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THE OPERATOR’S MANUAL

Total Laparoscopic Hysterectomy:

10 Steps Toward a Successful
Procedure
Jon I. Einarsson, MD, MPH, Yoko Suzuki, MD
Department of Obstetrics and Gynecology, Division of Minimally Invasive Gynecologic Surgery, Brigham
and Women’s Hospital, Boston, MA

Vaginal and laparoscopic hysterectomies have been clearly associated

with decreased blood loss, shorter hospital stay, speedier return to normal
activities, and fewer abdominal wall infections when compared with abdomi-
nal hysterectomies. In this review, the authors outline the 10 steps to a
successful laparoscopic hysterectomy.
[Rev Obstet Gynecol. 2009;2(1):57-64]

© 2009 MedReviews®, LLC

Key words: Total laparoscopic hysterectomy • Laparoscopic supracervical hysterectomy •

Minimally invasive gynecological procedure

H
ysterectomy is one of the most commonly performed surgical procedures
in the United States, with 570,000 cases performed in 2006.1 Vaginal hys-
terectomies have been performed successfully for almost 2 centuries, and
more recently Reich and colleagues2 introduced the laparoscopic hysterectomy.
However, despite the advent of these minimally invasive procedures, abdominal
hysterectomy remains the most common surgical approach, with well over half
of hysterectomies being performed via a laparotomy.3

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Vaginal and laparoscopic hysterec- A retrospective study found that 2.2% arms are tucked at the sides and a
tomies have been clearly associated of all cervical cancer cases originate foam mattress is situated directly
with decreased blood loss, shorter from the cervical stump.15 A prospec- under the patient to prevent sliding
hospital stay, speedier return to nor- tive cohort study of 70 patients during steep Trendelenburg. We keep
mal activities, and fewer abdominal undergoing LSH predominantly for the table in a low position and have a
wall infections when compared with endometriosis and pelvic pain found monitor directly facing each surgeon
abdominal hysterectomies.4-6 In light that at 5 years of follow-up, 22.8% to promote an ergonomic working
environment. The surgeon needs to be
Vaginal and laparoscopic hysterectomies have been clearly associated with familiar with all the equipment in the
operating room and should routinely
decreased blood loss, shorter hospital stay, speedier return to normal activ-
inspect equipment for any malfunc-
ities, and fewer abdominal wall infections when compared with abdominal tion or servicing needs. A partial
hysterectomies. equipment list is shown in Table 1. In
general, it is important for the sur-
of these findings, a recent review con- required further surgical treatment geon to simplify the equipment list as
cluded that vaginal hysterectomy is due to continued vaginal bleeding or much as possible. This prevents
preferable to abdominal hysterectomy pelvic pain.16 In addition, a prospec- crowding in the operating room and
and that a laparoscopic hysterectomy tive, randomized trial found higher facilitates room turnover and staff
should be attempted when vaginal readmission rates following LSH familiarity with the equipment being
hysterectomy is not possible.6 The than after total laparoscopic hys- used.
vaginal approach is less expensive, terectomy (TLH). In this relatively
but may be challenging in patients small study, there were no statisti- 2. Insertion of a Uterine Manipulator
with a history of an adnexal mass, cally significant differences in com- We generally prefer to use the
endometriosis, pelvic pain, and prior plications, symptom improvement, RUMI® Uterine Manipulator (Cooper-
abdominal surgery, or in patients with or activity limitations.17 Three ran- Surgical, Trumbull, CT); however, in
a narrow pubic arch or poor vaginal domized, controlled trials comparing patients with a very narrow introitus
descent. total to subtotal abdominal hysterec- we will use the VCare® Uterine
The relatively slow adaptation of tomy found no significant differences Manipulator/Elevator (ConMed Endo-
laparoscopic hysterectomy may in part in sexual function, urinary tract surgery, Utica, NY) because this is
be attributed to inadequate exposure symptoms, or bowel symptoms.18-20 A easier to insert. We find, however,
and training during residency.7 In recent study with a mean follow-up that the VCare cup is rather shallow,
addition, a number of provider barri- of 9 years found no significant differ- making the delineation of the vaginal
ers have been identified, including ences in development of pelvic organ fornices challenging in the setting of
insufficient experience and training, prolapse or other outcomes among a long cervix. Occasionally we will
lack of hospital equipment, and inad- patients having a total and subtotal have a patient who has never had
equate support from colleagues. Rela- hysterectomy.21 intercourse or has been on long-
tively low reimbursement rates may We discuss the available evidence standing testosterone treatment due
also curb provider enthusiasm for with our patients prior to surgery, and to gender reassignment and in these
additional training and incorporation we offer most of them the option of cases a uterine manipulator is not used.
of the laparoscopic hysterectomy into keeping their cervix if they so desire. Although placing the RUMI can be
their surgical armamentarium.8 However, we strongly recommend re- challenging, there are several tricks
moving the cervix in patients with a that can simplify this task. First, place
Cervix Removal history of abnormal Papanicolaou test a Sims speculum into the vagina, grab
Laparoscopic supracervical hysterec- results and in patients having a hys- the cervix with a tenaculum, and
tomy (LSH) has been associated with terectomy due to pelvic pain or sound the uterus. Then ask for the
a shorter operating time, decreased endometriosis. appropriately sized RUMI tip (6, 8, or
trauma, and less technical difficulty.9 10 cm). The tip can be difficult to
However, a small proportion of these 10 Steps Toward attach to the shaft, but dipping the
patients continue to have cyclical a Successful TLH distal end of the shaft in lubricant
bleeding until menopause,10-14 and 1. Preparation and Positioning prior to attaching the tip greatly facil-
there is a small risk of developing cer- Patients are placed in a dorsal lithot- itates this step. The pneumo-occluder
vical cancer if the cervix is retained. omy position with pneumoboots. The then slides over the tip and onto the

