Hysterectomy, the surgical removal of the uterus, is one of the most common gynecologic procedures performed worldwide. Indications include uterine fibroids, adenomyosis, abnormal uterine bleeding, endometriosis, and malignancy. In cases of large uterus, often defined as weighing over 500–600 grams or equivalent to a 12–16 week gestation size, surgical management can be challenging due to limited pelvic space, distorted anatomy, and increased risk of bleeding.

Laparoscopic hysterectomy offers a minimally invasive approach, even for large uteri, providing smaller incisions, reduced postoperative pain, shorter hospital stay, and faster recovery. Advances in laparoscopic techniques, energy devices, and specimen retrieval methods have made it feasible and safe for large uterine sizes.

Indications

Laparoscopic hysterectomy for large uterus is indicated in:

Symptomatic fibroids causing menorrhagia, pain, or pressure symptoms.

Adenomyosis unresponsive to medical therapy.

Endometrial hyperplasia or early-stage malignancy requiring surgical intervention.

Uterine prolapse with large uterine size complicating conservative approaches.

Patient selection is essential, taking into account comorbidities, previous abdominal surgeries, and BMI, as these factors can influence operative complexity.

Preoperative Evaluation

Clinical Assessment:

Detailed history including symptoms, parity, prior surgeries, and comorbidities.

Pelvic examination to assess uterine size, mobility, and associated pelvic pathology.

Imaging:

Ultrasound or MRI to evaluate uterine size, fibroid number and location, and endometrial thickness.

CT scan may be used in cases of suspected malignancy or complex anatomy.

Laboratory Investigations:

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

Preoperative tumor markers if malignancy is suspected.

Patient Counseling:

Discuss procedure benefits, risks, and potential need for morcellation or mini-laparotomy if specimen extraction is difficult.

Explain complications such as bleeding, infection, ureteral or bladder injury, and conversion to open surgery.

Anesthesia and Positioning

General anesthesia with endotracheal intubation is required.

Patient placed in dorsal lithotomy position with arms tucked.

Trendelenburg tilt (15–30 degrees) allows bowel displacement for better pelvic access.

A Foley catheter is inserted to decompress the bladder and aid visualization.

Port Placement

Port placement is critical in cases of large uterus due to limited pelvic working space:

Primary camera port: Usually supraumbilical or at Palmer’s point for better visualization of large uterus.

Two lateral 5 mm working ports: Placed under direct vision to allow instrument triangulation.

Optional accessory port: May be added for uterine manipulation or additional retraction.

Uterine manipulator is used vaginally to enhance mobilization and exposure of the uterine vessels.

Surgical Steps
Diagnostic Laparoscopy

Survey of the abdominal and pelvic cavity for adhesions, endometriosis, or adnexal pathology.

Adhesiolysis performed if required to mobilize the uterus safely.

Dissection and Vessel Control

Round ligaments are coagulated and transected.

Broad ligaments opened; ureters identified and protected.

Uterine arteries ligated at origin using bipolar or advanced energy devices to minimize blood loss.

Meticulous hemostasis is essential due to vascularity of large uteri.

Colpotomy

Circumferential incision around the cervix to detach the uterus from the vaginal cuff.

Large uteri may require mini-laparotomy, vaginal extraction, or contained morcellation for removal.

Vaginal Cuff Closure

Laparoscopic closure using absorbable sutures, either intracorporeal or extracorporeal, depending on surgeon preference.

Secure closure reduces risk of vaginal cuff dehiscence and supports pelvic floor integrity.

Specimen Retrieval Techniques

Vaginal extraction: Preferred if feasible.

Contained morcellation: Minimizes risk of tissue dissemination, especially in suspected malignancy.

Mini-laparotomy: Small incision to remove very large specimens safely.

Proper technique ensures minimal tissue trauma, reduced risk of adhesions, and safe retrieval.

Postoperative Care

Early ambulation and oral intake encouraged.

Pain managed with NSAIDs and opioids if needed.

Foley catheter usually removed within 24 hours.

Discharge within 24–48 hours depending on recovery.

Avoid heavy lifting and sexual activity for 4–6 weeks.

Advantages

Minimally invasive: Smaller incisions, reduced postoperative pain.

Faster recovery: Patients return to normal activities sooner than open surgery.

Lower wound complications: Reduced infection and hematoma rates.

Better visualization: Laparoscopy provides magnification for careful dissection of ureters and vessels.

Improved cosmetic outcome due to minimal scarring.

Complications

Intraoperative: Bleeding, bladder or ureteral injury, bowel injury, difficulty in specimen extraction.

Postoperative: Vaginal cuff dehiscence, infection, adhesion formation, ileus, and hematoma.

Prevention: Careful preoperative planning, meticulous dissection, and appropriate specimen retrieval techniques.

Conclusion

Laparoscopic hysterectomy for large uterus is a safe, effective, and minimally invasive surgical option in experienced hands. With careful preoperative planning, precise port placement, meticulous dissection, and proper specimen retrieval, even very large uteri can be removed laparoscopically.

This approach offers excellent clinical outcomes, minimal complications, faster recovery, and improved cosmetic results, demonstrating the feasibility and advantages of laparoscopy for complex gynecologic surgery.