Laparoscopic Hysterectomy

Prof. Dr. R. K. Mishra

INTRODUCTION
The first laparoscopic hysterectomy (LH) was performed in
January 1988 by Harry Reich in Pennsylvania. There has been
a great increase in interest following the introduction of LH
but most surgeons now perform laparoscopically-assisted
vaginal hysterectomy (LAVH) and then total laparoscopic
hysterectomy (TLH). This minimal access surgical procedure
was designed to be an alternative to abdominal hysterectomy
and not vaginal hysterectomy. Benign uterine diseases of
uterus are very common and often need hysterectomy and
laparotomy.
There are several subtypes of LH, including:
■ Total laparoscopic hysterectomy: The uterus and cervix
are removed. The entire procedure, including suturing
of the vaginal vault, is performed laparoscopically. The
uterine specimen is typically removed through the
vaginal vault, either intact or after morcellation.
■ Laparoscopic subtotal (supracervical) hysterectomy
Fig. 1: Anatomy of uterus. (1) Umbilical artery; (2) Ureter; (3) Uterine
(LSH): The uterus is removed; the cervix is conserved.
artery; (4) Internal iliac artery; (5) Ovarian artery; (6) Common iliac artery;
The uterine specimen is extracted via the abdominal (7) Uterosacral ligament.
ports or incisions.
■ Laparoscopic-assisted vaginal hysterectomy: The arteries ascending branch terminates by anatomizing with
laparoscopic approach is utilized to perform any needed the ovarian artery.
adnexal surgery and control the adnexal blood supply. From anterior to posterior, following important tubular
The remainder of the procedure is performed vaginally, structures are found crossing the brim of true pelvis:
including entry into the peritoneal cavity and ligation of the round ligament of the uterus, the infundibulopelvic
the uterine vessels from below. ligament, which contains the gonadal vessels and the ureter.
The ovaries and fallopian tube are found between the round
LAPAROSCOPIC ANATOMY OF UTERUS ligament and the infundibulopelvic ligament (Fig. 2).
The normal nulliparous uterus is approximately 8 cm The ovarian ligaments run from the ovaries to the lateral
in length and angled forward so the fundus lies over the border of the uterus. Ovary is attached to the pelvic side
posterior surface of the bladder. Uterus is all around covered wall with infundibulopelvic ligament, which carries ovarian
with peritoneum except where the bladder touches the lower artery. One of the common mistakes that may happen is
uterine segment at the anterior cul-de-sac and laterally at injury of the ureter during dissection of the infundibulopelvic
the broad ligaments (Fig. 1). ligament. If the uterus is deviated to the contralateral side
Two important arteries, uterine and ovarian, are of great with the help of uterine manipulator infundibulopelvic
significance in uterine surgery. The uterine arteries arise ligament is spread out and a pelvic side wall triangle is
from the internal iliac arteries. They pass medially on the created. The base of this triangle is the round ligament, the
levator ani muscle, cross the ureter and ultimately divide into medial side is the infundibulopelvic ligament, and the lateral
ascending and descending branch. The uterine artery runs side is the external iliac artery. The apex of this triangle is
in a tortuous course within the broad ligaments. The uterine the point at which the infundibulopelvic ligament crosses
 CHAPTER 34: Laparoscopic Hysterectomy 431

TABLE 1: Postoperative pain levels.

Day LAVH (n = 19) TAH (n = 19) p
1 6.6 6.4 NS
3 4.4 4.3 NS
7 2.8 3.6 S
14 1.6 2.4 S
21 1.46 1.8 S
Week 6 1.35 1.4 NS
Wilcoxon’s signed-rank test.
Ten-point activity scale: 1 = no pain; 10 = unbearable pain.
S = significant at p < 0.005; NS = not significant at p < 0.01

TABLE 2: Postoperative activity levels.

Day LAVH (n = 19) TAH (n = 19) p
1 3.4 3.3 NS
Fig. 2: Position of uterus. (1) Uterus; (2) Round ligament; (3) Utero-ovarian 3 5.4 4.4 NS
ligament (proper ovarian ligament); (4) Uterosacral ligament; (5) Ovary;
(6) Suspensory ligament of the ovary; (7) Ureter. 7 7.8 5.8 S
14 9.2 6.4 S
the external iliac artery. The ureter always enters medial to 21 9.6 7.9 S
this triangle into the pelvis. It is visible under the peritoneum Week 6 9.95 8.5 S
overlying the external iliac artery. Wilcoxon’s signed-rank test.
The ureters enter the pelvis in close proximity to Ten-point activity scale: 1 = extremely limited activity, 10 = no limits
the female pelvic organ and are at risk for injury during on activity
S = significant at p < 0.005; NS = not significant at p < 0.01
laparoscopic surgery of these organs. As the ureters course
medially over the bifurcation of the iliac vessels, they pass
obliquely under the ovarian vessels and then run in close prolapse (15%), and chronic pelvic pain (10%). For most of
proximity to the uterine artery. these conditions, other treatments should first be considered,
Laparoscopy hysterectomy needs careful identification and hysterectomy should be reserved as a last resort.
of ureter with some dissection of retroperitoneum. An Laparoscopic hysterectomy results in a significantly
incision is made in the peritoneum overlying the pelvic side shorter hospital stay, and a much more rapid return to
wall triangle between the fallopian tube and iliac vessel. normal activities than in total abdominal hysterectomy
Pelvic lymph node dissection is also necessary if (TAH). The drug requirement to control pain and the level of
gynecologist plans to perform radical LH. Node dissection pain patients experienced were also significantly less. Blood
as far distal as Cloquet’s node in the femoral triangle may be loss was not different for the two procedures (Tables 1 and 2).
included and proximally dissection may be necessary up to Postoperative recovery times and pain levels were
para-aortic lymph nodes. assessed in 37 patients with a primary complaint of pelvic
If a vaginal hysterectomy can be performed in the first pain and diagnoses of fibroid uterus, adenomyosis, and
place, there would be no point in adding the costs and severe endometriosis who underwent LH. Women reported
complications of laparoscopy. Its greatest benefit is the an activity level of 8.7 on a scale of 1–10 (10 no limits on
potential to convert what would have been an abdominal activity) by postoperative day 14. In another study, those
hysterectomy into a vaginal hysterectomy. An abdominal undergoing abdominal hysterectomy had a mean uterine
hysterectomy requires both a vaginal incision and a 4–6 weight of 418 g compared with 150 g for those undergoing
inch long incision in the abdomen, which is associated with LAVH. The mean hospital stay after abdominal hysterectomy
greater postoperative discomfort and a longer recovery was 4.5 days and after LH 2.5 days. An important public policy
period than for a vaginal procedure. Another advantage of issue now confronts us. As it is currently performed, LH is
the LH may be the removal of the tubes and ovaries which more expensive than TAH. The issue is whether the benefits
on occasion may not be easily removed with a vaginal of shorter convalescence and faster return to the work force,
hysterectomy. shorter hospitalization, and less need for narcotics for
The most common medical reasons for performing postoperative pain outweigh the disadvantage of the higher
hysterectomies include uterine fibroids (30%), abnormal cost. If total healthcare system costs are evaluated, the short-
uterine bleeding (20%), endometriosis (20%), genital term disability costs of 2 weeks of recovery after LH should
432 SECTION 3: Laparoscopic Gynecological Procedures