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Total Laparoscopic Hysterectomy

3. Abdominal Entry and Trocar

Table 1 Placement
Equipment List for Total Laparoscopic Hysterectomy A 5-mm skin incision is made at the
deepest part of the umbilicus using a
Standard Equipment Comments/Tips for Usage #15 blade.
We elevate the deepest part of the
0° laparoscope 5-mm scope most often used
umbilicus with a Kocher clamp and
Harmonic® Scalpel (Ethicon Endo-Surgery, insert a Veres needle into the peri-
Somerville, NJ) toneal cavity. The gas tubing is
Reusable bipolar grasper Power setting at 50 W already connected to the needle to
3 5-mm trocars and 1 12-mm trocar Prefer visual entry reduce manipulation following inser-
Two duckbill graspers Universal grasping ability tion. An easy way to confirm in-
RUMI® Uterine Manipulator Check for all parts prior to start traperitoneal entry is to look for a
(CooperSurgical, Trumbull, CT) negative pressure reading on the
Foley catheter
insufflator. Once intraperitoneal pres-
sure has reached 15 mm Hg, we insert
14  14 cm 0 PDO suture cut in half
an optical trocar through the umbili-
LapraTy (Ethicon Endo-Surgery) applicator cus under direct vision, followed by a
and clips complete survey of the abdomen to
Optional Equipment rule out any visceral injury at the
time of entry. The lower quadrant tro-
Diluted vasopressin Avoid using more than 10 units
car sleeves are placed under direct
5- and 10-mm tenaculum Helpful for larger uteri
vision. These trocars are placed lateral
Electronic morcellator to the rectus abdominis muscles, 2 cm
30° laparoscope Helpful for larger uteri above and 2 cm medial to the anterior
Suction irrigator superior iliac spine. Usually, a
Fascia closure device Not needed for thin patients 5-mm trocar is placed on the right
and a 12-mm trocar on the left. In
Triple hook clamps For vaginal morcellation
addition, a 5-mm trocar is placed
approximately 8 cm above and
parallel to the lower left trocar site.
This port will, in most cases, end up
shaft followed by attachment of the specimen removal through the vagina being nearly parallel to the umbilical
appropriately sized KOH ring (3, 3.5, at the end of the case. A Foley trocar. We find that the 2 ports on the
and 4 cm in width). It is important to catheter is inserted into the bladder left greatly facilitate suturing and
choose the correct size because a and finally the pneumo-occluder is help to maintain an ergonomic posi-
small ring will not delineate the vagi- filled with 60 to 100 cc of saline. tion for the surgeon throughout the
nal fornices and a large ring may in-
crease the risk of a ureteral injury.
Next, place a “figure 8” 0 monofilament Figure 1. The edge of the KOH colpotomizer
is clearly seen (arrow).
suture through the anterior lip of the
cervix, thread this through the KOH
ring, and secure with a hemostat. In-
sert the tip of the RUMI as far into the
cervix as it will go, then release the
tenaculum while keeping tension on
the cervical stitch. This prevents the
uterus from moving cephalad as the
tenaculum is removed. After confirm-
ing correct placement by palpation
or direct visualization (Figure 1), tie
the suture to the handle to facilitate

