What are the steps for a Total Laparoscopic Hysterectomy (TLH)?

Total Laparoscopic Hysterectomy: Procedural Steps

Total laparoscopic hysterectomy (TLH) involves complete laparoscopic dissection including uterine artery ligation, with vaginal removal of the specimen, and represents a minimally invasive alternative to abdominal hysterectomy with superior outcomes including reduced blood loss, shorter hospitalization, and faster recovery. 1, 2

Pre-Operative Setup and Patient Positioning

• Position the patient in dorsal lithotomy with steep Trendelenburg positioning to optimize pelvic visualization 1
• Insert a uterine manipulator (such as RUMI or KOH Colpotomizer System) to facilitate uterine mobilization and delineate the vaginal fornices 2
• Establish pneumoperitoneum and place primary trocar (typically 10-12mm umbilical port) followed by 2-3 accessory ports (5-10mm) in lower quadrants 1, 2

Systematic Surgical Steps

Step 1: Diagnostic Laparoscopy and Adhesiolysis

• Perform complete abdominal and pelvic survey to identify pathology and assess feasibility 3
• Lyse any adhesions to mobilize the uterus and adnexa, ensuring adequate visualization 2

Step 2: Round Ligament Division

• Coagulate and divide the round ligaments bilaterally using bipolar energy or ultrasonic devices 1
• This creates the initial entry point into the retroperitoneal space 1

Step 3: Bladder Peritoneum Incision and Bladder Dissection

• Incise the vesicouterine peritoneum transversely and develop the bladder flap inferiorly to expose the cervix and upper vagina 1, 2
• Adequate bladder mobilization prevents bladder injury (reported in 0.4% of cases) 2

Step 4: Infundibulopelvic Ligament or Utero-Ovarian Ligament Management

• For salpingo-oophorectomy: coagulate and divide the infundibulopelvic ligament after identifying the ureter 1, 3
• For ovarian preservation: divide the utero-ovarian ligament and fallopian tube separately 1
• Ureteral identification is critical—vascular injuries occurred in 5.5% of early series cases 3

Step 5: Broad Ligament Dissection

• Develop the broad ligament windows bilaterally by incising the anterior and posterior leaves 1
• This exposes the uterine vessels and allows retroperitoneal dissection 1

Step 6: Uterine Artery Ligation

• Skeletonize and coagulate the uterine arteries at their origin from the internal iliac vessels bilaterally 1, 4
• This step distinguishes TLH from laparoscopic-assisted vaginal hysterectomy (LAVH) 4
• Mean blood loss in experienced hands is 200-309ml 3, 2

Step 7: Cardinal and Uterosacral Ligament Division

• Sequentially coagulate and divide the cardinal and uterosacral ligaments down to the level of the vagina 1
• Maintain lateral dissection to avoid ureteral injury (ureterovaginal fistula rate 0.2%) 2

Step 8: Colpotomy

• Perform circumferential colpotomy using monopolar or ultrasonic energy, guided by the uterine manipulator 1, 2
• The vaginal fornices are clearly delineated by the manipulator cup 2

Step 9: Specimen Removal

• Extract the uterus through the vaginal opening, using morcellation if necessary for large specimens 1, 2
• Uteri up to 1000g can be removed laparoscopically 5
• Mean uterine size successfully removed is 11cm (range 5-17cm) 2

Step 10: Vaginal Cuff Closure

• Close the vaginal cuff laparoscopically using interrupted or running absorbable sutures, incorporating the uterosacral ligaments for support 1
• Perform underwater examination to ensure complete hemostasis and evacuate clots 5
• Cuff infection rates are extremely low with laparoscopic approach 5

Critical Intraoperative Considerations

• Mean operating time ranges from 133-210 minutes, decreasing with surgeon experience 3, 2
• Conversion to laparotomy (1.8-5.5%) should never be considered a complication but rather prudent surgical judgment 5, 3
• Major complications (excessive bleeding requiring transfusion, ureteric injury, bowel injury) occur in 4-4.5% of cases, with significant reduction in the second half of learning curves 3, 2

Post-Operative Outcomes

• Mean hospital stay is 2.7-5 days, significantly shorter than abdominal hysterectomy 3, 2
• Readmission rates are approximately 3.6%, primarily for vaginal bleeding or vault hematoma 2
• Patients experience faster return to normal activities compared to abdominal approach 5, 1

Common Pitfalls to Avoid

• Inadequate ureteral identification increases risk of injury—always visualize ureters before dividing infundibulopelvic or uterine vessels 3
• Insufficient bladder mobilization leads to bladder injury during colpotomy 2
• Vascular injuries occur more frequently early in the learning curve—maintain meticulous hemostasis throughout 3
• Attempting TLH beyond one's skill level—convert to laparotomy when uncomfortable rather than risking complications 5