be compared with disability costs of 6–8 weeks of recovery the benefits available with widespread application of this
after abdominal hysterectomy. procedure.
For LH to be economically viable compared with TAH,
savings in disability costs and the increased contribution CLASSIFICATION
to the gross domestic product must offset the increased Garry and Reich Classification of Laparoscopic
healthcare costs. In the current system, insurance companies
Hysterectomy
and hospitals do not have share in these benefits, only
consider the costs. The economic impact of laparoscopic ■ Type 1: Diagnostic lap + VH
surgery must take into account both the cost to the hospital ■ Type 2: Lap vault suspension after VH
and insurance payers and these productivity and social ■ Type 3: LAVH
issues. Insurance is based on a risk pool whereby the cost of ■ Type 4: LH (lap ligation of uterine artery)
a premium is based on the cost of treatment, not the ability ■ Type 5: TLH
of the subscriber to return to work. An economic and social ■ Type 6: LSH (lap supracervical hysterectomy)
cost–benefit analysis must be performed before decisions ■ Type 7: LHL (lap hysterectomy with lymphadenectomy)
are made to modify or judge a procedure that provides ■ Type 8: LHL + O (as above + omentectomy)
substantial benefits to the patient. ■ Type 9: RLH (radical lap hysterectomy)
Since its introduction in 1989, no one could have
imagined that with continued improvement of techniques AAGL Classification of Laparoscopic
will progress so rapidly that LH can be performed on Hysterectomy
daycare basis for many women, and will result in shorter American Association of Gynecologic Laparoscopists
recovery time. Thus, the increased operating room time of (AAGL) classification of laparoscopic hysterectomy is shown
approximately 46 minutes is significantly outweighed by in Table 3.

TABLE 3: Laparoscopic hysterectomy classification according to American Association of Gynecologic Laparoscopists.

Type 0 Laparoscopic-directed preparation for vaginal hysterectomy
Type I* Dissection up to but not including uterine arteries
Type IΑ Ovarian artery pedicle(s) only
Type IΒ¶ IΑ + anterior structures
Type IC IΑ + posterior culdotomy
Type ID¶ IΑ + anterior structures and posterior culdotomy
Type II* Type I + uterine artery occlusion and division, unilateral or bilateral
Type IIΑ Ovarian artery(ies) and uterine artery(ies) occlusion and division only
¶
Type IIΒ IIΑ + anterior structures
Type IIC IIΑ + posterior culdotomy
Type IID¶ IIΑ + anterior structures and posterior culdotomy
Type III* Type II + portion of cardinal-uterosacral ligament complex only, unilateral or bilateral
Type IIIΑ Uterine and ovarian artery pedicles with portion of the cardinal-uterosacral
complex only, unilateral or bilateral
Type IIIΒ¶ IIIΑ + anterior structures
Type IIIC IIIΑ + posterior culdotomy
Type IIID¶ IIIΑ + anterior structures and posterior culdotomy
Type IV* Type II + total cardinal-uterosacral ligament complex, unilateral or bilateral
Type IVΑ Uterine and ovarian artery pedicles with complete detachment of the total
cardinal-uterosacral ligament complex only, unilateral or bilateral
Type IVΒ¶ IVΑ + anterior structures
Type IVC IVΑ + posterior culdotomy
¶
Type IVD IVΑ + anterior structures and posterior culdotomy
Type IVE Laparoscopically directed removal of entire uterus
(AAGL: American Association of Gynecologic Laparoscopists)
The system describes the portion of the procedure completed laparoscopically.
*A suffix "o" may be added if unilateral or bilateral oophorectomy is performed concomitantly (e.g., type IoA).
¶
The B and D subgroups may be further subclassified according to the degree of dissection involving the bladder and whether an anterior
culdotomy is created: (1) incision of vesicouterine peritoneum only, (2) dissection of any portion of bladder from cervix, and (3) creation of an
anterior culdotomy.
 CHAPTER 34: Laparoscopic Hysterectomy 433

