Watch this detailed video of a Total Laparoscopic Hysterectomy (TLH) performed on a patient with a large uterus. In this surgical video, Dr. R.K. Mishra and the expert team at World Laparoscopy Hospital demonstrate advanced minimally invasive techniques for safe and efficient hysterectomy.

Total laparoscopic hysterectomy is a technically feasible procedure. It can be performed by experienced surgeons for large uteri regardless of the size, number or location of the myomas.

Hysterectomy, the surgical removal of the uterus, is one of the most commonly performed gynecological procedures worldwide. Traditionally, large uteri were considered challenging for laparoscopic removal due to space constraints and increased surgical complexity. However, advances in laparoscopic techniques have revolutionized the management of large uterine sizes, making Total Laparoscopic Hysterectomy (TLH) a safe, effective, and minimally invasive option for women.

What is TLH?
Total Laparoscopic Hysterectomy (TLH) is a minimally invasive surgery where the uterus is removed entirely through small abdominal incisions using a laparoscope and specialized instruments. Unlike abdominal hysterectomy, TLH avoids a large incision, reduces postoperative pain, and accelerates recovery.

Indications for TLH in Large Uterus
TLH is indicated for women with:

• Fibroids (Leiomyomas) causing an enlarged uterus

• Adenomyosis

• Abnormal uterine bleeding unresponsive to medical therapy

• Premalignant or early malignant uterine conditions

• Pelvic pain or pressure from uterine enlargement

Challenges in Large Uterus TLH
Performing TLH on a large uterus is technically demanding because:

• Visualization of pelvic structures is more difficult

• Space is limited for instrument maneuvering

• Risk of injury to nearby organs (bladder, ureters, bowel) is higher

• Longer operative time may be required

Surgical Techniques for Large Uterus
Experienced laparoscopic surgeons utilize several strategies to overcome these challenges:

1. Preoperative Planning

   • Imaging studies like ultrasound or MRI assess uterine size, fibroid location, and pelvic anatomy.

   • Patient counseling is important to discuss possible conversion to open surgery if needed.

2. Port Placement Optimization

   • Higher and slightly wider port placements provide better access and visualization.

   • Additional accessory ports may be used for instrument handling.

3. Use of Advanced Energy Devices

   • Harmonic scalpel, bipolar energy devices, and vessel sealing systems minimize blood loss and safely dissect tissue.

4. Uterine Morcellation or Contained Extraction

   • Large uteri may be removed in pieces using laparoscopic morcellation (with strict safety protocols) or via mini-laparotomy if necessary.

5. Indocyanine Green (ICG) Fluorescence Imaging (optional but advanced technique)

   • ICG helps identify ureters and assess tissue perfusion, reducing the risk of injury in complex cases.

Benefits of TLH for Large Uterus

• Minimally invasive: Small incisions lead to faster recovery.

• Less postoperative pain: Compared to abdominal hysterectomy.

• Shorter hospital stay: Many patients are discharged within 1–2 days.

• Reduced blood loss: Advanced energy devices and careful dissection minimize intraoperative bleeding.

• Cosmetic advantage: Tiny scars are less noticeable.

Postoperative Care
Patients typically recover faster than with open surgery, with most resuming normal activities within 2–4 weeks. Pain management, early ambulation, and follow-up for wound and urinary function are crucial.

Conclusion
Total Laparoscopic Hysterectomy for large uteri represents the pinnacle of minimally invasive gynecologic surgery. While technically challenging, with proper patient selection, advanced laparoscopic expertise, and modern surgical tools, TLH is safe, effective, and offers significant advantages over traditional open hysterectomy. Women with large uteri no longer need to endure long recovery periods, extensive scarring, or higher complication rates, thanks to this revolutionary approach.