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Figure 2. Dessication of the utero-ovarian of the broad ligament with the Har-
ligament (ie, hugging the ovary).
monic scalpel (Figures 5 and 6). It is
important to find the correct plane;
this is where the peritoneum separates
easily with gentle manipulation. Next,
identify the vesicouterine peritoneal
fold and continue the dissection ante-
riorly, thereby mobilizing the bladder
off the lower uterine segment (Figures 7
and 8). It is important to stay in the
loose areolar tissue if at all possible.
In patients who have had a prior ce-
sarean delivery, this area may be
scarred and it is important to stay rel-
procedure. The 12-mm port site is ligament or utero-ovarian ligament is atively high on the uterus during the
ideal for needle passage and specimen then transected close to the ovary dissection. A reevaluation of the route
retrieval. using the Harmonic® Scalpel of dissection is advised if fat is en-
(Ethicon Endo-Surgery, Somerville, countered because the fat belongs to
4. Hug the Ovaries NJ). We prefer to use the bipolar the bladder; this may indicate that the
The infundibulopelvic (IP) ligament or grasper prior to cutting with the Har- dissection is moving too close to the
the utero-ovarian ligament is initially monic scalpel because bleeding can bladder.
desiccated with a reusable bipolar be encountered despite appropriate
grasper (Figure 2). It is important to use of the Harmonic scalpel, espe- 6. Secure the Uterine Vessels
stay close to the ovary (hug the cially in the setting of an enlarged Due to a wide variety in anatomy and
ovary) as this helps to avoid the uterus with engorged vascular in the course of the uterine vessels,
pelvic sidewall during ovarian re- plexuses. During this step of the pro- we find it helpful to initially skele-
moval and the ascending uterine ves- cedure, the uterine manipulator is tonize them with the Harmonic scalpel.
sel during ovarian conservation. The being pushed upwards and to the We then desiccate the ascending uter-
surgeon should take special care to contralateral side to provide maximal ine vessels with the bipolar grasper at
desiccate the parametrial veins that visualization. the level of internal cervical os (Fig-
run between the ovary and the round ures 9 and 10). Note that pushing
ligament (Figures 3 and 4) as these 5. Mobilize the Bladder cephalad with the uterine manipulator
can be quite tortuous and tend to Transect the round ligament and sep- helps to move the uterine vessels away
bleed if left unattended. The IP arate the anterior and posterior leaves from the ureter. Complete desiccation

Figure 3. The parametrial venous plexus between the ovary and the
round ligament is seen (arrow). Figure 4. Dissection continues to the round ligament (arrow).

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Total Laparoscopic Hysterectomy

Figure 5. The anterior and posterior leaves of the broad ligament are Figure 6. The anterior and posterior leaves of the broad ligament
separated using the Harmonic® Scalpel (Ethicon Endo-Surgery, are further separated by using the tip of the Maryland bipolar
Somerville, NJ). grasper.

Figure 7. The dissection of the anterior leaf of the broad ligament Figure 8. The rim of the KOH ring is seen and felt after mobilizing
continues anteriorly, thereby enabling dissection of the bladder from the bladder.
the lower uterine segment.

Figure 9. The uterine vessels are skeletonized. Figure 10. The ascending uterine vessels are coagulated with the
bipolar grasper at the level of internal cervical os, staying above the
rim of the cervical cup.

