This video demonstrates Total Laparoscopic Hysterectomy for Very Large Uterus with Huge Fibroid. It is not uncommon for a laparoscopic surgeon to be able to perform the entire laparoscopic hysterectomy using a few 10mm and 5-mm ports and then a larger abdominal incision to remove the surgical specimen using a morcellator. In conclusion, this video shows that the size of the uterus does not forbid the laparoscopic approach for hysterectomy.  

Total Laparoscopic Hysterectomy (TLH) has revolutionized gynecological surgery, offering a minimally invasive alternative to traditional open hysterectomy. The procedure is especially challenging in cases of a very large uterus with huge fibroids, requiring advanced surgical skills, specialized instruments, and meticulous planning. This article explores the indications, preoperative considerations, surgical steps, advantages, and postoperative care for TLH in such complex cases.

Uterine fibroids (leiomyomas) are the most common benign tumors of the female reproductive system. While many fibroids are small and asymptomatic, some grow to enormous sizes, causing symptoms such as:

Heavy menstrual bleeding (menorrhagia)

Pelvic pain and pressure

Urinary frequency or retention

Gastrointestinal discomfort

Infertility or recurrent pregnancy loss

A very large uterus due to fibroids poses a significant challenge for hysterectomy. Traditionally, open abdominal hysterectomy was considered the only feasible option. However, with advances in laparoscopic surgery, TLH has become possible even for large uteri, offering faster recovery, less blood loss, and reduced postoperative pain.

Preoperative Considerations

Before undertaking TLH for a large uterus, thorough evaluation and preparation are critical:

Imaging Studies:

Ultrasound to assess size, number, and location of fibroids

MRI for detailed mapping of fibroids and surrounding structures

Medical Optimization:

Correction of anemia due to heavy bleeding

Management of comorbidities like hypertension or diabetes

Surgical Planning:

Choice of laparoscopic instruments, energy devices, and morcellation technique

Consideration for the patient’s abdominal space and port placement

Surgical Technique

Total Laparoscopic Hysterectomy for a very large uterus involves several critical steps:

Patient Positioning:

Lithotomy position with Trendelenburg tilt for optimal visualization

Port Placement:

Modified trocar positions to accommodate the large uterus

Use of additional ports if necessary for retraction

Uterine Mobilization:

Careful dissection of the broad ligament and uterine vessels

Identification and protection of ureters

Fibroid Management:

Myomectomy may be performed laparoscopically to reduce uterine bulk

Use of energy devices (harmonic scalpel or bipolar) for safe tissue dissection

Uterine Removal:

Vaginal extraction or power morcellation (with containment bag)

Ensuring complete removal to prevent recurrence or complications

Closure and Hemostasis:

Suturing the vaginal cuff laparoscopically

Thorough inspection for hemostasis and irrigation

Advantages of TLH for Large Uterus

Minimally invasive: smaller incisions and better cosmetic outcomes

Reduced postoperative pain and analgesic requirements

Shorter hospital stay and faster recovery

Lower risk of wound infection and hernia formation

Early return to normal activities

Postoperative Care

Early ambulation to prevent deep vein thrombosis

Pain management with oral analgesics

Monitoring for fever, bleeding, or urinary symptoms

Gradual return to normal diet and activities

Follow-up to ensure proper healing and rule out complications

Challenges and Considerations

Limited abdominal space makes visualization difficult

Risk of injury to surrounding organs (bladder, ureters, bowel)

Longer operative time compared to small uterus hysterectomy

Requirement for advanced laparoscopic skills and experience

Conclusion

Total Laparoscopic Hysterectomy for a very large uterus with huge fibroids is a complex but feasible procedure when performed by skilled laparoscopic surgeons. With careful preoperative planning, proper instrumentation, and adherence to surgical principles, TLH offers the benefits of minimally invasive surgery even in challenging cases, ensuring patient safety, reduced morbidity, and faster recovery.