Extended procedures greatly enhance the safety of laparoscopy, and allow the surgeon to complete an operation that otherwise would have required open surgery. They include uterine artery ligation, ureterolysis, enterolysis, and lateral bladder dissection.
- Uterine Artery Ligation
True Advanced Retroperitoneal Laparoscopic Surgeons are able to perform uterine artery ligation (UAL) in the retroperitoneal space. UAL is a technically difficult procedure to learn, but once mastered changes the approach and outcomes for surgery and patients dramatically. UAL is the ligation, or transection, of the uterine artery in the retroperitoneal space. This procedure once mastered is fast, efficient, and dramatically decreases blood loss and complications during surgery. A very important basic to any surgical procedure is to control bleeding. When bleeding is under control, complications during the procedure and to the patient decrease. UAL is used by ARLS surgeons for all cases of hysterectomy, and enables the surgeon to remove massive fibroid uteri easily and safely. It is also used for the treatment of severe cases of endometriosis or adhesions, allowing a minimally invasive approach where open procedures would almost always be used. UAL can also be used in some cases of myomectomy to prevent hysterectomy and to decrease bleeding during and after the procedure. - Ureterolysis
The gentle dissection and movement of the ureter, known as ureterolysis, is a very important part of ALS procedures. Ureterolysis is used to move the ureter from harms way during procedures. Since the ureter courses very close to the uterus and cervix, identification and dissection of the ureter is often needed to avoid injury. This allows completion of complex cases such as very large uteri, myomectomy, extensive endometriosis, or severe scar tissue from prior surgery. The ureter is one of the most common sites of injury during laparoscopic surgery, and it is an area of great concern for all GYN surgeons. ARLS surgeons have specialized training in the identification, dissection, and repair of the ureter should injury occur. Standard laparoscopic surgeons and OBGYN physicians rarely, if ever, perform retroperitoneal dissection and ureterolysis, and are not trained in the anatomy and repair of the ureter should this be required. - Enterolysis
The removal of scar tissue from the bowel, or enterolysis, is one of the most difficult of all procedures to perform in any type of surgery. Some patients who have had open surgery and some laparoscopic procedures have developed extensive scar to the bowel that will require removal should additional surgery be required. Scar tissue can occur in GYN procedures such as C-section, myomectomy, or in any open surgery to the pelvis or abdomen. Other patients who have had infection in the pelvic or abdominal cavities will have extensive scar tissue as well. Infection and prior surgery create rough surfaces to the lining of the body, called the peritoneal lining, and to the bowel itself. These rough surfaces cause the bowel to stick to other bowel loops and to the peritoneal lining. Scar tissue is formed by the healing process to these rough areas, and causes the surfaces to stick together. Extensive scarring leads to dense adhesions that must be removed in order to gain access to the pelvis for GYN procedures. This means that the adhesions between the bowel and bowel, and the bowel and the peritoneal lining, must be removed in order to complete the surgery. Enterolysis is essentially removal (lysis) of bowel (entero) adhesions. Once the adhesions are removed the surgeon can now see the normal orientation of structures in the pelvis. The ability of the surgeon to see all the structures greatly decreases the risk of injury and bleeding.
By far, the greatest cause of standard laparoscopic surgeons and OBGYNs failing to complete surgery with minimally invasive approaches is adhesive disease. Enterolysis allows an ARLS surgeon to “restore” normal anatomy safely, and complete the procedure laparoscopically. Laparoscopic surgeons not well trained in ARLS and enterolysis have a much greater risk of incurring bowel injury, and very commonly convert the procedure from laparoscopic to open to avoid this risk. Open procedures using large incisions increase pain, postoperative complications, blood loss, and extend recovery to 6 to 8 weeks or more. - Lateral Bladder Dissection
Lateral bladder dissection, or LBD, is a new advance in ARLS procedures that allow removal of a bladder that is adherent, or “stuck” to the uterus or other structures safely. In many cases of C-section, the bladder can be densely adherent to the uterus, and removal with standard approaches can difficult. There is a high risk of injury to the bladder when standard approaches are used during removal, including bladder defects and injury to the ureter, requiring additional surgery. With LBD, the retroperitoneal space is opened, and the bladder is dissected off the uterus from below with ease. The adhesions between the bladder and the uterus are lysed (cut) safely and quickly, and the risk of injury is dramatically decreased. Using LBD techniques, any patient becomes a candidate for laparoscopy regardless of how many C-sections they have had. This is an important point to understand. Many non ARLS surgeons without this training will not offer laparoscopic procedures to patients with prior C-section for fear of complications to the bladder during surgery.