LAPAROSCOPIC-ASSISTED VAGINAL side of the body of patient. One more assistant is required
HYSTERECTOMY between the legs to handle uterine manipulator. The patient
should ideally get general anesthesia with endotracheal
Laparoscopically-assisted vaginal hysterectomy is one of
intubation. A Foley catheter should be inserted to provide
the most frequently performed gynecologic operations,
bladder drainage throughout the operation.
and numerous authors have demonstrated its safety and
feasibility. A laparoscopic-assisted vaginal hysterectomy is
a type 3 Garry and Reich hysterectomy in which the adnexal Port Position
pedicles of the round ligament, fallopian tube, and ovarian A 10-mm umbilical port for camera should be along the
ligament are released abdominally through laparoscopic inferior crease. Two 5-mm ports should be placed at 5 cm
approach while the uterine artery and vein are secured away from umbilicus on either side. Sometime, accessory
through the vaginal approach. Further dissection of the broad port at right or left iliac region may be required according to
ligament anteriorly to free the bladder from the uterovesical need. Port position should be in accordance with baseball
fold is done laparoscopically. A 2 cm posterior colpotomy in diamond concept. If the left side of tube has to be operated,
between the uterosacral ligaments at the base of the pouch of one port should be in right iliac fossa and another below left
Douglas is also done laparoscopically. This dissection allows iliac fossa (Fig. 5).
completion of the surgery vaginally with ease.
Operative Technique
Preoperative Measures
It is important throughout the procedure to be
Patients are evaluated same way as that of any major surgery.
able to manipulate the uterus for optimal observation.
Routine preoperative tests include a complete blood count
with differential, serum electrolyte, bleeding time, and
urinalysis. More comprehensive blood studies include
thrombin time, partial thrombin time, ECG, chest X-ray,
and endometrial biopsy. Mechanical and antibiotic bowel
preparation is advised. Peglec powder 1 sachet with water a
night prior to surgery is advised.

Patient Position
Patient should be in steep Trendelenburg and lithotomy
position. One assistant should remain between the legs
of patient to do uterine manipulation whenever required
(Figs. 3A and B).

Position of Surgical Team (Fig. 4)

Surgeon stand left to the patient, camera assistant should be Fig. 4: Surgical team position in laparoscopically-assisted
left to the surgeon. Second assistant should be the opposite vaginal hysterectomy.

A B
Figs. 3A and B: Pervaginal examination should be routine. Fig. 5: Port position for laparoscopically-assisted vaginal hysterectomy.
434 SECTION 3: Laparoscopic Gynecological Procedures

A B
Figs. 6A and B: Laparoscopically-assisted vaginal hysterectomy using bipolar.

A B
Figs. 7A and B: Successive desiccation and dissection.

Different types of uterine manipulators are available. The dissection continues posteriorly on the broad ligament,
Depending on the laparoscopic procedure, digital taking care not to cut the uterine pedicle’s vessels (Figs. 7A
examination, probes, and sponge stick applicators are used and B).
in the cul-de-sac for identification of structures during The anterior leaf of the broad ligament is opened towards
laparoscopy. The direction and location of both ureters the vesicouterine fold and bladder flap is developed. The
should be identified as much as possible (Figs. 6A and B). anterior leaf of the broad ligament is grasped with forceps,
With the patient in lithotomy position, after the elevated and dissected from the anterior lower uterine
pneumoperitoneum insufflated to a pressure of 12–14 mm segment. The utero-ovarian ligament, proximal tube,
Hg, three ports should be introduced. The 10 mm optical and mesosalpinx are progressively dissected and cut and
umbilical trocar, 5 mm in lateral border of the right rectus posterior leaf of the broad ligament is opened. Similarly, the
abdominis in right iliac fossa, 5 mm in the same position round ligament, fallopian tube, and utero-ovarian ligament
on the left side for the Ligasure forceps. The ureters were are grasped closed to their insertion into the uterus then
visualized transperitoneally. If adnexectomy is planned, secured with the bipolar, Ligasure, or harmonic scalpel and
following electrodesiccation and cutting of the round cut. The distal end of the energized instruments must be
ligaments 2–3 cm from the uterus, then infundibulopelvic kept free of the bladder and ureter (Fig. 8).
ligament is desiccated and cut, taking progressive bites of The uterovesical junction is identified, grasped, and
tissue starting at pelvic brim and moving towards the round elevated with forceps while being cut with scissors. The
ligament. It is important to avoid the coagulation of the bladder pillars are identified desiccated and cut. The
round ligament near the uterus because of higher bleeding bladder can be completely freed from the uterus by
(Figs. 6A and B). In order to preserve the adnexa, the pushing downward with the tip of a blunt probe along the
coagulation and section is performed proximal to vesicocervical plane until the anterior cul-de-sac is exposed
the fallopian tubes and the utero-ovarian ligament. completely. In patients with severe anterior cul-de-sac
 CHAPTER 34: Laparoscopic Hysterectomy 435

coagulated and dissected. Further descent of the uterus is

gained, and the uterine pedicles are clamped, secured, cut
and tied.
The uterus is then delivered vaginally. Once the uterus
is removed, the vaginal vault is closed to ensure support of
the vault; the vaginal angles are attached to the uterosacral
and cardinal ligaments with 2-0 vicryl. Any coexisting
cystocele or rectocele is repaired. A very large fibroid uterus
should be debulked by morcellation for removal vaginally.
It can be combined with laparoscopic adnexal surgery,
e.g., ovariectomy or adhesiolysis. Once the vaginal surgery
is completed again laparoscopic inspection of the pelvis is
done.
Fig. 8: Dissection of bladder peritoneum.

