Minimally invasive surgery has revolutionized the way multiple surgical conditions can be treated in a single session. Traditionally, hysterectomy and cholecystectomy were performed as separate procedures through laparotomy, resulting in longer hospital stays, delayed recovery, and increased morbidity. With advancements in laparoscopic techniques, it has become feasible to perform both laparoscopic hysterectomy and laparoscopic cholecystectomy in the same surgical setting.

An additional innovation in this combined procedure is the transvaginal removal of the gallbladder, which eliminates the need for abdominal extraction incisions, thereby reducing postoperative pain, improving cosmesis, and enhancing recovery. This hybrid approach is an example of Natural Orifice Specimen Extraction (NOSE) surgery.

Indications

The combined procedure is most appropriate in patients who:

Require hysterectomy for conditions such as fibroids, adenomyosis, abnormal uterine bleeding, or prolapse.

Have symptomatic gallstones causing biliary colic, cholecystitis, or dyspepsia.

Prefer a single surgical session to address both gynecological and biliary pathology.

Are suitable for laparoscopic surgery with no contraindications like advanced cardiopulmonary compromise or extensive abdominal adhesions.

Preoperative Evaluation

A thorough workup is essential to ensure safe execution of both procedures:

Gynecological assessment: Pelvic ultrasound, Pap smear, endometrial evaluation if indicated.

Hepatobiliary assessment: Ultrasound abdomen, liver function tests, MRCP if choledocholithiasis is suspected.

Routine pre-anesthetic evaluation: CBC, coagulation profile, renal function, chest X-ray, and ECG.

Counseling: The patient must be explained about dual procedure risks, longer operative time, transvaginal specimen extraction, and recovery expectations.

Anesthesia and Positioning

General anesthesia with endotracheal intubation is used.

The patient is placed in a modified lithotomy position with Trendelenburg tilt, which provides exposure for hysterectomy and allows easy access to the upper abdomen for cholecystectomy.

Vaginal access is maintained for colpotomy and specimen retrieval.

Port Placement

A standard four-port laparoscopic setup is used, with slight modification to accommodate both surgeries:

Umbilical port (10–12 mm): Laparoscope insertion.

Epigastric 10 mm port: Main working port for cholecystectomy.

Right subcostal 5 mm port: Retraction of gallbladder.

Lateral 5 mm port: Assistance in both hysterectomy and gallbladder dissection.

Surgical Technique
Laparoscopic Hysterectomy

The procedure begins with laparoscopic hysterectomy.

Round ligaments are coagulated and cut, broad ligaments are dissected, and bladder is mobilized.

Uterine vessels are coagulated and transected at their origin to minimize blood loss.

Cardinal and uterosacral ligaments are divided.

Colpotomy is performed, and uterus is delivered vaginally.

The vaginal cuff is temporarily left open for specimen extraction.

Laparoscopic Cholecystectomy

After hysterectomy, the surgeon repositions focus on the right upper abdomen.

Gallbladder is retracted upward and laterally.

Calot’s triangle is dissected to clearly identify cystic duct and artery.

Both are clipped and divided.

Gallbladder is separated from the liver bed using electrocautery.

Instead of enlarging an abdominal port site, the gallbladder is placed in a retrieval bag.

Transvaginal Gallbladder Extraction

Through the colpotomy made for hysterectomy, the retrieval bag containing the gallbladder is gently pulled out.

This avoids additional abdominal incision and preserves cosmetic appearance.

The vaginal cuff is then securely closed laparoscopically with absorbable sutures to restore pelvic integrity.

Postoperative Care

Early ambulation and oral intake are encouraged within 6–8 hours.

Foley catheter is removed after 24 hours.

Pain management requires minimal opioids due to the absence of a large incision.

Vaginal bleeding is monitored.

Hospital stay is typically 2–3 days, depending on patient recovery.

Advantages

Single anesthesia exposure: Both pathologies treated at once.

Reduced trauma: Transvaginal extraction avoids additional abdominal incision.

Cosmetic benefit: No enlarged port sites, scarless abdomen.

Faster recovery: Less postoperative pain and shorter hospital stay.

Cost-effectiveness: Reduces overall expenses by combining procedures.

Challenges and Limitations

Longer operative time compared to a single procedure.

Requires surgeons skilled in both gynecological and hepatobiliary laparoscopy.

Vaginal extraction may be difficult if gallbladder is large, distended, or contains multiple stones.

Not suitable in patients with vaginal stenosis, nulliparous women with narrow introitus, or suspicion of gallbladder malignancy.

Risk of infection at the vaginal cuff, though minimized with proper sterile technique.

Complications

Intraoperative:

Bleeding from uterine vessels or cystic artery.

Bile duct or ureteral injury.

Postoperative:

Vaginal cuff dehiscence.

Pelvic infection.

Bile leak or abscess (rare).

Prompt recognition and management of these complications are essential for favorable outcomes.

Conclusion

The combined laparoscopic hysterectomy and cholecystectomy with transvaginal gallbladder extraction represents an advanced step in minimally invasive surgery. By addressing two common pathologies in a single setting and using the vaginal route for specimen removal, this technique maximizes patient benefit while minimizing surgical trauma. Although it requires advanced laparoscopic expertise and careful patient selection, it provides an excellent option for women requiring both gynecological and biliary interventions, with the added advantages of enhanced cosmesis, quicker recovery, and reduced postoperative morbidity.