Total Laparoscopic Hysterectomy
Ernest G. Lockrow, DO, FACOG, FACOOG Developed in association with
Professor and Vice Chair of Education Uniformed
Services University
Fellowship Program Director
Minimally Invasive Gynecologic Surgery
Version 2.0 Reaffirmed June 2024
Reviewed by: Heisy Asusta, MD, MPH,
FACOG
Objectives
By the end of this unit, you should be able to do the following:
• Describe the indications for total laparoscopic hysterectomy
• Explain preoperative planning for total laparoscopic hysterectomy,
including options for anesthesia and patient preparation
• Demonstrate the correct technique to perform a total laparoscopic
hysterectomy
• Describe possible perioperative complications
2
Evolution of Hysterectomy
• 1989: Reich reported the first laparoscopically assisted vaginal
hysterectomy
• 1990s: Hysterectomy was introduced into residency training programs
• 1989: 600,000 hysterectomies were performed in the United States, of
which 70% were total abdominal hysterectomies
• 2016: 70–80% of hysterectomies were done using minimally invasive
techniques
3
Evolution of Hysterectomy
The evolution of hysterectomy can be described as starting with traditional
abdominal and vaginal routes for hysterectomy:
• Total abdominal and vaginal hysterectomy (TAH, TVH)
• Laparoscopic-assisted vaginal hysterectomy, introduced by Harry Reich
in late 1980s (LAVH)
• Laparoscopic supracervical hysterectomy (LSH)
• Total laparoscopic hysterectomy (TLH)
• Despite this evolution over the past 20 years, half of all hysterectomies
still are performed through the abdominal approach (as of 2012).
Sources: Wu et al, Ob Gyn 2007; Desai et al, Ob Gyn 2015
4
Total Laparoscopic Hysterectomy:
Advantages
A total laparoscopic hysterectomy:
• Reduces hospital stay by 2 days
• Reduces post-operative recovery by 2 weeks
• Can allow for same-day discharge in some clinical scenarios
• Causes less postoperative pain and discomfort
• Results in
o less blood loss
o substantial financial savings because of lower hospital costs
5
Disadvantages
Total laparoscopic hysterectomy:
• Requires increased laparoscopic skills
• Reduces time for training in vaginal surgery skills
• Increases
o operative time
o procedure cost
6
Indications
Should be considered when an abdominal hysterectomy is planned for
• pelvic adhesive disease
• endometriosis
Should not be used in cases of
• advanced malignancy
• large pelvic masses
• inadequate visualization because of dense adhesions
A total laparoscopic hysterectomy should not be
• used as a substitute for total vaginal hysterectomy
• performed without proper equipment and training
7
Preparation
• Check that equipment is available and
functioning properly before starting the
procedure
• Position the patient in low lithotomy
(See Allen® stirrups in see Fig. 1)*
• Tuck both arms to sides—see Fig. 1
• Foley catheter (see Fig. 2) Fig. 1
• Position dual monitors (see Fig. 3)
• Check camera resolution
Fig. 2
*Note: any reference to products in this presentation are made by the Fig. 3 8
authors. ACOG does not promote or endorse any product or company.
The Surgeon
• Optimizes visualization
• Requests Trendelenburg position
• Maintains hemostasis
• Avoids unnecessary blood loss
9
Introduction: Anatomic Landmarks
• Check anatomic landmarks
• Umbilicus
• Anterior superior iliac spine
• Pubic symphysis
Umbilicus
• Aorta
• Surgical scars
10
Introduction: Abdominal Vessels
See the blue text to identify these abdominal vessels:
• Superficial epigastric artery
• Inferior epigastric artery
• Superficial circumflex iliac artery
• Deep circumflex iliac artery
Ascending branch
of deep circumflex
iliac artery
Superficial circumflex Inferior
iliac artery epigastric artery
Superficial
Superficial epigastric epigastric artery
artery (cut)
Used with permission of Elsevier. All rights reserved.
Step 1: Trocar Insertion
• Insert umbilical trocar through a Hulka or Veress needle or open
technique
• Consider the Palmer point as an alternative to the umbilicus for
initial entry site
12
Trocar Insertion Techniques
Veress needle entry Optical trocar entry Direct trocar entry
13
Step 2: Establish Pneumoperitoneum
• Ensure entry into the peritoneal cavity
o Technique for verification depends on entry technique utilized
• Connect gas tubing to the appropriate port
• Insufflate the abdomen with CO2 to a target pressure of 12-15 mmHg
o Use the lowest effective pressure to minimize adverse effects related
to pneumoperitoneum
o Monitor for signs of extra-peritoneal insufflation (e.g. rapidly rising abdominal
pressure, asymmetric abdominal distension, crepitus)
Step 3: Lateral Ports
• Lateral ports: lateral margin of rectus muscle
• 3–4 fingerbreadths medial to anterior superior iliac spine
• Transilluminate
15
Transillumination
Transillumination is the shining of a light through the abdomen to
identify abnormalities.
Image courtesy of Vaman Ghodake, MD, Ghodake Hospital, Sangli, India.
16
Step 4: Survey
• Abdominal survey
• Ureteral identification
Pelvis uterus Appendix
Liver edge and gallbladder Ureter
Images courtesy of Ernest Lockrow, DO.