Total Laparoscopic Hysterectomy

endometriosis, previous CS or adhesions, sharp dissection Preparation and Positioning of Patient
can be performed. Injecting 5 mL of indigo carmine in the
patient’s bladder helps to detect bladder trauma (Figs. 9 Preoperative check of consent form and patient past medical
and 10). history should be taken followed by proper preanesthetic
checkup (PAC). Patients is placed in a dorsal lithotomy
position. The arms are tucked at the sides and a foam
Colpotomy mattress is situated directly under the patient to prevent
A folded gauze in sponge forceps is used to mark the fornix. sliding during steep Trendelenburg. Gynecologist should
The vaginal wall is tented and transacted horizontally keep the table in a low position and have a monitor directly
with hook electrode (Figs. 11A to C). Once the dissection facing each surgeon to promote an ergonomic working
is extended to the lower uterine segment or to the level of environment (Fig. 14).
cardinal ligament, laparoscopic procedure is temporarily
terminated and vaginal part of LAVH started.
Abdominal Entry and Trocar Placement
A 10-mm supraumbilical skin incision is made using a
VAGINAL PART OF LAPAROSCOPIC-
#15 blade and insert a Veress needle is introduced into
ASSISTED VAGINAL HYSTERECTOMY the peritoneal cavity. Once intraperitoneal pressure has
The sponge forceps occluding the colpotomy is withdrawn reached 15 mm Hg, insert trocar through the supraumbilical
together with the uterine manipulator. Three vaginal specula incision, followed by a complete survey of the abdomen to
are used to get proper access for vaginal part of LAVH (Figs. rule out any visceral injury at the time of entry. The lower
12A to D). With aid of appropriate-sized speculum and quadrant trocar sleeves are placed under direct vision. These
adequate lateral and anterior retraction by the assistant, trocars are placed lateral to the rectus abdominis muscles,
the anterior and posterior lips of the cervix are held by 2 cm above and 2 cm medial to the anterior superior iliac
tenaculum. Using monopolar energy in circumcision of the spine. These secondary trocar position varies according to
skin at 2.5 cm above the external os towards the vaginal vault the size of uterus. Usually, a 5-mm trocar is placed on the
is done. Further dissection with gloved finger or dissecting right and a 5-mm trocar on the left. For TLH port position
scissors creates a flap in which the superior Sims speculum can be ipsilateral or contralateral. Two ports on the left
or narrow angled retractor is placed to lift the bladder greatly facilitate suturing and help to maintain an ergonomic
away. Gradual release of the tissues results in entry to the position for the surgeon throughout the procedure
abdominal cavity (Figs. 13A to H). (Figs. 15A and B).
Using appropriate-sized caucus clamp, the uterosacral
pedicles are identified bilaterally clamped, secured, cut,
Insertion of a Uterine Manipulator
and tied with the tail of the thread left as mark or coagulated
with Ligasure, harmonic scalpel, or bipolar instrument Different types of uterine manipulators are available.
specially made for vaginal hysterectomy (Figs. 12A to D). Generally, most of the gynecologists use the RUMI® or
With release of the uterosacral, the uterus descends into Mangeshkar Uterine Manipulator; however, in patients with
the vaginal cavity. Similarly, the cardinal ligaments are a very narrow introitus the VCare® Uterine Manipulator is
bilaterally clamped, secured, cut, and tied with a mark or useful because this is easier to insert (Fig. 16).
436 SECTION 3: Laparoscopic Gynecological Procedures

Fig. 9: Opening of anterior and posterior leaf broad ligament. Fig. 10: Separation of bladder.

A B C
Figs. 11A to C: Steps of colpotomy.

A B

C D
Figs. 12A to D: Anterior and posterior colpotomy.
 CHAPTER 34: Laparoscopic Hysterectomy 437

A B

C D

E F

G H
Figs. 13A to H: Successive clamping and desiccation of uterine pedicle through the vaginal route using bipolar.
438 SECTION 3: Laparoscopic Gynecological Procedures

Dissection of Infundibulopelvic Ligament off the lower uterine segment. It is important to stay in the
The infundibulopelvic (IP) ligament or the utero-ovarian loose areolar tissue if at all possible. In patients who have
ligament is initially desiccated with a reusable bipolar had a prior cesarean section, this area may be scarred and
grasper, Ligasure, or harmonic scalpel. It is important to stay it is important to stay relatively high on the uterus during
close to the ovary as this helps to avoid the pelvic sidewall the dissection. In case of adhesion a pledget dissection
during ovarian removal and the ascending uterine vessel combined with sharp dissection with cold scissors is helpful.
during ovarian conservation. The gynecologists should A reevaluation of the route of dissection is advised if fat is
take special care to desiccate the parametrial veins that run encountered because the fat belongs to the bladder; this
between the ovary and the round ligament as these can be may indicate that the dissection is moving too close to the
quite tortuous and tend to bleed if left unattended. The IP bladder (Fig. 18).
ligament or utero-ovarian ligament is then transacted close
to the ovary. During this step of the procedure, the uterine Securing the Uterine Vessels
manipulator is being pushed upward and to the contralateral Uterine artery course is diverse and due to a wide variety
side to provide maximal visualization (Fig. 17). in anatomy and in the course of the uterine vessels, it is
helpful to initially skeletonize them with the harmonic
Mobilization of the Bladder scalpel. Then desiccate the ascending uterine vessels
Transect the round ligament and separate the anterior and with the bipolar grasper or Ligasure at the level of internal
posterior leaves of the broad ligament with the harmonic cervical os. Note that pushing cephalad with the uterine
scalpel or monopolar scissors. It is important to find the manipulator helps to move the uterine vessels away from the
correct plane; this is where the peritoneum separates easily ureter. Complete desiccation of the vessels can be assessed
with gentle manipulation. After peritoneal separation, visually by observing the bubbles coming and going during
identify the vesicouterine peritoneal fold and continue this process; when the bubbles stop forming and tissue
the dissection anteriorly, thereby mobilizing the bladder color turns brown the vessel is desiccated and safe to transect
with the harmonic scalpel or Ligasure. It is important to take
the uterine vessels high and then dissect medially to the
uterine vessels down to the cup of colpotomizer. This averts
ureteral injury and provides a healthy vascular pedicle that
can be safely desiccated further in the event of bleeding
(Figs. 19A and B).

Colpotomy
After dissection of uterine pedicle the next step is to identify
the vaginal fornices while pushing cephalad with the uterine
manipulator. Gynecologist will either see the indentation
of the KOH colpotomizer or be able to palpate it with a
laparoscopic instrument. The harmonic scalpel is then used
to cut circumferentially around the cup. Take care not to
direct the harmonic scalpel directly into the metal because
Fig. 14: Position of the patient for total laparoscopic hysterectomy. this may result in failure of the device and may even break

A B
Figs. 15A and B: Abdominal entry and trocar placement.
 CHAPTER 34: Laparoscopic Hysterectomy 439

Fig. 16: Insertion of a uterine manipulator. Fig. 17: Dissection of upper pedicle, conserving ovary.

not tie a knot at the end of vault if they use barbed suture.
Extracorporeal knot with Clark knot pusher is also very good
to close the vault especially in deep pelvis. The pelvis can
now be irrigated and hemostasis at all sites is assured.

