Laparoscopic hysterectomy has become a widely accepted minimally invasive alternative to abdominal hysterectomy for the treatment of benign and malignant gynecological conditions. One of the key steps in this procedure is the ligation of the uterine arteries, which ensures effective hemostasis and facilitates safe removal of the uterus. In selected patients, particularly those with coexisting appendiceal pathology such as chronic appendicitis, endometriosis involving the appendix, or incidental appendiceal disease, a simultaneous laparoscopic appendectomy may be performed.

The combination of both procedures during a single laparoscopic session minimizes the need for multiple surgeries, reduces anesthesia exposure, and improves overall patient outcomes.

Indications
Laparoscopic Hysterectomy

Symptomatic uterine fibroids.

Adenomyosis with refractory symptoms.

Endometriosis involving the uterus.

Abnormal uterine bleeding not responding to medical therapy.

Pelvic organ prolapse in selected patients.

Early-stage endometrial carcinoma in appropriate candidates.

Simultaneous Appendectomy

Chronic right iliac fossa pain associated with chronic appendicitis.

Endometriosis involving the appendix.

Incidental appendiceal pathology detected during hysterectomy.

Preventive appendectomy in women at risk of future appendicitis, particularly when pelvic anatomy is already exposed.

Preoperative Evaluation

Clinical History and Examination:

Detailed gynecological and gastrointestinal history.

Abdominal and pelvic examination for tenderness, mass, or prolapse.

Imaging:

Pelvic ultrasound or MRI for uterine pathology.

Abdominal ultrasound or CT if appendiceal disease is suspected.

Laboratory Investigations:

Complete blood count, renal function, coagulation profile.

Tumor markers in cases of suspected malignancy.

Patient Counseling:

Discuss risks and benefits of dual procedure.

Explain potential complications including bleeding, bowel injury, urinary tract injury, or infection.

Anesthesia and Positioning

General anesthesia with endotracheal intubation.

Patient placed in dorsal lithotomy position with both arms tucked.

Trendelenburg tilt (15–30 degrees) for pelvic exposure.

Foley catheter placed to decompress the bladder.

Port Placement

A four-port laparoscopic configuration is typically used:

Umbilical port (10–12 mm): For the laparoscope.

Two lateral 5 mm ports: For operative instruments.

Additional suprapubic or right lower quadrant port: Facilitates appendectomy.

Port placement may be modified depending on uterine size and pelvic anatomy.

Surgical Steps
Diagnostic Laparoscopy

Inspection of pelvic and abdominal cavity.

Identification of uterus, adnexa, ureters, and appendix.

Adhesiolysis performed if necessary.

Ligation of Uterine Artery

Round ligaments coagulated and divided to access broad ligament.

Broad ligament opened, and ureters identified and safeguarded.

Uterine arteries skeletonized and coagulated at their origin using bipolar cautery or advanced vessel sealing devices.

This step significantly reduces intraoperative blood loss, especially in large or vascular uteri.

Completion of Hysterectomy

Bladder dissected downward from cervix.

Cardinal and uterosacral ligaments divided.

Colpotomy performed circumferentially, and uterus detached.

Specimen retrieved vaginally, morcellated if necessary.

Vaginal cuff closure performed laparoscopically with absorbable sutures, ensuring hemostasis and cuff integrity.

Simultaneous Appendectomy

Appendix identified in right iliac fossa.

Mesoappendix coagulated and divided to control appendicular vessels.

Base of appendix ligated using endoloop, stapler, or intracorporeal suturing.

Appendix removed through a specimen retrieval bag to prevent contamination.

Postoperative Care

Early mobilization and oral intake encouraged.

Pain management primarily with NSAIDs; opioids reserved for breakthrough pain.

Foley catheter typically removed within 24 hours.

Antibiotics may be continued if appendiceal inflammation was present.

Discharge within 24–48 hours, depending on recovery.

Follow-up scheduled to assess wound healing and postoperative recovery.

Advantages

Single anesthesia exposure: Avoids the risks of two separate surgeries.

Minimally invasive approach: Smaller incisions, less pain, faster recovery.

Reduced hospital stay and cost: Both conditions treated simultaneously.

Enhanced visualization: Laparoscopy allows magnification for safe dissection of vessels and appendix.

Prophylactic benefit: Removal of appendix prevents future appendicitis, especially valuable in women with recurrent pelvic pain.

Complications

Intraoperative: Ureteral, bladder, bowel, or vascular injury.

Postoperative: Infection, vaginal cuff dehiscence, bleeding, ileus, or adhesions.

Appendectomy-related: Abscess, stump leak, or bowel injury (rare).

Prevention: Careful dissection, identification of anatomic landmarks, meticulous hemostasis, and use of retrieval bags for specimen removal.

Conclusion

Laparoscopic hysterectomy with ligation of uterine artery and simultaneous appendectomy is a safe, effective, and efficient approach for patients presenting with uterine pathology and concurrent or incidental appendiceal disease. The dual procedure reduces operative trauma, hospital stay, and the need for subsequent surgeries.

With meticulous surgical planning, proper port placement, and careful dissection, this combined laparoscopic approach offers excellent outcomes, minimal complications, and faster recovery, reflecting the strength of modern minimally invasive gynecologic and general surgery.