Step 5: Remember A B C
A Identification of Anatomy
Detachment of Adnexa
B Broad ligament
Bladder
Blood vessels
C Cardinal ligaments
Colpotomy
Cuff closure
Uterus and right broad ligament, seen from behind.
The broad ligament has been spread out and the
ovary drawn downward.
Source: Gray, H. (1918). Anatomy of the human body. Lea
& Febiger. 17
Step 6: Salpingectomy
Start with salpingectomy
• Identify the fallopian tube at its fimbriated end
• Transect along the mesosalpinx from the fimbriated end to the cornual
insertion
• Stay at the level of the mesosalpinx, parallel to the fallopian tube
• Avoid ovarian vessels
19
Step 7: Cauterize and Transect the Round
Ligaments
Image courtesy of Ernest Lockrow, DO.
20
Step 8: Cauterize and Transect the
Ovarian Vasculature
Identify the appropriate ovarian vasculature for transection
• Ovarian preserving hysterectomy: Utero-ovarian ligaments
• Planned oophorectomy: Infundibulopelvic ligaments.
Utero-ovarian (UO) ligament transection:
• Make a peritoneal window in the broad ligament, cephalad to the
transected round ligament, using scissors or Maryland graspers
• Isolate the UO ligament: Stretch the peritoneal window using two
blunt instruments and applying traction in a cephalo-caudal direction
between the round and utero-ovarian ligaments
• Once the UO has been isolated, cauterize and transect bilaterally.
Cauterize the Infundibulopelvic Ligament
Image courtesy of Ernest Lockrow, DO. 20
Transect the Infundibulopelvic Ligament
Image courtesy of Ernest Lockrow, DO.
21
Step 9: Complete Dissection to Round
Ligament
Image courtesy of Ernest Lockrow, DO.
22
Identify Ureters Again
Image courtesy of Ernest Lockrow, DO. 25
Step 10: Make the Bladder Flap
Dissection
Image courtesy of Ernest Lockrow, DO. 26
Step 11: Isolate, Cauterize & Transect
the Uterine Vessels
• Isolate the uterine vessels bilaterally by taking down the posterior
peritoneum
• Transect the uterine vessels by taking perpendicular bites of the
uterine vessels using a vessel sealing device
• Lateralize the cardinals by taking a "straight" bite of the uterine vessels
by orienting the vessel sealer vertically with the tips towards the cervix
while "hugging" the colpotomy cup
o Protect the ureters
25
Cauterize and Transect the Uterine Vessels
Image courtesy of Ernest Lockrow, DO. 26
Step 12: Complete the Colpotomy
Incision
Image courtesy of Ernest Lockrow, DO. 29
Cauterize and Transect the Vaginal Artery
Image courtesy of Ernest Lockrow, DO. 30
Step 13: Complete the Posterior
Colpotomy
Image courtesy of Ernest Lockrow, DO. 31
Last Steps
• Remove the uterus from below or from the umbilical incision with
contained in-bag morcellation
• Close the vaginal cuff from below or laparoscopically
• Laparoscopic cuff closure is associated with lower cuff dehiscence and
complications compared to vaginal closure (Uccella et al, AJOG 2018)
• Two-layer cuff closure is associated with lower post-operative complications
compared with a one-layer closure (Peters et al, Ob Gyn 2021)
• Finish with removal of ports
• Close fascia defects for incisions 10 mm or greater in size
32
Close the Vaginal Cuff Laparoscopically
Image courtesy of Ernest Lockrow, DO. 33
References
Cheetham, G., & Chivers, G. E. (2005). Professions, competence and informal learning.
Edward Elgar Publishing, p. 337.
Desai VB, Xu X. An update on inpatient hysterectomy routes in the United States. Am
J Obstet Gynecol. 2015 Nov;213(5):742-3. doi: 10.1016/j.ajog.2015.07.038.
Epub 2015 Jul 28. PMID: 26226555.
Eraut, M. (1994). Developing professional knowledge and competence.
Psychology Press, p. 124.
Hoffman. B.L., Schorge, J.O., Halverson, L. M., Hamid, C.A., Corton, M.M., & Schaffer, J. I. (2020) Williams Gynecology, 4e.
Chapter 44: “Mininally Invasive Surgery,” pp. 873- 906.
Levine, R. L., & Pasic, R. P. (2002). A practical manual of laparoscopy: a clinical cookbook.
London: Parthenon. Chapter 11 “Ectopic Pregnancy” Roy G and Luciano A.,
pp. 157–171.
Peters A, Ali R, Miles S, Foley CE, Buffie A, Ruppert K, Mansuria SM. Two-Layer Compared With One-Layer Vaginal Cuff
Closure at the Time of Total Laparoscopic Hysterectomy to Reduce Complications. Obstet Gynecol. 2021 Jul
1;138(1):59-65. doi: 10.1097/AOG.0000000000004428. PMID: 34259464; PMCID: PMC9534582.
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Uccella S, Malzoni M, Cromi A, Seracchioli R, Ciravolo G, Fanfani F, Shakir F, Gueli Alletti S, Legge F, Berretta R, Corrado G,
Casarella L, Donarini P, Zanello M, Perrone E, Gisone B, Vizza E, Scambia G, Ghezzi F. Laparoscopic vs transvaginal cuff 34
closure after total laparoscopic hysterectomy: a randomized trial by the Italian Society of Gynecologic Endoscopy. Am J