Port Site Closure

The fascia at the 10 mm incision is closed using 0 vicryl
sutures with a fascia closure device. The skin is closed
with 4-0 monocryl suture in a continuous subcutaneous
fashion or skin stapler. The 5-mm incisions are closed
with Dermabond. Many gynecologists then inject 20 cc
Fig. 18: Mobilization of bladder. of 0.5% Marcaine at all incision sites to reduce immediate
postoperative pain. It is not necessary to perform cystoscopy
routinely, but in selected cases cystoscopy is performed after
the active blade or harmonic (Figs. 20A to D). For colpotomy
vaginal closure to check ureteral patency and for any signs
hook can also be used if harmonic is not available.
of bladder injury. The patient is given 5 cc of Indigo carmine
intravenously 5 minutes prior to closure. Please note that
Removal of the Uterus a normal cystoscopy does not exclude a delayed thermal
Once complete separation of uterus with vaginal cuff is injury to either the ureters or the bladder.
achieved pull the uterus into the vagina if it fits (Figs.
21A and B). The uterus can remain there to maintain Subtotal Hysterectomy
pneumoperitoneum during suturing. Alternatively, the Supracervical hysterectomy is performed to preserve libido
uterus is removed and a glove with a pair of 4 × 4 sponges is of patient. The procedure is performed fully laparoscopically.
placed into the vagina to maintain pneumoperitoneum. If the After desiccating and cutting the uterine vessels at the level
uterus is too large to fit through the vagina, it can be carefully of cardinal ligaments above the uterosacral ligament, uterus
morcellated transvaginally by using a 10-blade scalpel and is retracted, and its lower segment is amputated with the
triple hooks for retraction. In patients with limited vaginal scissors and unipolar cutting current. After transecting the
access, the uterus can be morcellated laparoscopically using uterus from the cervix, uterine manipulator is removed
an electronic morcellator. It is important to keep the tip of vaginally, the cervical stump is irrigated, and hemostasis is
the morcellator in clear view at all times. achieved. The endocervical epithelium, lining the cervical
canal, is vaporized or coagulated with laser or electrosurgery.
Vaginal Cuff Closure The rest of the endocervical canal is ablated vaginally to
There are various ways of vaginal cuff closure (Figs. 22A reduce the risk of intraepithelial cervical neoplasia. The
to D). One can use barbed suture, extracorporeal square cervical stump is closed with interrupted absorbable sutures
knot, intracorporeal continuous suture, or interrupted and covered with peritoneum, which is stitched transversely
suture. Most commonly used technique of vault closure is with interrupted sutures. The dissected uterus is morcellated
intracorporeal continuous suturing. Closure begins at the and removes through a 10-mm cannula. Mini-laparotomy or
distal angle of the vaginal cuff and proceeds in a running posterior colpotomy can also be performed to remove the
fashion, making sure to include the vaginal mucosa and the uterus in case of subtotal hysterectomy. These patients are
pubocervical and rectovaginal fascia. Many surgeons do advised for annual examination for Pap smear.
440 SECTION 3: Laparoscopic Gynecological Procedures

A B
Figs. 19A and B: Securing uterine artery.

A B

C D
Figs. 20A to D: Colpotomy by harmonic scalpel.

A B
Figs. 21A and B: Removal of uterus through the vaginal route.
 CHAPTER 34: Laparoscopic Hysterectomy 441

A B

C D
Figs. 22A to D: Vault closure with by continuous suturing.

Ending the Procedure recovery, and smaller hospital stay than laparotomy.
LH requires greater surgical expertise and has a steep
One of the benefits of LAVH or TLH over nondescent vaginal
learning curve. Randomized trials have shown advantages
hysterectomy (NDVH) is inspection of pedicles at the end
of laparoscopy vs. laparotomy, including reduced
of surgery. The vaginal cuff can be closed from below or
postoperative pain, shorter hospitalization, rapid recovery,
above but after that pneumoperitoneum is again restored to
and substantial financial benefits to society. The objective of
see the pelvic and abdominal cavity. Irrigation and suction
performing hysterectomy laparoscopically can be achieved
should be performed. In case of any residual bleeding it is
but the question is, does this offer any advantage over
controlled laparoscopically. At the end pelvis is filled with
vaginal route? Every mode of hysterectomy has advantages
300 mL Ringer’s lactate and it should be seen for any change
and disadvantages but the indications for each remain
in color. Once inspection is satisfactory, the fluid is sucked
controversial. Good surgical practice is when the indication
and instrument and cannula are removed after deflating the
for hysterectomy is considered as the primary criterion for
abdominal cavity.
selecting the route of hysterectomy and not factors such as
It has been demonstrated that TLH and LAVH are
surgeon’s choice and experience. A major determinant of
associated with a shorter hospital stay and patients require
the route of hysterectomy is not the clinical situation but the
less pain medication compared to TAH. LAVH or TLH
attitude of the surgeon. There is no need for extra training
can replace most of the abdominal hysterectomy for the
and special skills or complicated equipment for vaginal
benign disease of uterus and with the technology available
hysterectomy.
today, it has definite benefit over nondescended vaginal
Laparoscopic hysterectomy took a long time to perform
hysterectomy.
in all studies. However, with increasing weight of the uterus,
there was a linear increase in operating time and blood
DISCUSSION loss in hysterectomy performed vaginally which was not
Vaginal hysterectomy is a part of repertoire of every observed in laparoscopic-assisted vaginal hysterectomy.
trained gynecologist. It is considered as a feasible option There is no statistically significant difference in postoperative
to abdominal hysterectomy and many studies have shown analgesia requirement, hospital stay, recovery milestones,
that vaginal hysterectomy has fewer complications, short or complication rates. The biggest drawback of laparoscopic
442 SECTION 3: Laparoscopic Gynecological Procedures

