominal the primary goal of minimally invasive surgery. retractor that is capable of creating a rapid, effective, Use of traditional minilaparotomy for hysterec- nontraumatic, and predictable circular area of abdom- tomy has been reported only rarely. Hoffman et al1 inal retraction would be helpful, particularly one that found the procedure safe and effective in non- could be placed through the minilaparotomy obese women in whom a vaginal approach was pre- Kustner’s incision.6 Once this retractor system was cluded. Benedetti Panicci et al2,3 also have used developed, using technology borrowed from hand- minilaparotomy successfully in benign gynecologic assisted laparoscopy,7-10 the minilaparotomy hys- disease and hysterectomy. terectomy became a much simpler, more useful sur- The Kustner incision gical option. 4 Originally reported in 1896, this incision is avoided REFERENCES by most surgeons in favor of complete transverse 1. Hoffman MS, Lynch CM. Minilaparotomy hysterectomy. Am J Obstet Gynecol. 1998;179:316-320. or complete vertical incisions—largely due to diffi- 2. Benedetti Panicci P, Maneschi F, Cutillo G, et al. Surgery by minilaparotomy culties with exposure, troublesome seroma forma- in benign gynecologic disease. Obstet Gynecol. 1996;87:456-459. 3. Benedetti Panicci P, Zullo MA, Casalino B, et al. Subcutaneous drainage ver- tion, and wound complications secondary to sus no drainage after minilaparotomy in gynecologic benign conditions. Am J increased fluid accumulation in the large dead Obstet Gynecol. 2003;188:71-75. 4. Kustner O. Der suprasymphysare kruzschnitt, eine methode der coeliotomie space that results from wide dissection of the sub- bei wening umfanglichen affektionen der weiblichen beckenorgane. cutaneous flap. Monatsschr Geburtshilfe Gynakol. 1896;4:197-206. 5. Pelosi MA II, Pelosi MA III. The suprapubic cruciate incision for laparoscopic In the early 1990s, we realized the potential assisted microceliotomy. J Soc Laparoendosc Surg. 1997;1:269-272. benefits of a scaled-down Kustner’s incision (2 cm 6. Pelosi MA II, Pelosi MA III. Self-retaining abdominal retractor for minilaparo- tomy. Obstet Gynecol. 2000;96:775-778. to 5 cm) when assistance was needed via minila- 7. Pelosi MA II, Pelosi MA III. Hand-assisted laparoscopy for complex hysterec- parotomy during such laparoscopic-assisted proce- tomy. J Am Assoc Gynecol Laparosc. 1999;6:183-188. 8. Pelosi MA II, Pelosi MA III. Hand-assisted laparoscopic cholecystectomy at dures as uterine morcellation, tubal reanastomosis, cesarean section. J Am Assoc Gynecol Laparosc. 1999;6:491-495. and extensive uterine suture and reconstruction fol- 9. Pelosi MA II, Pelosi MA III. Hand-assisted laparoscopy (handoscopy) for megamyomectomy: A case study. J Reprod Med. 2000;45:519-525. lowing complex laparoscopic myomectomy.5 As a 10. Pelosi MA II, Pelosi MA III, Eim J. Hand-assisted laparoscopy for pelvic malig- substitute for laparoscopy and laparotomy, we then nancy. J Laparoendosc Adv Surg Tech. 2000;10:143-150. CONTINUED April 2003 • OBG MANAGEMENT 19 Pelosi minilaparotomy hysterectomy tor is of paramount importance for the hys- Squeeze the inner ring into the peritoneal terectomy, as it facilitates exposure of the cavity through the minilaparotomy incision, adnexa as well as elevation/rotation of the allowing it to spring open against the parietal uterus and the uterine attachments. We rec- peritoneum. Conduct a digital assessment to ommend the Pelosi Uterine Manipulator ensure that no viscera are trapped by elevating (Apple Medical Corporation, Marlboro, Mass) the outer ring. Next, roll the outer ring onto or its equivalent (FIGURE 1). the sleeve, collecting excess length, until it sits Incision: Modified Kustner’s. Open the firmly against the skin (FIGURES 3B and 3C). abdomen with a cruciate incision. Using a The result, when there is adequate tension conventional scalpel and the Bovie device, within the sleeve, is a circular area of retrac- make a 2.5-cm to 5-cm transverse incision tion offering excellent exposure of the pelvis. through the skin and subcutaneous fat until Note that during surgery you may need to you reach the anterior rectus fascia (FIGURE adjust the outer ring if the sleeve loosens. 2A). Clear the fat from the midline superiorly The soft, self-retaining abdominal retrac- and inferiorly to expose approximately 5 cm tor offers several advantages over traditional to 6 cm of fascia in the vertical axis. Then abdominal retraction: incise the anterior rectus fascia in a vertical Atraumatic retraction. This device distrib- direction through the full length of the utes retraction force evenly around the entire cleared area (FIGURE 2B). incision. Because standard retractors concen- Retract the rectus muscles from the mid- trate retraction force at only a few points, they line, exposing the transversalis fascia and the often lead to tissue trauma, nerve damage, underlying peritoneum. Enter the peri- bruising, and postoperative pain. toneum digitally or with scissors above the Incision protection. The retractor’s flexible level of the bladder dome, incising vertically material lines the incision, protecting the until the entrance extends the full length of wound’s edges from contamination and the fascial incision (FIGURE 2C). potential implantation of malignant cells. This modified Kustner’s incision is essen- Improved
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