Laparoscopic subtotal hysterectomy includes morcellation of the myometrium and of the endometrium; therefore it is very important to exclude endometrial hyperplasia and malignancy. Preoperative endometrial assessment with transvaginal ultrasound scanning and, where appropriate, outpatient hysteroscopy and endometrial sampling is of paramount importance for all women undergoing the procedure.

Women are advised that there is a small chance of developing cyclical bleeding despite diathermy of the endocervix and it is impossible to predict which women will develop this symptom. This cyclical bleeding invariably lasts for 1 day only in a periodical pattern and will never evolve into a heavy period. We believe that women who are informed of the possibility of cyclical bleeding are much less likely to be disturbed by its occurrence and much less likely to request a trachelectomy following a laparoscopic subtotal hysterectomy. The importance of continued cervical screening is also reinforced.

Contraindications to laparoscopic subtotal hysterectomy include the following:

We consider it good practice to offer the results of our own continuous audit to the women attending the clinic.

This is a comprehensive account of our standardised technique. In other units, alternative forms of thermal energy, different types of morcellating devices and uterine manipulators are used with equally good results.

The procedure is performed under general anaesthesia by two surgeons, with the women in the Lloyd–Davies position. Preparation of the woman includes indwelling bladder catheterisation and placement of a Pelosi uterine manipulator (Apple Medical Corporation, Bolton, MA, USA Apple Medical Corporation, Marlboro, MA, USA) in the cervix. This is an articulated manipulator that allows extreme anteversion and retroversion as well as lateral manipulation of the uterus even in the absence of an assistant. The use of an indwelling catheter is essential as it will keep the bladder empty as the suprapubic port is placed later during the procedure and the collecting bag will immediately fill with carbon dioxide if the bladder is injured. If Palmer’s point entry is indicated, a nasogastric tube is inserted to decompress the upper gastrointestinal tract after the introduction of anaesthesia.

The procedure is performed through a 4-port operative laparoscopy: a 10 mm infraumbilical port for the laparoscope, two 5 mm lateral ports and a suprapubic 12 mm port for morcellation. The lateral ports are placed high in the abdomen, at the same level as the umbilicus. This allows more space for handling pedicles in large uteruses and also facilitates the angle of coagulation as the line of the instrument is parallel to the lateral margin of the uterus and away from the pelvic sidewall.

Laparoscopic subtotal hysterectomy is a two-surgeon procedure, with both surgeons predominantly operating with their right hand. The surgeon on the left uses the right hand to handle instruments through the left port and the left hand to manipulate the Pelosi uterine manipulator and maximise exposure of the operating field. The surgeon on the right of the woman under surgery uses the right hand to handle instruments through the right port and the left hand to handle the laparoscope.

The laparoscopic steps include coagulation and transection of the infundibulopelvic ligament in the case of bilateral salpingo-oophorectomy or the ovarian ligament in the case of conservation of the ovaries. The round ligament is coagulated and transected. The broad ligament is incised and the uterovesical fold is deflected to allow more space for the Lap Loop (Roberts Surgical Healthcare, Kidderminster, UK) monopolar diathermy device at the level of the cervical isthmus. The broad ligament is incised lateral to the uterus so that the uterine plexus is not inadvertently injured.

Transection of the uterine vessels is performed at the same time as the detachment of the uterine corpus using the Lap Loop monopolar wire after removal of the uterine manipulator. The Lap Loop device is inserted through the suprapubic port to the left of the uterus and the wire is grasped by the surgeon on the right, advanced behind the cervix and attached to the Lap Loop applicator. The pouch of Douglas is checked with the wire under tension to avoid bowel entrapment inside the monopolar wire. The diathermy is set at 100 W coagulation and the surgeon on the left keeps the uterus retroflexed. With this technique, the angle of cutting is vertical and the Lap Loop device provides a conisation effect removing a wedge off the endocervix.

When the uterine vessels are cut with the wire, they remain attached on the sides of the cervical stump instead of retracting to the pelvic sidewall. All pedicles are cross-coagulated, i.e. coagulated from the left and the right side trocars at right angles, by the surgeon and the assistant. Any complementary coagulation to the uterine vessels is easy, does not require any additional dissection and most importantly does not jeopardise the integrity of the ureters and the major vessels of the pelvic sidewall.

The uterus is then morcellated by drawing the specimen into the morcellator using a single-tooth or a gallbladder forceps while the uterus is lifted and stabilised by the surgeon on the right. The tip of the rotating electromechanical morcellator is always kept within 2 cm of the lower abdominal wall (Erian et al. 2007), and the single-tooth forceps is only advanced 3–4 cm beyond the edge of the trocar to avoid inadvertent grasping of bowel or omentum during the morcellation. We routinely use the suprapubic port for the morcellator as we feel this provides more space inferiorly and laterally from the blade of the morcellator to the abdominal viscera and the pelvic sidewall, therefore minimising the risk of accidental damage to vital structures.

After morcellation is completed, the peritoneal cavity is cleared of any collected blood and fragments of myometrium by collection and irrigation with normal saline solution followed by suction. The bowel is not displaced before all the visible fragments are removed to minimise missing uterine corpus fragments in between bowel loops. The clearance of the pelvis, paracolic gutters and upper abdomen (as the woman is in deep head-down position) is of paramount importance as there have been reports of pelvic seeding of morcellated uterine tissue and subsequent development of adenomyotic masses (morcelloma) (Donnez et al. 2007; Hilger and Magrina 2006) in the peritoneal cavity or the cervical stump. Meticulous clearance of the peritoneal cavity has been advocated (Sutton 1995; Johns 1997) because several complications may be attributed to incomplete collection of uterine fragments. The endocervix is cauterised with bipolar diathermy.

Haemostasis is checked after decompressing the peritoneal cavity. Then the abdominal cavity is re-inflated and a 16 gauge drain is passed through the lateral port to the pouch of Douglas. The drain is connected with a decompressed collection container as suction drainage may draw small or large bowel into the drain and cause ischaemia and subsequent perforation (Reed et al. 1992). Finally, the laparoscopic instruments and trocars are removed under direct vision and the port sites are closed with a J-shaped needle and number 1 Vicryl® (polyglactin 910; Ethicon Endo-Surgery, Cincinnati, OH, USA) under laparoscopic control before decompression of the pneumoperitoneum.

As with all new procedures, mentoring and preceptorship are essential to minimise the risk of complications (Cutner and Erian 1995). Once introduced as routine practice, the complication rate of minimal access hysterectomy seems to fall by 11–13 % per year reaching a plateau after about 5–7 years of practice (Brummer et al. 2008; Wattiez et al. 2002). The fall in complication rates may be associated with the early identification of potential visceral injury and laparoscopic repair of the injured viscera.