Laparoscopic Hysterectomy
Hysterectomy, the surgical removal of the uterus, is one of the most commonly performed gynecological procedures worldwide. Indications include uterine fibroids, abnormal uterine bleeding, adenomyosis, endometriosis, pelvic organ prolapse, malignancy, and chronic pelvic pain.
Laparoscopic hysterectomy has transformed the field of gynecology by offering a minimally invasive alternative to open abdominal hysterectomy. Compared to traditional approaches, laparoscopic hysterectomy provides smaller incisions, less postoperative pain, faster recovery, shorter hospital stay, and improved cosmetic outcomes.
Types of Laparoscopic Hysterectomy
Total Laparoscopic Hysterectomy (TLH):
Entire uterus, including the cervix, is removed laparoscopically.
Vaginal vault closure is performed laparoscopically.
Laparoscopic Supracervical Hysterectomy (LSH):
Only the uterine body is removed; the cervix is preserved.
Recommended in selected benign cases.
Laparoscopic-Assisted Vaginal Hysterectomy (LAVH):
Initial laparoscopic dissection followed by vaginal removal of the uterus.
Often used when vaginal access alone is challenging.
Preoperative Evaluation
Clinical Assessment:
Detailed gynecologic history, including menstrual history, parity, and previous pelvic surgeries.
Physical examination including pelvic examination to assess uterine size, mobility, and adnexal masses.
Imaging:
Ultrasound or MRI may be used to evaluate uterine size, fibroid location, endometrial thickness, or adnexal pathology.
Laboratory Investigations:
Complete blood count, coagulation profile, and blood type.
Pregnancy test if of reproductive age.
Anesthesia Clearance:
General anesthesia is required for laparoscopic hysterectomy.
Patient Counseling:
Discuss procedure, alternatives, risks (bleeding, infection, injury to bladder, bowel, ureter), and recovery.
Patient Positioning and Anesthesia
General anesthesia with endotracheal intubation.
Patient placed in dorsal lithotomy position with arms tucked.
Trendelenburg tilt (15–30 degrees) allows bowel to fall away from the pelvis for better visualization.
Foley catheter inserted to decompress the bladder.
Port Placement
Standard four-port technique:
Umbilical port (10–12 mm): Camera port.
Two lateral ports (5 mm): Working ports for dissection, coagulation, and suturing.
Suprapubic port (5 mm): Optional, used for uterine manipulation or retraction.
Alternative port configurations may be used depending on uterine size, adhesions, or surgeon preference.
Surgical Steps
Initial Inspection:
Laparoscopic survey of the pelvis and abdomen.
Assessment of adhesions, adnexa, and uterine pathology.
Uterine Manipulation:
Uterine manipulator inserted vaginally to mobilize the uterus.
Facilitates visualization of uterine vessels, broad ligament, and adnexa.
Dissection:
Round ligaments are coagulated and transected.
Broad ligaments opened, ureters identified and protected.
Fallopian tubes and ovaries may be preserved or removed based on indication.
Uterine arteries are coagulated at their origin from the internal iliac vessels for hemostasis.
Colpotomy:
Circumferential incision around the cervix or vaginal cuff.
Uterus detached and removed through the vagina or morcellated for large uteri.
Vaginal Vault Closure:
Done laparoscopically using absorbable sutures in a continuous or interrupted fashion.
Ensures hemostasis and prevents vault prolapse.
Postoperative Care
Early ambulation to reduce risk of deep vein thrombosis.
Pain management primarily with NSAIDs; opioids if needed.
Oral intake as tolerated.
Most patients discharged within 24–48 hours depending on procedure complexity.
Avoid heavy lifting or sexual activity for 4–6 weeks.
Advantages of Laparoscopic Hysterectomy
Minimally invasive: Smaller incisions and better cosmesis.
Reduced postoperative pain and analgesic requirement.
Faster recovery and return to daily activities.
Shorter hospital stay compared to open hysterectomy.
Enhanced visualization: Ability to identify adhesions, endometriosis, and adnexal pathology.
Reduced blood loss due to meticulous vessel control.
Complications and Risk Management
Intraoperative: Bleeding, injury to bladder, ureter, bowel, or major vessels.
Postoperative: Infection, hematoma, vaginal cuff dehiscence, thromboembolism, and port-site hernia.
Prevention: Proper patient selection, careful dissection, identification of ureters and bladder, and meticulous hemostasis.
Conclusion
Laparoscopic hysterectomy is a safe and effective minimally invasive alternative to open abdominal hysterectomy for benign and selected malignant indications. With proper patient selection, meticulous surgical technique, and attention to detail, it provides excellent functional outcomes, reduced postoperative morbidity, faster recovery, and superior cosmetic results.
