Hysterectomy, the surgical removal of the uterus, is a common procedure in gynecology performed for both benign and malignant conditions. While hysterectomy for a normal-sized uterus is routine, removal of a large uterus presents unique challenges due to its size, vascularity, and proximity to surrounding organs.

A large uterus is commonly seen in conditions such as fibroids (leiomyomas), adenomyosis, and, rarely, malignancies. Advances in minimally invasive surgery now allow surgeons to perform hysterectomy even in cases of significantly enlarged uteri, reducing morbidity, hospital stay, and recovery time.

Dr. R. K. Mishra, a pioneer in advanced laparoscopic gynecology, has developed techniques and approaches that make hysterectomy for a large uterus safe, effective, and reproducible.

Indications

Hysterectomy for a large uterus is indicated in patients with:

Symptomatic fibroids: Causing heavy menstrual bleeding, pain, or pressure symptoms

Adenomyosis: Unresponsive to medical management

Suspicion of malignancy: When conservative treatments are insufficient

Recurrent abnormal uterine bleeding affecting quality of life

Pelvic organ prolapse associated with a large uterine mass

Contraindications include poor general health, uncorrected coagulopathy, or active pelvic infection unless surgery is urgent.

Preoperative Assessment
Imaging

Ultrasound or MRI to determine uterine size, fibroid number and location, and relationship to adjacent organs

Helps in planning surgical approach and anticipating technical challenges

Laboratory Evaluation

Complete blood count, coagulation profile, renal and liver function tests

Blood typing and crossmatch in case transfusion is needed

Patient Counseling

Discuss surgical approach (open, laparoscopic, or hybrid)

Explain risks such as bleeding, infection, injury to bladder or ureters, and need for transfusion

Recovery expectations and activity restrictions

Surgical Approaches
Abdominal Hysterectomy

Traditional approach for very large uteri (>1–1.5 kg)

Provides excellent exposure and control of blood vessels

Requires a larger incision and longer recovery compared to minimally invasive techniques

Laparoscopic Hysterectomy

Feasible for moderately large uteri with skilled surgeons

Uses small incisions, laparoscopic instruments, and morcellation (if indicated) for extraction

Benefits include less postoperative pain, shorter hospital stay, and faster recovery

Vaginal or Laparoscopically Assisted Vaginal Hysterectomy

Rarely used for extremely large uteri

Vaginal delivery may be limited by size, mobility, and pelvic anatomy

Surgical Technique (Laparoscopic Approach)

Patient Positioning:

Dorsal lithotomy with Trendelenburg tilt for optimal pelvic access

Port Placement:

Umbilical port (10–12 mm) for the camera

Accessory ports (5–10 mm) strategically placed to accommodate uterine size and instrument movement

Uterine Mobilization:

Identify and ligate round ligaments, uterine arteries, and ovarian ligaments

Careful dissection to preserve ureters and bladder

Reduction of Uterine Size:

Morcellation or debulking techniques may be required for extremely large uteri

Ensures safe extraction through laparoscopic ports or vaginally

Specimen Removal:

Intact or morcellated uterus is removed depending on size and malignancy risk

Ensure minimal spillage and tissue handling

Closure:

Vaginal cuff or abdominal closure performed with absorbable sutures

Hemostasis confirmed and ports closed

Advantages of Minimally Invasive Hysterectomy for Large Uterus

Reduced postoperative pain and smaller scars

Shorter hospital stay and faster return to daily activities

Lower risk of wound complications and infection

Enhanced visualization for precise dissection, reducing the risk of bladder and ureteral injury

Fertility considerations for women undergoing hysterectomy for benign conditions in earlier stages (if partial procedures are considered in specific cases)

Challenges

Limited working space and visualization

Increased vascularity, raising the risk of bleeding

Morcellation carries risks of tissue dissemination if malignancy is unsuspected

Requires advanced laparoscopic skills and experience

Dr. R. K. Mishra emphasizes that careful preoperative planning, patient selection, and meticulous surgical technique ensure safety and optimal outcomes.

Conclusion

Hysterectomy for a large uterus is a complex but achievable procedure with modern surgical techniques. Whether performed abdominally or laparoscopically, meticulous attention to anatomy, vascular control, and careful dissection are essential.

Minimally invasive approaches, when feasible, offer reduced pain, faster recovery, and excellent cosmetic results, while maintaining surgical safety. Surgeons trained in advanced techniques, like those taught by Dr. R. K. Mishra, can perform hysterectomy for large uteri effectively, ensuring patient safety, satisfaction, and improved quality of life.