Nuala Campbell & Jonathan Hindley

(This article was originally published in the Journal of One-Day Surgery Vol. 23 No. 1, 2013. It was Number 2 in the 'How i Do It' series, updated in 2020)

Patient Selection

• Any woman listed for laparoscopic hysterectomy  who fulfills DSU criteria and desires day surgery pathway  – patient led

• We have tended to avoid women with chronic pain either incidental to or being treated with hysterectomy as we feel that their postoperative pain management is more complex. This is a pragmatic rather than evidence based criterion and is flexible on discussion with patient.

• We have avoided women with large (greater than 14 week equivalent) uteri or other pathology that we feel increase the likelihood of conversion to laparotomy

Anaesthetic Techniques

• Induction and maintenance with target controlled propofol and remifentanyl infusions.
• Intubation and controlled ventilation using Pressure Controlled Ventilation- Volume Guaranteed and 5 mmHg of PEEP – this procedure requires very steep trendelenberg, and this mode keeps barotrauma to a minimum whilst reducing atelectasis.
• Large suction beanbag behind shoulders to prevent patient slipping when tipped.
• Minimum 3 metre infusion line for TIVA and a tap and extension on the fluid line: arms are tucked to the side and inaccessible during the case. 
• Always give 1 litre crystalloid as this reduces PONV and dizziness: usually do not need more than this.
• IV Dexamethasone 4mg, cyclizine 50mg. Give the cyclizine just before pneumoperitoneum as the tachycardia side effect is useful at this stage!
• Subcutaneous fragmin 5000u at end of procedure

Surgical Technique

• Standard Total Laparoscopic Hysterectomy with or without removal of ovaries
• Verres entry with high CO₂ pressures then operating at 12 to 15mmHg. Three or four port laparoscopy
• RUMI manipulator with balloon colpo-pneumo-occluder and KOH cups to manipulate uterus and maintain pnuemoperitoneum (Have previously used McCartney tubes)
• Pedicles secured with bipolar diathermy throughout (reusable instruments)
• Vault sutured laparoscopically – needle introduced through 11mm port

Peri-operative Analgesia

• Pre medication with oral Ibuprofen Retard 1600mg and Paracetamol 1G
• Intra operative: IV fentanyl 2 mcg/kg.
• Post operative IV fentanyl, then oramorph and regular paracetamol.

Take Home Medication

• Paracetamol 500 mg/ codeine 30mg po qds, laxido 1 sachet bd, plus ibuprofen 400 mg po qds
• Organisational issues
• Pre operative brief to include PACU staff member as anticipation of individual patient issues hugely valuable in this patient group
• Day Surgical Unit theatre team experienced in major gynaecological laparoscopic cases with skills that enable conversion to open procedures – staff rotate to main theatres if unfamiliar with open cases.
• Urinary catheter throughout procedure but removed in theatre prior to reversal of anaesthesia

Organisational issues

• Pre operative brief to include PACU staff member as anticipation of individual patient issues hugely valuable in this patient group
• Day Surgical Unit theatre team experienced in major gynaecological laparoscopic cases with skills that enable conversion to open procedures – staff rotate to main theatres if unfamiliar with open cases.
• Urinary catheter throughout procedure but removed in theatre prior to reversal of anaesthesia

Common Pitfalls

• Fluid redistribution from positioning: warn patient beforehand of periorbital/facial swelling

Anticipated day case rates

• 75%