Reich and colleagues reported the first case of laparoscopically assisted vaginal hysterectomy in 1989. Since that time, the use of laparoscopy to perform hysterectomy has increased concordant with the evolution of surgical techniques and instrumentation. There are several subdivisions of “laparoscopic hysterectomy” that are defined according to the extent of laparoscopic surgery used to accomplish surgical removal of the uterus. Vaginal hysterectomy (VH) assisted by laparoscopy includes laparoscopic lysis of adhesions or excision of endometriosis prior to vaginal hysterectomy. Laparoscopically assisted vaginal hysterectomy (LAVH) includes laparoscopic dissection down to but not including transection of the uterine arteries, with the remainder of the dissection being done via the vaginal approach. Laparoscopic hysterectomy (LH) extends the use of laparoscopy from LAVH to include transection of the uterine arteries, while colpotomy and division of the cardinal ligaments is performed vaginally. Total laparoscopic hysterectomy (TLH) consists of complete laparoscopic excision of the uterus with laparoscopic closure of the vaginal cuff.

The main advantage of laparoscopy for hysterectomy is to convert those cases that would otherwise have to be performed via an abdominal approach to a minimally invasive procedure. The indications for laparoscopic hysterectomy are the same as those for abdominal hysterectomy. Most minimally invasive hysterectomies performed in the United States are either LAVH or LH, although the frequency of TLH is increasing. This chapter describes one variation of the surgical approach to TLH.

A number of laparoscopic instruments have been developed to afford the laparoscopic surgeon the same or similar functionality to that of open surgery. Several different instruments can be used for vessel occlusion, including monopolar and bipolar grasping forceps, Harmonic® scalpel (Ethicon Endo Surgery, Cincinnati, OH), stapling/cutting devices, vessel-sealing/cutting devices (Ligasure™, Covidien, Mansfield, MA; Enseal®, Ethicon Endo Surgery, Cincinnati, OH), and tools for extracorporeal suturing.

In preparation for TLH, all patients should undergo a comprehensive history and physical examination, focusing on those areas that may indicate a reduced capacity to tolerate major surgery or the steep Trendelenburg position necessary for pelviscopy. Routine laboratory testing should include a complete blood count, serum electrolytes, age-appropriate health screening studies, and electrocardiogram for women aged 50 years and older. Preoperative imaging of the pelvis (ultrasonography and computed tomography) may be indicated to evaluate the extent of uterine pathology and associated anatomical changes for surgical planning purposes.

Preoperative mechanical bowel preparation (oral polyethylene glycol solution or sodium phosphate solution with or without bisacodyl) may facilitate pelvic
exposure by making the small bowel and colon easier to manipulate. Prophylactic antibiotics (Cephazolin 1 g, Cefotetan 1 to 2 g, or Clindamycin 800 mg) should be administered 30 minutes prior to incision, and thromboembolic prophylaxis (e.g., pneumatic compression devices and subcutaneous heparin) should be initiated prior to surgery. Following is a brief description of the surgical procedure used (see also video: Total Laparoscopic Hysterectomy).

General anesthesia is required. The patient should be positioned in low dorsal lithotomy position using Allen-type stirrups (Allen Medical Systems, Cleveland, OH) with arms tucked. Care is taken to avoid hyperextension at the elbows or external rotation of the arms. The abdomen is prepped and a Foley catheter placed. Examination under anesthesia should pay particular attention to uterine size and topography. Any one of a variety of uterine manipulators can be used; however, using an instrument with a colpotomy ring or cup (e.g., V-Care®, Conmed Endosurgery, Utica, NY; RUMI® with KOH Colpotomizer, CooperSurgical, Trumbull, CT) will greatly facilitate incision of the proximal vagina. Alternatively, a laparoscopic tenaculum or transvaginal placement of a colon anastomosissizing instrument can be used to elevate the uterus during laparoscopic dissection.

The number and size of trocars used for TLH can vary according to surgeon preference, but in general, TLH requires a midline 12-mm port placed through or in close proximity to the umbilicus, and bilateral 5-mm ports placed lateral to the lateral margin of the rectus abdominis muscles. As dictated by uterine size and pathology, a third 5-mm or second 12-mm port can be placed either midline in the lower abdomen or in the left or right upper quadrant equidistant between the umbilical and lateral ports (Figure 4.1). Laparoscopic suturing of the vaginal cuff usually requires a second 12-mm port through which the suture and needle can be introduced and extracted. Either a 10- or 5-mm laparoscope can be utilized through the umbilical port. The 5-mm scope has the advantage of being able to be temporarily relocated from the umbilical port to the lateral abdominal ports for improved visualization during the pelvic sidewall dissection in the presence of a large myomatous uterus or broad ligament leiomyoma. Alternatively, a 30° laparoscope can be used instead of the 0° laparoscope for this purpose. The patient is placed in steep Trendelenburg position to facilitate displacement of the bowel out of the pelvis. Adhesions are taken down and normal anatomy is restored.

The lateral leaf of the broad ligament is opened between the round ligament and infundibulopelvic ligament, and the retroperitoneal space is developed bluntly. The round ligament is cauterized and divided, and the lateral portion of the anterior leaf of the broad ligament is divided, incising the vesicouterine
peritoneal reflection toward the uterine midline. Attention is directed to the posterior lateral pelvis, and the pararectal space is developed. The ureter should be identified on the inner surface of the medial leaf of the broad ligament or should be visualized transperitoneally. The ureter is usually easier to locate at the level of the pelvic brim rather than deep within the pararectal space (Figure 4.2).