TLH困難症例に対する施設内の新しい試み

At our hospital, we have incrementally expanded the indications for total laparoscopic hysterectomy (TLH) since its introduction in 2019. We report on our experience with a patient who had TLH for a cervical fibroid complicated by endometriosis, which resulted in a surgery of more than eight hours. Through this case, we considered the indications and approach for TLH within our institution. The patient was a 48-year-old female with two previous childbirths and her medical history included left adnexectomy due to endometriosis and two cesarean sections. The patient presented to our department with a chief complaint of persistent urinary frequency over several years. Magnetic resonance imaging revealed a cervical fibroid compressing the bladder and suspected adhesions in the pouch of Douglas. After explaining the possibility of conversion to open surgery and obtaining consent, the decision was made to proceed with TLH using a uterine transilluminator and a fluorescent ureteral catheter. TLH was performed by three doctors without complications, but the operating time was significantly prolonged to 8 hours and 21 minutes. In light of this case, we considered establishing institutional standards for TLH, focusing on the following two new approaches: (1) Conducting a preoperative evaluation for patients where TLH might be difficult, and considering open surgery or TLH under the guidance of an expert, if necessary; (2) Implementing timely time-outs during the procedure. We aim to assess the effectiveness of these measures in the future.