Space Oriented Approach for Total Laparoscopic Hysterectomy: A New Concept to Prevent Ureteral Heat Damage Based on Clinical Pelvic Anatomy

Study Objective Ureteral thermal damage is an important complication of hysterectomy. Blind electrocautery or electrocautery against hemorrhage from periureteral vessels is supposed as a major cause of this complication. New concept of a rearranged approach to retroperitoneal space based on clinical anatomy of pelvis is introduced as ‘space oriented approach’ to prevent thermal damage of ureter in total laparoscopic hysterectomy. This approach is introduced in video and effect on peri-ureteral hemorrhage is verified. Design Retrospective case series. Setting Single hospital in Japan. Patients or Participants Randomly selected 16 patients, 8 patients in each category, undergone total laparoscopic hysterectomy in Osaka Rosai Hospital between 2018-2020. Interventions Total laparoscopic hysterectomy was done by 'space-oriented approach' and 'organ-oriented approach'. In ‘space-oriented approach’, ureter is kept wrapped in subperitoneal fascia with its feeding vessels. Pararectal space of Latzko is the primary target to be developed. A space in lateral side of sacrouterine ligament is the other target to be developed. Ureter is dislocated from uterine cervix as a consequence. In 'organ-oriented approach', ureter is directly approached to dislocated from uterine cervix. Measurements and Main Results Randomly selected surgical video of 8 cases of total laparoscopic hysterectomy done by 'space-oriented approach' was compared to 8 cases done by 'organ-oriented approach on periureteral electrocauterization before and after colpotomy. Fisher's exact test is used for statistical analysis. Total sides of electrocautery attempted in 8 cases are decreased significantly in ‘space-oriented approach’ before colpotomy (15/16 vs. 0/16, p=0.0000000566) and after colpotomy (10/16 vs. 0/16, p=0.000248) compared to historical control. Conclusion ‘Space oriented approach’ is an effective method to prevent ureteral thermal damage theoretically and clinically in total laparoscopic hysterectomy.