Just Stay until the Uterus is Out

The other day I scrubbed in three times. I put in three Foley catheters. I used eight pairs of sterile gloves. I sewed up three incisions. I watched an intubation. And I took out three uteruses.

Okay, so I didn't actually perform any hysterectomies; my preceptor is the only one licensed to do that. However, I was operating the uterine manipulator at the bedside while my preceptor worked at the da Vinci robot. And the person operating the uterine manipulator is the person who slides the uterus out once the hysterectomy is complete.

That it is pretty amazing for me. I have slowly moved into incrementally larger roles in the operating room: may I put in the Foley catheter in? I'll take that Vcare! Could you show me how to use the Rumi? And before I knew it, I was "delivering" a large uterus.

Admittedly, all these roles and jobs are very, very menial in the long run. It does not take a Ph.D. to obediently rotate a handle attached to a balloon in a uterus. However, it is cool to help, especially when the helping is as demonstrative as removing the organ in question. Let me tell you more about it.

Specimen from a total hysterectomy and BSO.

There were three cases that day, and each patient was very different. However, each one was scheduled for the same procedure: a TLH (total laparoscopic hysterectomy) possible BSO (bilateral salpingoophorectomy). A total hysterectomy is opposed to a supracervical hysterectomy (where the cervix is left in place), and as far as I have seen no one takes out ovaries (oophorectomy) without tubes (salpingectomy). The patients were scheduled for "possible" BSO because Dr. D likes to leave the ovaries in place when possible, to avoid placing patients on hormone replacement therapy (HRT). Dr. C preferred to take everything, reasoning that HRT keeps women comfortable sans risk of cysts, cancer, or reoperation. I don't have an authoritative opinion yet.

Anyway, the three cases were very similar. Each time, I scrubbed in and double-gloved like Dr. D (it's standard procedure always to double-glove when working at the perineum before working at the abdomen, since the vagina is naturally colonized with a ton of bacteria that the abdomen would do better without). Dr. D placed the uterine manipulator by sounding the uterus, inserting the manipulator, sewing the cervix shut around it, and inflating balloons to keep it inside the uterus and the vagina. I placed the Foley by inserting its lubricated tip into the urethra, watching for urine in the catheter, and inflating another balloon to keep it inside the bladder.

Each time, I watched as Dr. D made four small (8 to 12 millimeter) incisions in the patient's abdomen and placed trocars. Then, the scrub tech docked the da Vinci robot at the bedside, attaching the robotic arms to the trocars and placing long laparoscopic instruments into the patient's abdomen. I stood between the patient's legs, right next to the robot (in fact, sometimes my hat brushed the drapes on the robot's arms), with one hand on the uterine manipulator and both eyes on the screen. It was tricky to match what I was doing with my hands with what I saw!

I was continually confused between "patient's right," my right, and "right" on the screen. (Finally, I realized that the manipulator is a lever with its fulcrum at the patient's perineum, so almost every movement needs no translation between my right and the patient's right...except twisting, which is backwards...groan.) Dr. D sat at the robot console during the actual procedure. Throughout, she'd discuss the patient, the anatomy, and the operative technique aloud. She only quizzed me occasionally ("what ligament is this? what artery is this?"); more often, I was the one asking questions.

Each time, after the uterus was separated from its associated ligaments, its blood supply, any adhesions, and the urinary bladder, I pulled on the uterine manipulator (making sure to grab the handle, the balloon strings, and the hemostat with the stitch in the cervix) and "delivered" the uterus into the vagina, where it remained (to maintain pneumoperitoneum) until Dr. D stitched the vaginal cuff closed. At that time, I slid the uterus out and carried it carefully to a blue tub behind me. I was suprised at how small each one was! Even the largest uterus (11-12 week size and so big it was running into the camera trocar at the beginning of the case) was only as big as a pear.

The first case was unique because of the size of the uterus. The second case was unique because I closed two incisions (I'm getting faster) and because a pre-med shadowed! For the first time, I found myself a rung above someone on the medical hierarchy, and used the opportunity to the maximum, to warmly show her everything I wish someone had shown me during my first time observing surgery. The third case was unique because a newly-hired scrub tech was being introduced to the team. 

Although the new tech was experienced in her field and with the da Vinci robot, she was observing/working the case while the usual scrub tech showed her the ropes. This was because a surgical team has to be very tight-knit for a quick and smooth procedure. Especially key is a surgeon's reliance on other staff to anticipate the surgeon's instrument preferences and tendencies. This reliance and community is especially key when something remarkable or alarming happens.

Because this tech was still getting used to Dr. D's style and preferred instruments (including the particular uterine manipulator), she was glad that I was there. I was glad to actually be needed, and I liked the new tech. However, it was getting close to 1700, the time when I normally excused myself on surgery days in order to go to Mass. I watched the clock tick past 1315. Instead of the usual conscience/appetites battle, there was a very civil inquiry going on within my conscience about whether to leave or not.

"Could you just stay until the uterus is out?" asked the scrub tech when she found out I usually left at 1700.

"I see Christ in this new scrub tech," my conscience observed. "It might be uncharitable to leave. St. Therese urged her novices to put down their work and get up quickly when they heard a knock on their cell doors, and St. James tells us to see Christ in our neighbor's needs." (James 2:15-16). So I stayed.

Side note....the uterus could have slipped back into the abdomen and/or resulted in lost pneumoperitoneum. The combination of these is especially lousy, because without air in the abdomen, laparoscopy isn't safe. At the same time, the severed uterus must be taken out to prevent infection. If the uterus couldn't be returned to the vagina and if pneumoperiteum was lost, I think patient would have to be opened up. That's the crazy thing about surgery; everything can be going swimmingly, but a small thing might happen and suddenly everything can blow up in a very dangerous chaos. This incident was, on a scale of 0 (yawn) to 10 (yikes), maybe a 2.5?

And I'm glad I did, because the uterine manipulator came out of the uterus as I attempted to "deliver" it. It was probably my fault, having not grabbed the stitches attached to the cervix. I tried to grab them after the manipulator was out, but they tore through the cervix and Dr. D had to leave the console, glove, grab the cervix with a tenaculum, and pull it to the introitus.

After Dr. D returned to the robot, I maintained a tenuous grip on the anterior lip of the cervix with my fingers. The assistant was applying suction only a few centimeters away from my grip (inside the patient's body); this, combined with the conical shape of the muscular vagina, made the cervix begin to slip through my fingers again. Without anyone's notice or permission, I whipped the tenaculum out (the first time I've ever touched or used one) and clicked its merciless jaws shut onto the cervix until I withdrew the uterus.

Tenaculum. Source. 

Once the uterus was out I bid good-bye to the tech and the rest of the team. And Mass was beautiful.

The next day, I scrubbed in on a TLH/BSO and took out a patient's uterus, fallopian tubes, and ovaries. (That was a especially nifty because I got to see all the structures that are hard to see in cadavers, like the epoophoron and the mesosalpinx. I also closed two incisions!) I was careful to grab the stitches through the cervix when I withdrew the manipulator. :)