This video demonstrates the step-by-step surgical technique of Total Laparoscopic Hysterectomy (TLH) for a large uterus. In this educational video, viewers can learn key operative steps including patient positioning, port placement, uterine manipulation, vascular control, and safe specimen removal. This video is designed for gynecologists, laparoscopic surgeons, and trainees who want to enhance their understanding of advanced minimally invasive hysterectomy techniques. The video also highlights important surgical tips, anatomical landmarks, and safety measures to improve surgical outcomes and reduce complications.

Total laparoscopic hysterectomy (TLH) was developed in the early 90s by Prabhat K. Ahluwalia in Upstate New York. TLH is performed solely through the laparoscopes in the abdomen, starting at the top of the uterus, typically with a uterine manipulator. The entire uterus is disconnected from its attachments using long thin instruments through the "ports". Then all tissue to be removed is passed through the small abdominal incisions.

Total Laparoscopic Hysterectomy (TLH) is a minimally invasive surgical procedure used to remove the uterus using laparoscopic instruments and camera guidance. Over the last two decades, TLH has become a preferred alternative to abdominal hysterectomy because of faster recovery, less postoperative pain, reduced blood loss, and better cosmetic outcomes. Traditionally, large uterus size was considered a limitation for laparoscopic surgery, but with advances in technology, surgical skill, and energy devices, TLH is now increasingly performed even in cases of very large uterus.

Definition of Large Uterus

A large uterus usually refers to uterine enlargement beyond 12–14 weeks pregnancy size or significantly increased uterine weight due to conditions like fibroids (leiomyoma), adenomyosis, or malignancy. Studies have shown that laparoscopic hysterectomy can be performed safely even in very large uteri weighing more than 1 kg and in some reported cases more than 5 kg.

Indications for TLH in Large Uterus

Common indications include:

• Symptomatic fibroid uterus

• Abnormal uterine bleeding not responding to medical therapy

• Adenomyosis

• Endometrial pathology

• Chronic pelvic pain

• Selected malignancy cases

Modern evidence suggests that uterine size alone should not be the only deciding factor against laparoscopic hysterectomy if performed by experienced surgeons and with proper patient selection.

Surgical Challenges in Large Uterus

Performing TLH in a large uterus presents several technical difficulties:

• Limited pelvic working space

• Difficulty in visualization of pedicles

• Increased vascularity leading to higher blood loss risk

• Need for advanced dissection skills

• Difficulty in specimen retrieval

Studies show that larger uterine size is associated with longer operative time and slightly increased blood loss, but complication rates and hospital stay are usually similar when surgery is performed by experienced laparoscopic surgeons.

Surgical Techniques and Modifications

To overcome technical challenges, surgeons may use:

• Higher port placement

• Early uterine artery ligation

• Myoma debulking if required

• Vaginal or contained morcellation

• Advanced energy devices

Large case series confirm that minimally invasive hysterectomy remains feasible and safe regardless of uterine weight when proper technique is used.

Outcomes and Advantages

Even in large uterus cases, TLH offers multiple benefits:

• Short hospital stay

• Early mobilization

• Less postoperative pain

• Better cosmetic results

• Faster return to normal activity

Case reports have demonstrated successful laparoscopic removal of extremely large uteri with good postoperative recovery, highlighting the expanding boundaries of minimally invasive surgery.

Complications

Possible complications include:

• Bleeding

• Ureteric or bladder injury

• Conversion to laparotomy in difficult cases

• Prolonged operative time

However, overall complication rates remain low, and conversion to open surgery occurs in a small percentage of cases, usually due to adhesions or poor visualization.

Conclusion

Total Laparoscopic Hysterectomy for large uterus is now considered a safe and effective surgical option in the hands of trained laparoscopic surgeons. Advances in surgical techniques, instrumentation, and surgeon experience have expanded the indications of TLH beyond conventional size limitations. Careful patient selection, adequate preoperative planning, and advanced laparoscopic skills are essential to achieve optimal outcomes. TLH continues to play an important role in modern gynecologic surgery, offering the benefits of minimally invasive surgery even in complex large uterus cases.