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Total Laparoscopic Hysterectomy continued

Figure 11. Two incisions are made with the Alternatively, the uterus is removed
Harmonic® Scalpel (Ethicon Endo-Surgery,
Somerville, NJ) medial to the uterine and a glove with a pair of 4  4
vessels, roughly following an inverted sponges is placed into the vagina to
V–shaped pattern. This makes the vascular
pedicle fall out laterally and provides avas- maintain pneumoperitoneum (Fig-
cular access to the cervical ring. ure 14). If the uterus is too large to fit
through the vagina, it can be carefully
morcellated transvaginally by using a
10-blade scalpel and triple hooks for
retraction. In patients with limited
vaginal access, the uterus can be mor-
cellated using an electronic morcella-
tor. It is important to keep the tip of the
morcellator in clear view at all times.

of the vessels can be assessed visually 7. Separate the Uterus and Cervix 9. Vaginal Cuff Closure
by observing the bubbles coming and From the Vaginal Apex We use one half of a 14  14 cm
going during this process; when the Identify the vaginal fornices while 0 Quill™ SRS suture (Angiotech, Van-
bubbles stop forming the vessel is des- pushing cephalad with the uterine couver, BC, Canada) that has been cut
iccated and safe to transect with the manipulator. You will either see the in the middle with a LapraTy clip
Harmonic scalpel. We will then usu- indentation of the KOH colpotomizer (Ethicon Endo-Surgery) secured at the
ally make 2 cuts with the Harmonic or be able to palpate it with a la- distal end.22 Closure begins at the dis-
scalpel in an inverted V–shape ante- paroscopic instrument. The Har- tal angle of the vaginal cuff and pro-
rior and medial and posterior and monic scalpel is then used to cut ceeds in a running fashion, making
medial to the vascular pedicle. This circumferentially around the cup. sure to include the vaginal mucosa and
enables the vascular pedicle to fall out Take care not to direct the Harmonic the pubocervical and rectovaginal fas-
laterally, thereby providing easy and scalpel directly into the metal because cia (Figures 15-17). Each bite should
avascular access to the cervical cup this may result in failure of the device be approximately 1 cm in thickness—
(Figure 11). It is important to take the and may even break the active blade this can be easily underestimated due
uterine vessels high and then dissect (Figures 12 and 13). to the magnification of the laparo-
medially to the uterine vessels down scope. A LapraTy is then placed at the
to the cup. This averts ureteral injury 8. Removal of the Uterus end of suture and the needle is cut free
and provides a healthy vascular pedi- Pull the uterus into the vagina if it fits. and removed through the 12-mm port.
cle that can be safely desiccated fur- The uterus can remain there to maintain The pelvis can now be irrigated and
ther in the event of bleeding. pneumoperitoneum during suturing. hemostasis at all sites is assured.

Figure 13. Completion of the colpotomy. The stitch was placed at

Figure 12. The KOH colpotomizer can be seen. Please note the vas- the beginning of the procedure and helps with vaginal retrieval of
cular pedicle lateral to the line of incision (arrow). the uterus (arrow).

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Total Laparoscopic Hysterectomy

Figure 14. A glove with 2 4  4 sponges is seen in the vagina Figure 15. Vaginal cuff closure. 0 Quill™ SRS suture (Angiotech,
(arrow) and is used to maintain pneumoperitoneum prior to and Vancouver, BC, Canada) with a LapraTy (Ethicon Endo-Surgery,
during vaginal cuff suturing. Somerville, NJ) at the end (arrow). Please note the orientation of the
needle during insertion. The smiley-face configuration facilitates
easy loading on the needle driver.

Figure 16. Vaginal cuff closure. It is important to take full thickness Figure 17. Completion of the vaginal cuff closure.
bites here.

