Total Laparoscopic Hysterectomy with Bilateral Salpingo-Oophorectomy: Surgical Steps
Total laparoscopic hysterectomy with bilateral salpingo-oophorectomy follows a systematic approach involving port placement, abdominal exploration, vascular ligation, uterine and adnexal removal, and vaginal cuff closure, with the procedure offering superior recovery compared to open approaches. 1
Port Placement and Initial Access
- Establish pneumoperitoneum through umbilical access, though single-port techniques through the umbilicus are feasible alternatives 2, 3
- Place additional ports as needed for instrument triangulation, typically 2-3 accessory ports in standard multi-port technique 2
Systematic Abdominal Exploration
- Perform thorough visual evaluation of the peritoneal, diaphragmatic, and serosal surfaces 4
- Inspect and palpate abdominal organs including liver, diaphragm, omentum, and peritoneal surfaces 5, 6
- Obtain peritoneal washings for cytology 4, 5, 7
- Biopsy any suspicious lesions to exclude extrauterine disease 4
Sequential Vascular and Ligamentous Division
- Identify and ligate the round ligaments bilaterally 5
- Complete excision of the lumbar-ovarian vessels (infundibulopelvic ligaments) bilaterally for removal of tubes and ovaries 5, 6
- Critical step: Identify the ureter before ligating the infundibulopelvic ligament to prevent ureteral injury 8
- Isolate, coagulate, and transect the infundibulopelvic ligament 8
- Identify, ligate, and divide the uterine vessels 5
Hysterectomy Completion
- Perform total hysterectomy with complete removal of the uterus and cervix 4, 5
- Remove fallopian tubes and ovaries bilaterally 4, 5
- The adnexa can be removed through the umbilical site in single-port approaches 3
Vaginal Cuff Management and Hemostasis
- Close the vaginal cuff laparoscopically 5, 6
- Ensure meticulous hemostasis throughout the procedure 8
- Re-evaluate ureter position and integrity after completion 8
Key Technical Considerations
Anatomical Restoration
- In cases with prior surgery or adhesive disease, restore normal anatomy before proceeding with vascular ligation 8
- This step is particularly critical in post-hysterectomy patients requiring subsequent adnexal surgery 8
Specimen Removal
- Avoid morcellation outside of endoscopic bags, as this carries high risk of worsening prognosis if malignancy is discovered post-operatively 4
- Remove specimens intact through vaginal cuff or enlarged port sites 3
Documentation Requirements
- Document precise operative findings including tumor size, location, depth of invasion, and histologic features 4
- Record quality of excision margins and completeness of procedure 5, 6
- Specify peritoneal cytology results even though they no longer affect FIGO staging 4
Clinical Advantages
- Laparoscopic approach results in better postoperative quality of life in the first 12 weeks compared to abdominal hysterectomy 1
- Shorter hospital stays and fewer moderate-to-severe postoperative complications versus open procedures 7
- Reduced blood loss and operating time compared to traditional approaches 3
- Patients typically discharged the following morning with single-port techniques 2