• Procedure and steps
• Indications and alternatives
• Risks, recovery, and aftercare
• Comparison with abdominal or vaginal hysterectomy
• Exam-style surgical notes

Total laparoscopic hysterectomy: operative steps

1. Preparation, anesthesia, and positioning

• General anesthesia.
• Dorsal lithotomy position, arms tucked, with the patient secured for Trendelenburg positioning.
• Examination under anesthesia.
• Foley catheter insertion to decompress the bladder.
• Placement of a uterine manipulator with a vaginal delineator or colpotomy cup.
• Gastric decompression may be used.

2. Abdominal entry and port placement

• Create pneumoperitoneum, commonly through an umbilical entry.
• Insert the laparoscope.
• Place accessory ports under direct vision, generally in the lower abdomen.
• Inspect the abdomen and pelvis for adhesions, endometriosis, enlarged uterus, adnexal pathology, and anatomy relevant to safe dissection.

3. Survey and identify key anatomy

• Ureters
• Uterine arteries
• Bladder and vesicouterine peritoneal reflection
• Ovarian vessels and infundibulopelvic ligaments
• Round ligaments and broad ligaments

4. Salpingectomy, if planned

• The fallopian tube is separated from the mesosalpinx, taking care to remain close to the tube and preserve ovarian blood supply when the ovaries are retained.
• The tube is removed on each side.

5. Divide the round ligaments and open the broad ligament

• Coagulate and transect each round ligament.
• Open the anterior and posterior leaves of the broad ligament.
• Develop the retroperitoneal space as needed to visualize the ureter and vascular pedicles.

6. Manage the ovarian pedicle

• Ovarian conservation: coagulate and divide the utero-ovarian ligament and proximal tube.
• Oophorectomy planned: identify the ureter, then coagulate and divide the infundibulopelvic ligament, which contains the ovarian vessels.

7. Create the bladder flap

• Incise the vesicouterine peritoneum.
• Dissect the bladder downward away from the cervix and upper vagina.
• This exposes the anterior vaginal fornix and reduces risk of bladder injury during colpotomy.

8. Skeletonize, seal, and divide the uterine vessels

• Identify the uterine arteries and veins at the level of the cervix.
• Mobilize the ureter laterally and keep it under consideration throughout.
• Coagulate, seal, and transect the uterine vascular pedicles on each side.
• Cephalad traction on the uterus increases the distance between the ureter and uterine vessels. ACOG TLH module

9. Divide cardinal and uterosacral attachments

• Progressively divide the paracervical tissues, including cardinal and uterosacral ligaments, staying close to the cervix.
• This fully mobilizes the cervix before entering the vagina.

10. Perform colpotomy

• Use the vaginal cup as a guide.
• Circumferentially incise the vagina around the cervix, separating the uterus and cervix from the vaginal apex.
• Complete anterior, lateral, and posterior colpotomy while maintaining ureter and bladder awareness.

11. Remove the specimen

• Remove the uterus and cervix through the vagina if feasible.
• With a large uterus, options include contained in-bag tissue reduction or an abdominal extraction incision, according to patient factors and institutional policy.
• Avoid uncontained power morcellation when there is a concern for unsuspected malignancy.

12. Close the vaginal cuff

• Close the vaginal cuff laparoscopically or vaginally using delayed-absorbable sutures.
• Incorporate supportive tissue, such as uterosacral ligaments, when appropriate to support the vaginal apex.
• Reinspect the cuff for hemostasis and secure closure.

13. Final inspection and closure

• Reduce pneumoperitoneum and inspect all pedicles, cuff, and dissection planes for bleeding.
• Recheck ureteral course and bladder integrity. Cystoscopy may be performed selectively or routinely depending on local practice and intraoperative concern.
• Remove ports under vision.
• Close fascial defects at larger trocar sites, usually those greater than 10 mm.
• Close skin incisions.

Key safety points

• Hemorrhage
• Ureteric injury
• Bladder injury
• Bowel injury
• Thermal injury from energy devices
• Vaginal-cuff bleeding or dehiscence