10. Port Site Closure signs of bladder injury. The patient is the appropriate prophylactic and thera-
The fascia at the 12-mm incision in the given 5 cc of Indigo carmine intra- peutic antiemetics, such as dexametha-
left lower quadrant is closed using 0 venously 5 minutes prior to closure. sone, ondansetron, and a hyoscine hy-
vicryl sutures with a fascia closure de- Please note that a normal cystoscopy drobromide patch.25 Patients either go
vice. The skin is closed with 4-0 does not exclude a delayed thermal in- home the day of surgery or the follow-
monocryl suture in a continuous sub- jury to either the ureters or the bladder. ing morning. We are prospectively
cutaneous fashion. The 5-mm incisions evaluating recovery and resumption of
are closed with Dermabond® (Ethicon Postoperative Management normal activities following our laparo-
Endo-Surgery). We then inject 20 cc of We give our patients 30 mg of ketoro- scopic hysterectomy cases and we
0.5% Marcaine® (Sanofi, Markham, lac tromethamine intravenously at the have found that patients resume their
ON, Canada) at all incision sites to re- end of surgery and every 6 hours normal activities on average within 2
duce immediate postoperative pain.23 after that for a total of 4 doses. Oral to 3 weeks following surgery.
We do not perform cystoscopy rou- oxycodone/acetaminophen per os is
tinely, but in select cases cystoscopy is used for breakthrough pain. Postoper- Summary
performed after vaginal closure to ative nausea and vomiting risk factors Total laparoscopic hysterectomy is a
check ureteral patency and for any are evaluated24 and patients are given safe and effective procedure for women

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needing a hysterectomy. We enjoy a LapraTy and the needle is cut away 9. Lyons TL. Laparoscopic supracervical hysterec-
tomy. Obstet Gynecol Clin North Am. 2000;27:
high operative volume and perform and removed. 441-450.
approximately 200 laparoscopic hys- • If access to the uterine vessels is 10. Van der Stege JG, van Beek JJ. Problems related
terectomy cases annually with a con- difficult, take the uterine vessels up to the cervical stump at follow-up in laparo-
scopic supracervical hysterectomy. JSLS. 1999;
version rate of 1 in every 400 cases. high initially to secure the blood 3:5-7.
The 10 steps described herein are not supply to the upper uterus and then 11. Planas MV. Cervicectomy following supravaginal
meant to be an absolute truth, but gradually work down, staying me- hysterectomy. Am J Obstet Gynecol. 1960;79:
480-485.
rather a true and tested method that dially to the vessels.
12. Härkki-Siren P, Sjöberg J, Kurki T. Major com-
has served us well to safely accom- • Maintain exposure at all times—do plications of laparoscopy: a follow-up Finnish
plish this procedure. not dig yourself into a hole—always study. Obstet Gynecol. 1999;94:94-98.
be ready to deal with a sudden 13. Nisolle M, Donnez J. Subtotal hysterectomy in
patients with endometriosis–an option. Fertil
Additional Practical Tips onset of bleeding. Steril. 1997;67:1185-1187.
for Challenging Cases • The combination of a prior cesarean 14. Harris WJ, Daniell JF. Early complications of
delivery and a large uterus is a set up laparoscopic hysterectomy. Obstet Gynecol
• If the uterus is large and requires
Surv. 1996;51:559-567.
manipulation with a tenaculum, for bladder injury—stay high on the 15. Hellström AC, Sigurjonson T, Pettersson F. Carci-
consider injecting dilute vaso- vesicouterine peritoneum, respect noma of the cervical stump. The radiumhemmet
pressin subserosally prior to apply- any fat that you see, and watch out series 1959-1987. Treatment and prognosis. Acta
Obstet Gynecol Scand. 2001;80:152-157.
ing traction to the uterus. This can for air in the Foley balloon. 16. Okaro EO, Jones KD, Sutton C. Long term out-
reduce bleeding associated with • In severely distorted anatomy con- come following laparoscopic supracervical hys-
pulling and tearing of the uterine sider entering the retroperitoneum terectomy. BJOG. 2001;108:1017-1020.
17. Morelli M, Noia R, Chiodo D, et al. Laparoscopic
serosa. sooner rather than later. The easiest supracervical hysterectomy versus laparoscopic
• In cases with poor exposure, we starting point is usually at the total hysterectomy: a prospective randomized study
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18. Thakar R, Ayers S, Clarkson P, et al. Outcomes
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