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Laparoscopic Hysterectomy: Indications, Technique, and Outcomes

Total laparoscopic hysterectomy (TLH) — removal of uterus and cervix via laparoscopic ports — is the standard minimally invasive approach for benign and select malignant indications.

Indications

  • Benign: Fibroids (size/location permitting), adenomyosis, AUB refractory to medical therapy, endometriosis, prolapse.
  • Malignant: Early endometrial cancer (stage IA), cervical cancer (stage IA1–IB1), ovarian cancer (staging).

Contraindications / Relative

  • Uterus >12–14 wk size (or >500–1000g) — morcellation challenges, visualization.
  • Extensive adhesions (prior surgeries, severe endometriosis).
  • Severe cardiopulmonary disease (pneumoperitoneum intolerance).
  • Suspected adnexal malignancy requiring intact removal.

Procedure Overview

  1. Pneumoperitoneum (CO₂, 12–15 mmHg); 3–4 ports (umbilical camera, 2–3 working).
  2. Uterine manipulator (VCare, Hohl) for exposure.
  3. Securing vessels: Uterine arteries (ligasure, harmonic, sutures), ovarian vessels (if oophorectomy).
  4. Colpotomy (vaginal cuff incision) — circumferential.
  5. Uterus removal: Vaginally (if fits) or morcellated in bag (contained).
  6. Cuff closure: Laparoscopic suturing (barbed) or vaginal.

Outcomes vs. Abdominal

  • Less blood loss, pain, shorter stay (0–1d vs. 2–4d), faster recovery (2–3w vs. 6w).
  • Similar complication rates (ureteral injury ~0.5–1%, vault dehiscence, infection).
  • Cost: Higher OR time/equipment; lower hospitalization cost.

Robotic-Assisted

Da Vinci: Improved ergonomics, 3D vision, wristed instruments — facilitates suturing; higher cost; similar outcomes.

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