Get me images of total laporoscopic hysterectomy from bailey and love
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Intraoperative laparoscopic photograph showing a subserosal/fundal fibroid - the most common indication for laparoscopic (including total laparoscopic) hysterectomy.
Figure 87.21 - Diagram of Uterine Fibroid Locations
Anatomical diagram showing the uterus with fibroid positions: intramural, subserosal (pedunculated and sessile), and submucosal - key to understanding the surgical anatomy relevant to laparoscopic hysterectomy.
Figure 87.22 - MRI of Uterine Fibroids
Sagittal MRI showing a markedly enlarged fibroid uterus. MRI is used preoperatively to plan the route of hysterectomy (vaginal, abdominal, or laparoscopic).
Figure 87.19 - Pre-embolisation Angiogram of Left Uterine Artery
Pre-embolisation angiogram showing catheterisation of the left uterine artery and blood supply to a large fundal fibroid. Uterine artery anatomy is directly relevant to ligation of uterine arteries in TLH.
Summary: Bailey and Love's 28th Edition does not contain dedicated intraoperative step-by-step TLH photographs (the textbook covers the laparoscopic approach to hysterectomy mainly in the context of indications and technique principles). The images above are all the laparoscopic/gynaecological figures from Chapter 87 that relate to laparoscopic hysterectomy. For detailed operative step images of TLH, a dedicated gynaecology operative atlas (such as Berek & Novak's Gynecology, which is also in the library) would be a better source.
Shaw's Textbook of Gynaecology Te Linde's Operative Gynecology Sabiston — general laparoscopy For surgery i want steps for surgery
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Library availability note: Shaw's Gynaecology and Te Linde's Operative Gynecology are not in the library. Only Sabiston is available - but Sabiston's chapter covers LAVH/TLH only briefly. The richest TLH operative content (with dedicated step-by-step surgical figures from the Cleveland Clinic) comes from Berek & Novak's Gynecology, which is in the library. Schwartz's Principles of Surgery also has a good hysterectomy steps figure. Both are presented in full below.
Total Laparoscopic Hysterectomy (TLH) - Surgical Steps & Images
Source: Berek & Novak's Gynecology (Chapter 27) + Schwartz's Principles of Surgery (Chapter 41)
PREOPERATIVE SETUP
Patient positioning: Dorsal lithotomy with legs in Allen/Yellowfin stirrups. Arms tucked. Egg-crate mattress to prevent sliding in Trendelenburg. No shoulder braces (brachial plexus injury risk).
Before first trocar:
- Examination under anesthesia
- Foley catheter inserted
- Uterine manipulator placed (e.g., Koh colpotomizer or VCare device)
- Oral/nasogastric tube inserted
STEP 1 - PORT PLACEMENT
Three lateral accessory ports + umbilical camera port. Ports placed ~8 cm from midline and ~8 cm above the pubic symphysis. The inferior epigastric vessels must be avoided - they run medial to the round ligament insertion at the deep inguinal ring and cannot be transilluminated.
Port positions (dots) relative to inferior epigastric, deep circumflex iliac, and femoral arteries.
STEP 2 - MESOSALPINX & ROUND LIGAMENT DIVISION
If the fallopian tubes are removed: coagulate and transect the mesosalpinx first, then the round ligament. The incision is carried anteriorly to create a bladder peritoneal flap by sharp dissection of the loose cervicovesical areolar tissue.
STEP 3 - BROAD LIGAMENT & RETROPERITONEAL SPACE
Transect the round ligament and open the posterior broad ligament toward the uterosacral ligament. Open the retroperitoneal space and identify the ureter on the medial leaf of the broad ligament. The utero-ovarian ligament is coagulated and transected (ovary conserved) or the infundibulopelvic ligament is divided (oophorectomy).
STEP 4 - UTERO-OVARIAN LIGAMENT DIVISION
With ovaries conserved: coagulate and transect the utero-ovarian ligament and its blood vessels. The posterior leaf of the broad ligament is now clearly visible.
STEP 5 - UTERINE ARTERY LIGATION (Key Step)
The uterus is torqued away from the uterine artery to be occluded. The posterior peritoneum is cut up to the uterosacral ligament to skeletonize the uterine artery. With the ureter clearly in view, the uterine artery is coagulated and transected at the level of the internal os. Repeated on the contralateral side.
STEP 6 - COLPOTOMY (Distinguishes TLH from LAVH)
The anterior dissection is completed so the bladder is fully mobilised off the anterior fornix. Using the Koh colpotomizer (maintains pneumoperitoneum), monopolar cautery makes a circumferential colpotomy around the cervix. The uterus is then delivered vaginally or morcellated.
STEP 7 - VAGINAL CUFF CLOSURE
The vaginal cuff is closed laparoscopically (or vaginally) with interrupted or continuous delayed-absorbable suture. The uterosacral ligaments are incorporated into the vaginal angles (McCall culdoplasty) for apical support. Cystoscopy with IV fluorescein confirms ureteral integrity.
Schwartz's Principles of Surgery - Hysterectomy Steps Diagram (Figure 41-12)
A complete 8-panel operative sequence (A-H) showing the full hysterectomy from initial exposure through vaginal cuff closure:
Panels A-F: Uterus + bladder anatomy → Round ligament clamped → Ovarian/fallopian ligament divided → Bladder reflected → Uterine vessels identified → Cardinal ligament.
Panel G: Colpotomy - entry into the vaginal fornix.
Panel H: Vaginal cuff closure incorporating cardinal ligament stumps.
Summary of TLH Steps
| Step | Action | Key Point |
|---|---|---|
| 1 | Patient positioning + instrumentation | Uterine manipulator is essential |
| 2 | Port placement | Avoid inferior epigastric vessels |
| 3 | Mesosalpinx + round ligament division | Creates bladder peritoneal flap |
| 4 | Retroperitoneal dissection + ureter ID | Ureter on medial leaf of broad ligament |
| 5 | Utero-ovarian or IP ligament division | Depends on oophorectomy decision |
| 6 | Uterine artery skeletonization + ligation | Ureter must be visualised first |
| 7 | Colpotomy (circumferential) | Distinguishes TLH from LAVH |
| 8 | Uterus removal (vaginal or morcellation) | |
| 9 | Vaginal cuff closure + McCall culdoplasty | Incorporate uterosacral ligaments |
| 10 | Cystoscopy | Confirm ureteral integrity |
Sources: Berek & Novak's Gynecology (Chapter 27, Figures 27-23 to 27-29) | Schwartz's Principles of Surgery 11th Ed (Chapter 41, Figure 41-12)
Shaw's Gynaecology and Te Linde's Operative Gynecology are not currently in the library and could not be retrieved. The steps above from Berek & Novak's represent the gold-standard operative gynecology reference available.
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