route over vaginal one is its cost due to expensive disposable larger randomized controlled trials are required to compare
instruments, prolonged operating and anesthesia time, and different types of hysterectomies.
the need for a trained senior gynecologist. For laparoscopic- When the size of the uterus is greater than 16 weeks
assisted vaginal hysterectomy to be cost effective expensive gestation, there is an increase in the operative time and
disposable instruments must be eliminated. blood loss in VH compared to LAVH which is statistically
Laparoscopic surgeons argue that subtotal hysterectomy significant.
can be performed laparoscopically but most randomized Laparoscopically-assisted vaginal hysterectomy is a
trials have failed to demonstrate any benefit of subtotal useful adjunct to transvaginal hysterectomy for lysis of
hysterectomy over total hysterectomy. In women who wish extensive adhesions and sometimes for certain concomitant
to retain their cervix vaginal subtotal hysterectomy described adnexal surgery. Besides, LAVH can also secure almost
by Döderlein-Krönig technique can be performed. The all the main blood supplies to the uterus, i.e., the uterine
disadvantage of vaginal approach is vault hematomas. The vessels and the adnexal collaterals. Although, a skilled
abdominal approach to hysterectomy does ensure good surgeon can do transvaginal hysterectomy with a larger
hemostasis under direct vision, while during the vaginal uterus by employing volume-reducing techniques, Kohler
operation, the vault is closed and subsequent bleeding from reported that laparoscopic coagulation hemostasis of
the vagina between the mucosa and the peritoneum can the uterine vessels was associated with less blood loss. It
give rise to problems, especially if a vasoconstrictor has been may take time to achieve these goals, but they may make
given that subsequently wears off. Laparoscopic approach subsequent extirpation or volume-reducing procedures
can help check hemostasis and reduce the incidence of vault easier and safer to perform. Therefore, the average operative
hematomas. However; this aspect needs to be evaluated in time and estimated blood loss for LAVH remained almost
studies. constant regardless of increasing uterine weight. Generally,
Lack of uterine descent and nulliparity, fibroid uterus, the average operative time for LAVH is longer than that for
need for oophorectomy, and previous pelvic surgery are transvaginal hysterectomy. It takes time to secure the uterine
no more considered as contraindications to the vaginal blood supply before extirpation and volume-reducing
route. With adequate vaginal access and technical skill, and procedures, but it also makes LAVH superior to transvaginal
good uterine mobility, vaginal hysterectomy can easily be hysterectomy when dealing with a larger uterus. In our
achieved. Multiparity, lax tissues due to poor involution opinion, LAVH might be considered for a larger uterus in
following multiple deliveries and lesser tissue tensile view of the relatively shorter operative time and less blood
strength afford a lot of comfort to vaginal surgeon even in loss, whereas transvaginal hysterectomy is preferable for a
the presence of significant uterine enlargement. None of the small uterus, not only for shorter operative time and minimal
evidence supports the use of LH rather than VH if latter can wound, but also for much lower costs.
be performed safely. No outcomes are significantly worse for
vaginal hysterectomy as compared to LAVH. There are clinical BIBLIOGRAPHY
situations where vaginal surgeries are not appropriate such 1. Carley ME, McIntire D, Carley JM, Schaffer J. Incidence, risk
factors and morbidity of unintended bladder or ureter injury
as dense pelvic adhesions, severe endometriosis, adnexal
during hysterectomy. Int Urogynecol J Pelvic Floor Dysfunct.
disease, when vaginal access is reduced wherein LH is 2002;13:18-21.
indicated as it has advantages over the abdominal approach. 2. Chapron C, Dubuisson JB, Aubert V. Total laparoscopic
Laparoscopic approach may be helpful postoperatively to hysterectomy: preliminary results. Hum Reprod. 1994;9: 2084-9.
3. Chapron C, Dubuisson JB. Laparoscopic hysterectomy. Lancet.
rule out hemorrhage in some cases. Laparoscopic assistance
1995;345:593.
should not be used to supplant inadequate skills of vaginal 4. Chapron C, Fauconnier A, Goffinet F, Bréart G, Dubuisson JB.
hysterectomy. Laparoscopic surgery is not inherently dangerous for patients
Lack of training in laparoscopic surgery is not a reason presenting with benign gynaecologic pathology. Results of a
meta-analysis. Hum Reprod. 2002;17:1334-42.
for not removing uteri vaginally. The learning curve of VH
5. Chapron C, Laforest L, Ansquer Y, Fauconnier A, Fernandez B,
is noticeably short as compared to laparoscopic surgery, Breart G, et al. Hysterectomy techniques used for benign
however, the current scenario in residency programs is disorders: results of a French multicentre study. Hum Reprod.
not providing a level of surgical competency in performing 1999;14:2464-70.
6. Chauveaud A, de Tayrac R, Gervaise A, Anquetil C, Fernandez H.
difficult vaginal hysterectomies. There is a need to improve
Total hysterectomy for a nonprolapsed, benign uterus in women
this training. without vaginal deliveries. J Reprod Med. 2002;47:4-8.
In order to compare the complication rates of different 7. Cosson M, Querleu D, Crepin G (Eds). Hystérectomies pour
types of hysterectomies, considering an incidence of 4–5% pathologies bénignes. Masson: Paris; Williams et Wilkins; 1997.
pp. 160.
of serious complications of hysterectomies, at least 1,460
8. Councell RB, Thorp JM Jr, Sandridge DA, Hill ST. Assessments of
women would be required in each arm of the study to laparoscopic-assisted vaginal hysterectomy. J Am Assoc Gynecol
detect 50% increase in the complication rate. Therefore, Laparosc. 1994;2:49-56.
 CHAPTER 34: Laparoscopic Hysterectomy 443

