Total Laparoscopic Hysterectomy of the 7400g Uterus

Study objective: To demonstrate improved techniques and safety measures for total laparoscopic hysterectomy for the severely enlarged uterus.

Design: Technical video of the surgery which demonstrates various techniques for improved visualization, hemostasis and manipulation for total laparoscopic hysterectomy for 7.4kg uterus.

Setting: Academic tertiary care hospital, University of Louisville Hospital, Louisville, Kentucky INTERVENTION: A 44yo G0 presented with severely enlarged fibroid uterus, class III obesity with a body mass index of 40.4 kg/m² and hypertension seeking minimally invasive hysterectomy. MRI demonstrated a uterus measuring 26 × 26 × 17cm with multiple fibroids. The patient was counseled in detail regarding minimally invasive surgery. She underwent total laparoscopic hysterectomy, bilateral salpingectomy, right oophorectomy and cystoscopy. Total operative time was 4 hours 12 minutes and estimated blood loss was 700cc. Pre and post-operative hemoglobin was 13.3 g/dL and 11.3 g/dL, respectively. A 4cm mini laparotomy incision was created as an extension of the umbilical port and the specimen was extracted via scalpel morcellation using ExCITE technique. The patient was discharged home on post-operative day one and recovered without any complications.

Conclusion: There is an increasing trend in performance of laparoscopic hysterectomy for large uteri which has a lower incidence of overall complications compared to laparotomy [1,2]. Additionally, cost analysis has demonstrated superiority of laparoscopic hysterectomy for myomatous uterus accounting for the rare incidence of leiomyosarcoma [3]. Our video demonstrates improved hemostasis and visualization techniques through the use of high cephalad camera and assistant ports, generous traditional bipolar desiccation, blunt retraction with suction irrigator in midline umbilical port and surgical bed rotation. We also describe in detail scalpel morcellation technique. To date we believe this is the largest uterine size removed laparoscopically reported in the literature. In the hands of an experienced surgeon and with the demonstrated techniques, laparoscopic approach to hysterectomy of very enlarged uterus is safe and feasible.

Keywords: fibroid uterus; hysterectomy; laparoscopy; minimally invasive; surgery.