This procedure has become a cornerstone of modern gynecologic surgery, offering both surgeons and patients the advantages of precision, safety, and minimally invasive care.
Laparoscopic hysterectomy has transformed the field of gynecology by offering a minimally invasive alternative to open abdominal hysterectomy. Compared to traditional approaches, laparoscopic hysterectomy provides smaller incisions, less postoperative pain, faster recovery, shorter hospital stay, and improved cosmetic outcomes.
Types of Laparoscopic Hysterectomy
Total Laparoscopic Hysterectomy (TLH):
Entire uterus, including the cervix, is removed laparoscopically.
Vaginal vault closure is performed laparoscopically.
Laparoscopic Supracervical Hysterectomy (LSH):
Only the uterine body is removed; the cervix is preserved.
Recommended in selected benign cases.
Laparoscopic-Assisted Vaginal Hysterectomy (LAVH):
Initial laparoscopic dissection followed by vaginal removal of the uterus.
Often used when vaginal access alone is challenging.
Preoperative Evaluation
Clinical Assessment:
Detailed gynecologic history, including menstrual history, parity, and previous pelvic surgeries.
Physical examination including pelvic examination to assess uterine size, mobility, and adnexal masses.
Imaging:
Ultrasound or MRI may be used to evaluate uterine size, fibroid location, endometrial thickness, or adnexal pathology.
Laboratory Investigations:
Complete blood count, coagulation profile, and blood type.
Pregnancy test if of reproductive age.
Anesthesia Clearance:
General anesthesia is required for laparoscopic hysterectomy.
Patient Counseling:
Discuss procedure, alternatives, risks (bleeding, infection, injury to bladder, bowel, ureter), and recovery.
Patient Positioning and Anesthesia
General anesthesia with endotracheal intubation.
Patient placed in dorsal lithotomy position with arms tucked.
Trendelenburg tilt (15–30 degrees) allows bowel to fall away from the pelvis for better visualization.
Foley catheter inserted to decompress the bladder.
Port Placement
Standard four-port technique:
Umbilical port (10–12 mm): Camera port.
Two lateral ports (5 mm): Working ports for dissection, coagulation, and suturing.
Suprapubic port (5 mm): Optional, used for uterine manipulation or retraction.
Alternative port configurations may be used depending on uterine size, adhesions, or surgeon preference.
Surgical Steps
Initial Inspection:
Laparoscopic survey of the pelvis and abdomen.
Assessment of adhesions, adnexa, and uterine pathology.
Uterine Manipulation:
Uterine manipulator inserted vaginally to mobilize the uterus.
Facilitates visualization of uterine vessels, broad ligament, and adnexa.
Dissection:
Round ligaments are coagulated and transected.
Broad ligaments opened, ureters identified and protected.
Fallopian tubes and ovaries may be preserved or removed based on indication.
Uterine arteries are coagulated at their origin from the internal iliac vessels for hemostasis.
Colpotomy:
Circumferential incision around the cervix or vaginal cuff.
Uterus detached and removed through the vagina or morcellated for large uteri.
Vaginal Vault Closure:
Done laparoscopically using absorbable sutures in a continuous or interrupted fashion.
Ensures hemostasis and prevents vault prolapse.
Postoperative Care
Early ambulation to reduce risk of deep vein thrombosis.
Pain management primarily with NSAIDs; opioids if needed.
Oral intake as tolerated.
Most patients discharged within 24–48 hours depending on procedure complexity.
Avoid heavy lifting or sexual activity for 4–6 weeks.
Advantages of Laparoscopic Hysterectomy
Minimally invasive: Smaller incisions and better cosmesis.
Reduced postoperative pain and analgesic requirement.
Faster recovery and return to daily activities.
Shorter hospital stay compared to open hysterectomy.
Enhanced visualization: Ability to identify adhesions, endometriosis, and adnexal pathology.
Reduced blood loss due to meticulous vessel control.
Complications and Risk Management
Intraoperative: Bleeding, injury to bladder, ureter, bowel, or major vessels.
Postoperative: Infection, hematoma, vaginal cuff dehiscence, thromboembolism, and port-site hernia.
Prevention: Proper patient selection, careful dissection, identification of ureters and bladder, and meticulous hemostasis.
Conclusion
Laparoscopic hysterectomy is a safe and effective minimally invasive alternative to open abdominal hysterectomy for benign and selected malignant indications. With proper patient selection, meticulous surgical technique, and attention to detail, it provides excellent functional outcomes, reduced postoperative morbidity, faster recovery, and superior cosmetic results.
This procedure has become a cornerstone of modern gynecologic surgery, offering both surgeons and patients the advantages of precision, safety, and minimally invasive care.
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