9. Dandolu V, Mathai E, Chatwani A, Harmanli O, Pontari M, 29. Johnson N, Barlow D, Lethaby A, Tavender E, Curr E, Garry R.
Hernandez E. Accuracy of cystoscopy in the diagnosis of ureteral Surgical approach to hysterectomy for benign gynaecological
injury in benign gynecologic surgery. Int Urogynecol J Pelvic disease. Cochran Database Syst Rev. 2006;(2):CD003677.
Floor Dysfunct. 2003;14:427-31. 30. Johnson N, Barlow D, Lethaby A, Tavender E, Curr L, Garry R.
10. Daraï E, Soriano D, Kimata P, Laplace C, Lecuru F. Vaginal Methods of hysterectomy: systematic review and meta-analysis
hysterectomy for enlarged uteri, with or without laparoscopy of randomised controlled trials. Br Med J. 2005;330:1478.
assistance: randomized study. Obstet Gynecol. 2001;97:712-6. 31. Kadar N. Dissecting the pelvic retroperitoneum and identifying the
11. Davies A, Vizza E, Bournas N, O’Connor H, Magos A. How to ureters. A laparoscopic technique. J Reprod Med. 1995;40:116-22.
increase the proportion of hysterectomies performed vaginally. 32. Kreiker G, Bertoldi A, Sad Larcher J, Ruiz Orrico G, Chapron C.
Am J Obstet Gynecol. 1998;179:1008-12. Prospective evaluation of the learning curve of total laparoscopic
12. Dicker RC, Greenspan JR, Strauss LT, Cowart MR, Scally MJ, hysterectomy in a university hospital. J Am Assoc Gynecol
Peterson HB, et al. Complications of abdominal and vaginal Laparosc. 2004;11:229-35.
hysterectomy among women of reproductive age in the United 33. Leonard F, Chopin N, Borghese B, Fotso A, Foulot H, Coste J,
States. The Collaborative Review of Sterilization. Am J Obstet et al. Total laparoscopic hysterectomy: preoperative risk factors
Gynecol. 1982;144:841-8. for conversion to laparotomy. J Minim Invasive Gynecol.
13. Dorairajan G, Rani PR, Habeebullah S, Dorairajan LN. Urological 2005;12:312-17.
injuries during hysterectomies: a 6-year review. J Obstet Gynaecol 34. Leonard F, Chopin N, Borghese B, Fotso A, Foulot H, Coste J,
Res. 2004;30:430-5. et al. Total laparoscopy hysterectomy: preoperative risk factor
14. Dorsey JH, Steinberg EP, Holtz PM. Clinical indications for for conversion to laparotomy. J Minim Invasive Gynecol.
hysterectomy route: patient characteristics or physician 2005;12:312-7.
preference? Am J Obstet Gynecol. 1995;173:1452-60. 35. Liu CY, Reich H. Complications of total laparoscopic hysterectomy
15. Dwyer PL, Carey MP, Rosamilia A. Suture injury to the urinary in 518 cases. Gynecol Endoscopy. 1994;3:203-8.
tract in urethral suspension procedures for stress incontinence. 36. Mäkinen J, Johansson J, Tomas C, Tomas E, Heinonen PK,
Int Urogynecol J Pelvic Floor Dysfunct. 1999;10:15-21. Laatikainen T, et al. Morbidity of 10110 hysterectomy by type
16. Farquhar CM, Steiner CA. Hysterectomy rates in the United States approach. Hum Reprod. 2001;16:1473-8.
1990–1997. Obstet Gynecol. 2002;99:229-34. 37. McMaster-Fay RA, Jones RA. Laparoscopic hysterectomy and
17. Garry R, Fountain J, Brown J, Manca A, Mason S, Sculpher M, ureteric injury: a comparison of the initial 275 cases and the last
et al. Evaluate hysterectomy trial. A multicentre randomised
1,000 cases using staples. Gynecol Surg. 2006;3:118-21.
trial comparing abdominal, vaginal and laparoscopy methods of
38. Meikle SF, Nugent EW, Orleans M. Complications and recovery
hysterectomy. Health Technol Assess. 2004a;8:1-154.
from laparoscopy-assisted vaginal hysterectomy compared
18. Garry R, Fountain J, Mason S, Hawe J, Napp V, Abbott J, et al.
with abdominal and vaginal hysterectomy. Obstet Gynecol.
(2004b) The evaluate study: two parallel randomised trials,
1997;89:304-11.
one comparing laparoscopy with abdominal hysterectomy, the
39. Mteta KA, Mbwambo J, Mvungi M. Iatrogenic ureteric and
other comparing laparoscopy with vaginal hysterectomy. BMJ.
bladder injuries in obstetric and gynaecologic surgeries. East Afr
2004;328:129. Erratum in BMJ. 2004;328:494.
Med J. 2006;83:79-85.
19. Gilmour DT, Das S, Flowerdew G. Rates of urinary tract injury from
40. National Centre for Disease Control and Prevention 1997.
gynecologic surgery and the role of intraoperative cystoscopy.
Hysterectomy surveillance United States 1980–1993. CDC
Obstet Gynecol. 2006;107:1366-72.
surveillance summaries, August. Mabille de Poncheville L (1998)
20. Gilmour DT, Dwyer PL, Carey MP. Lower urinary tract injury
Coeliochirurgie gynécologique en France, instantanée 1996.
during gynecologic surgery and its detection by intraoperative
cystoscopy. Obstet Gynecol. 1999;94:883-9. Résultats d’une enquête nationale. Thèse de médecine, Tours,
21. Gimbel H, Settnes A, Tabor A. Hysterectomy on benign France. Moller C, Kehlet H and Ottesen BS. Hospita- lization and
indication in Denmark 1988–1998. Acta Obstet Gynecol Scand. convalescence after hysterectomy. Open or laparoscopy surgery?
2001;80:267-72. Ugeskr Laeger. 1999;161:4620-4.
22. Härkki-Siren P, Kurpi T, Sjöbery J, Tiitinen A. Safety aspects 41. Nezhat F, Nezhat C, Admon D, Gordon S, Nezhat C. Complications
of laparoscopic hysterectomy. Acta Obstet Gynecol Scand. and results of 361 hysterectomies performed at laparoscopy. J Am
2001;80:383-91. Coll Surg. 1995;180:307-16.
23. Härkki-Siren P, Sjöberg J, Mäkinen J, Heinonen PK, Kaudo M, 42. O’Shea RT, Petrucco O, Gordon S, Seman E. Adelaide laparoscopic
Tomas E, et al. Finnish national register of laparoscopic hysterectomy audit (1991–1998): realistic complications rates.
hysterectomies: A review and complications of 1165 operations. Gynaecol Endoscopy. 2000;9:369-72.
Am J Obstet Gynecol. 1997;176:118-122. 43. Oh BR, Kwon DD, Park KS, Ryu SB, Park YI, Presti JC Jr. Late
24. Härkki-Siren P, Sjöberg J, Tiitinen A. Urinary tract injury after presentation of ureteral injury after laparoscopic surgery. Obstet
hysterectomy. Obstet Gynecol. 1998;92:113-8. Gynecol. 2000;95:337-39.
25. Harris MB, Olive DL. Changing hysterectomy patterns after 44. Ou CS, Beadle E, Presthus J, Smith M. A multicenter review of
introduction. Gynecol. 1994;171:340-3. 839 laparoscopic-assisted vaginal hysterectomies. J Am Assoc
26. Hurd WW, Bude RO, De Lancey JO, Pearl ML. The relationship of Gynecol Laparosc. 1994;1:417-22.
the umbilicus to aortic bifurcation: implications for laparoscopic 45. Paulson JD. Laparoscopically-assisted vaginal hysterectomy. A
technique. Obstet Gynecol. 1992;80:48-51. protocol for reducing urinary tract complications. J Reprod Med.
27. Hwang JL, Seow KM, Tsai YL, Huang LW, Hsieh BC, Lee C. 1996;41:623-8.
Comparative study of vaginal, laparoscopically-assisted vaginal 46. Phipps JH, Tyrrell NJ. Transilluminating ureteric stents for
and abdominal hysterectomies for uterine myoma larger than preventing operative ureteric damage. Br J Obstet Gynaecol.
6 cm in diameter or uterus weighing at least 450 g: a prospective 1992;99:81.
randomized study. Acta Obstet Gynecol Scand. 2002;81:1132-8. 47. Reich H, De Caprio J, McGlynn F. Laparoscopic hysterectomy.
28. Johns DA, Carrera B, Jones J, DeLeon F, Vincent R, Safely C. J Gynecol Surg. 1989;5:213-6.
The medical and economic impact of laparoscopically-assisted 48. Ribeiro S, Reich H, Rosenberg J, Guglielminetti E, Vidali A. The
vaginal hysterectomy in a large, metropolitan, not-for-profit value of intraoperative cystoscopy at the time of laparoscopic
hospital. Am J Obstet Gynecol. 1995;172:1709-15. hysterectomy. Hum Reprod. 1999;14:1727-9.
444 SECTION 3: Laparoscopic Gynecological Procedures

