A Gauze-tying Trocar Technique for Laparoscopic Hysterectomy Procedures Involving Large Uteri.

To the Editor,

At present, as a laparoscopic approach is widely preferred during surgery for benign gynecological lesions, laparoscopic hysterectomy is widely performed even in obese patients.[1] The uterine size indications for such surgery have expanded. However, in cases involving large uteri, laparoscopic hysterectomy is difficult, and the operation time and estimated amount of intraoperative blood loss are significantly increased in cases involving uterine weights of >750 g. In a previous study, the frequencies of excessive bleeding and transfusion use during laparoscopic hysterectomy were significantly increased in patients with large uteri.[2] In addition, laparoscopy was found to be superior to laparotomy with regard to pain levels, the speed of recovery, and the frequency of complications.[3] Therefore, it is important to have skilled surgeons in cases of gynecological lesions in patients with large uteri. Here, we introduce the effective use of limited surgical fields in the abdominal cavity.

In large uteri, the effective creation of the surgical field is essential. Due to the small size of the surgical field in laparoscopic hysterectomy, the distances between trocars and uterine ligaments are very short, and there is little space in which to move grasping tools. In Japan, the modified diamond trocar positions are widely used for laparoscopic hysterectomy, and scalpels and energy devices are usually used via the central trocar. In large uteri, central trocars are located close to uterine ligaments, and we often experience cases in which the graspers of energy devices are not able to open because the tip of the trocar is in contact with the tissue that is about to be cut [Figure 1a]. Thus, we propose a technique for tying gauze to a trocar [Figure 1b]. In this technique, gauze is attached to the abdominal wall, so that the trocar cannot pass into the abdominal cavity [Figure 1b and c]. Therefore, it is possible to freely adjust the length of the trocar, even in obese patients, in which long trocars have to be used. This technique is quite useful when trocars that do not have anti-slip mechanisms, such as cheap and reused trocars, are employed. We successfully used this technique with robotic trocars, which aided the learning curve.[4] The greatest advantages of this technique are very low cost and easy to perform.

Figure 1

(a) The grasper of the energy device could not open because the tip of the trocar was in contact with the tissue that was about to be cut. (b) Gauze was tied to a trocar. (c) The gauze was stuck in the abdominal wall, so the trocar could not pass into the abdominal cavity

Laparoscopic surgery has many merits as treatment for gynecological lesions in patients with large uteri, but it requires an experienced surgeon.[5] As our skill and experience increased, we were able to perform laparoscopic hysterectomy in patients with large uteri.

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Conflicts of interest

There are no conflicts of interest.