In this video, we assessed the feasibility of total laparoscopic hysterectomy (TLH) in cases of very large uterus weighing more than 9500 grams. We have analyzed whether it is possible for an experienced laparoscopic surgeon to perform an efficient total laparoscopic hysterectomy for large myomatous uteri regardless of the size, number, and location of the myomas. 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.

Uterine fibroids (leiomyomas) are the most common benign tumors of the female reproductive system and may lead to significant symptoms such as menorrhagia, pelvic pain, pressure effects, anemia, and infertility. When fibroids are multiple and the uterus becomes very large, hysterectomy is often the definitive treatment. Traditionally, such cases were managed by open abdominal surgery. However, with advancements in minimally invasive surgery, Total Laparoscopic Hysterectomy (TLH) has emerged as a safe and effective option even for a very large uterus with multiple fibroids in experienced hands.

Challenges of Large Uterus with Multiple Fibroids

Performing TLH in cases of very large uterus presents unique technical challenges. These include limited pelvic space, distorted anatomy, reduced uterine mobility, increased vascularity, and difficulty in visualization of vital structures such as the ureters and uterine vessels. Multiple fibroids can further alter normal anatomy, making dissection more complex. Despite these challenges, careful planning and advanced laparoscopic skills can ensure safe outcomes.

Preoperative Evaluation and Planning

A thorough preoperative assessment is essential. Imaging studies such as ultrasonography or MRI help determine uterine size, number and location of fibroids, and relation to surrounding organs. Correction of anemia, optimization of comorbid conditions, and detailed patient counseling are crucial. In selected cases, preoperative GnRH analogues may be used to reduce uterine size and vascularity.

Surgical Technique

The procedure begins with proper patient positioning and safe creation of pneumoperitoneum. Port placement is modified according to uterine size, often using higher and wider ports to achieve adequate working space. Stepwise devascularization of the uterus is the key principle in managing large fibroid uteri.

The round ligaments are coagulated and divided, followed by careful opening of the broad ligaments. Early identification and sealing of uterine vessels help reduce blood loss. Meticulous dissection is required to safeguard the ureters, which may be displaced due to fibroid enlargement. The bladder is carefully dissected down to expose the cervicovaginal junction.

Colpotomy is performed circumferentially under laparoscopic vision. Specimen removal is achieved by vaginal morcellation or contained laparoscopic morcellation, depending on uterine size and clinical considerations. The vaginal vault is then closed laparoscopically, ensuring adequate hemostasis.

Advantages of TLH in Large Fibroid Uterus

Total laparoscopic hysterectomy offers several advantages over open surgery, even in cases of very large uterus. These include reduced intraoperative blood loss, smaller incisions, less postoperative pain, lower risk of wound complications, faster recovery, and shorter hospital stay. Patients typically resume normal activities earlier and experience better cosmetic outcomes.

Complications and Safety Considerations

Although TLH for large uterus is technically demanding, complication rates are low when performed by skilled laparoscopic surgeons. Potential risks include bleeding, urinary tract injury, bowel injury, and conversion to open surgery. Adherence to the principles of safe laparoscopic surgery, clear identification of anatomy, and timely decision-making are essential to minimize complications.

Postoperative Care and Recovery

Postoperative care focuses on early mobilization, pain control, and monitoring for complications. Most patients can be discharged within 24–48 hours. Follow-up includes evaluation of wound sites, vaginal vault healing, and overall recovery.

Conclusion

Total Laparoscopic Hysterectomy for a very large uterus with multiple fibroids is a feasible and safe procedure in experienced hands. With meticulous surgical technique, proper patient selection, and advanced laparoscopic expertise, TLH can successfully replace open hysterectomy, offering patients the benefits of minimally invasive surgery even in complex gynecological cases.