49. Ribeiro SC, Ribeiro RM, Santos NC, Pinotti JA. A randomized 55. Vakili B, Chesson RR, Kyle BL, Shobeiri SA, Echols KT, Gist R,
study of total abdominal, vaginal and laparoscopy hysterectomy. et al. The incidence of urinary tract injury during hysterectomy: a
Int J Gynaecol Obstet. 2003;83:37-43. prospective analysis based on universal cystoscopy. Am J Obstet
50. Rutkow IM. Obstetric and gynecologic operations in the United Gynecol. 2005;192:1599-1604.
States, 1979 to 1984. Obstet Gynecol. 1986;67:755-9. 56. Vessey MP, Villard-Mackintosh L, McPherson K, Coulter A, Yeates D.
51. Saidi MH, Sadler RK, Vancaillie TG, Akright BD, Farhart SA, The epidemiology of hysterectomy: findings in a large cohort
White AJ. Diagnosis and management of serious urinary study. Br J Obstet Gynaecol. 1992;99:402-7.
complications after major operative laparoscopy. Obstet Gynecol. 57. Visco AG, Taber KH, Weidner AC, Barber MD, Myers ER. Cost-
1996;87:272-6. effectiveness of universal cystoscopy to identify ureteral injury at
52. Shen CC, Wu MP, Kung FT, Huang FJ, Hsieh CH, Lan KC, et al. hysterectomy. Obstet Gynecol. 2001;97:685-92.
Major complications associated with laparoscopic-assisted 58. Wattiez A, Soriano D, Cohen SB, Nervo P, Canis M, Botchorisvili R,
vaginal hysterectomy: ten-year experience. J Am Assoc Gynecol et al. The learning curve of total laparoscopic hysterectomy:
Laparosc. 2003;10:147-53. comparative analysis of 1647 cases. J Am Assoc Gynecol Laparosc.
53. Soriano D, Goldstein A, Lecuru F, Daraï E. Recovery from vaginal 2002;9:339-45.
hysterectomy compared with laparoscopy-assisted vaginal 59. Wood EC, Maher P, Pelosi MA. Routine use of ureteric
hysterectomy: a prospective, randomized, multicenter study. catheters at laparoscopic hysterectomy may cause unnecessary
Acta Obstet Gynecol Scand. 2001;80:337-41. complications. J Am Assoc Gynecol Laparosc. 1996;3:393-7.
54. University of York (UK) Centre for Health Economics. The 60. Wu SM, Chao Yu YM, Yang CF, Che HL. Decision making tree for
management of menorrhagia. Effective Healthcare. 1991;1(9). women considering hysterectomy. J Adv Nurs. 2005;51:361-8.