An original and effective technique to improve exposure in open surgery
Nohuz and Chêne Gynecological Surgery
An original and effective technique to improve exposure in open surgery
E. Nohuz 0 1 3
G. Chêne 2 4
0 EA 4681, PEPRADE, Université d'Auvergne , CHU Estaing, 1, place Lucie Aubrac, 63001 Clermont-Ferrand , France
1 Department of Obstetrics and Gynecology, General hospital of Thiers , Route du Fau, 63300 Thiers , France
2 Department of Obstetrics and Gynecology , hôpital Femme-Mère-Enfant, HFME, Hospices civils de Lyon, CHU de Lyon, 59, boulevard Pinel, 69000 Lyon , France
3 EA 4681, PEPRADE, Université d'Auvergne , CHU Estaing, 1, place Lucie Aubrac, 63001 Clermont-Ferrand , France
4 EMR 3738 , Université Claude Bernard Lyon 1, 69000 Lyon , France
Background: Exposure, especially when the organs are enlarged, remains one of the most important issue in open surgery. Considering this constraint appears critical in the progress of the surgical procedure. We highlight our technique which affords optimal exposure and improves manipulation and extraction of enlarged organs. Results: This original and effective technique is derived from an obstetrical device used to perform an assisted vaginal delivery. It improves exposure, reduces tissue manipulation, and enhances removal of the surgical specimen during hysterectomies and myomectomies. It can be similarly helpful sometimes to grasp and remove (by mini laparotomy) enlarged adnexa during laparoscopic procedures. Moreover, this trick appears particularly suited in case of obese patients. Conclusion: This new technique procures a real benefit for both the patient and the surgeon in terms of ergonomics and safety.
Laparotomy; Myomectomy; Hysterectomy; Obstetric vacuum cup; Surgical technique
Material and methods
In our practice, we use a trick with which exposure and
maneuvering are facilitated. The use of a disposable Kiwi
OmniCup® delivery device (Clinical Innovations®, Murray,
Utah, USA) is a simple method to enhance exposure in
open surgery, providing optimization of the operating space
with adequate manipulation of the surgical specimen. This
device, commonly used by obstetricians to perform an
assisted vaginal delivery (instrumental extraction), is
also used during a difficult fetal extraction by cesarean
section [
1–3
]. It is a plastic, cup-shaped instrument which
is applied to the fetal head after verification of the absence
of vaginal wall (in case of vaginal delivery) and uterine
wall (in case of cesarean section) in the suction area. As
opposed to other surgical instruments, it does not increase
the fetal head diameter for delivery. These advantages can
be used in open surgery procedures. Indeed, the limited
size of the device and the mobility of its traction system
can release the operative field and facilitate the
uteroadnexal exposure and extraction during open surgical
procedures. Moreover, the laparotomy incision size is reduced
because it is not necessary for the hands of the surgeon
(or any instrument) to grasp the organ by surrounding it.
Thus, this technique avoids the need for potentially
hemorrhagic gests as traction sutures, or traumatic
maneuvers, as surgical retractors whose use can lead to
significant postoperative pain and even bowel, bladder, or
parietal injuries. The use of a screw when performing a
hysterectomy by laparotomy seems less ergonomic since
this instrument does not allow all the degrees of freedom
that the vacuum cup provides. In addition, the vacuum
cup avoids any hysterotomy, and thus any tearing of the
serous and the muscularis of the uterus. These points can
thus represent advantages in terms of bleeding and
carcinological safety. Additionally, the use of a single-use
suction cup simplifies the sterilization logistics.
Results and discussion
Surgical technique (Additional file 1)
We use a device of 50-mm diameter which provides the
exposure of voluminous uterus during hysterectomies
performed by laparotomy (Fig. 1). This size is commonly
used in our obstetric practice. The vacuum cup is
positioned on the fundus of the uterus to tract it, through
the parietal incision. Its flexible-stem and low profile cup
enable placement over the uterus no matter the depth of the
operating space, making this technique particularly suited in
an obese patient in whom the pelvic cavity offers a limited
accessibility. This one is used as a real lever that allows the
gripping while improving the dissection. Care must be
taken to check the absence of tissue between the organ
and the device (bowel, omentum, or fringes of the fallopian
tubes) when applying the suction cup. This verification is
visual but can sometimes be manual when the deepness of
the operative field imposes it (surgeon’s fingers must
circumscribe the contours of the suction cup before the
priming of the vacuum). It is then necessary to manually
activate the hand-held pump (connected to the vacuum
cup by a hose) which also serves as a traction handle
(manometer associating tactile sensation and traction force).
Depressions of (...truncated)