Surgical Technique, Anatomy & Clinical Decision-Making
Surgical removal of the uterus performed through small abdominal incisions (5–12 mm) using a laparoscope and specialized instruments, with CO₂ pneumoperitoneum providing the operative field.
Symptomatic fibroids causing menorrhagia, bulk symptoms, or failed conservative management. Most common indication (~40%).
Severe pelvic pain, dysmenorrhea, dyspareunia unresponsive to medical therapy. Adenomyosis causing heavy bleeding.
Refractory menorrhagia or metrorrhagia after failed endometrial ablation or medical management.
Symptomatic pelvic organ prolapse requiring surgical correction with concurrent hysterectomy.
Intractable pelvic pain with identifiable uterine pathology after exhaustive conservative measures.
Severe cardiopulmonary disease precluding Trendelenburg position and pneumoperitoneum
Active bleeding disorder or anticoagulation that cannot be reversed perioperatively
Open radical hysterectomy preferred per LACC trial evidence
Active intra-abdominal infection or obstruction requiring open exploration
Technically challenging; may require morcellation or conversion. Surgeon experience dependent.
Prior multiple laparotomies, PID, endometriosis stage IV — increased conversion risk
Increased anesthetic risk; limited instrument reach; consider robotic assistance
Tissue friability, poor healing, altered anatomy — higher complication risk
Avoid power morcellation; use contained extraction systems if needed
Two HD monitors at foot of table, at surgeon eye level. Scrub nurse on patient's left.
HD camera system (4K preferred), CO₂ insufflator, light source, electrosurgical unit, vessel sealing device
Monopolar diathermy, bipolar forceps, advanced vessel sealing (LigaSure™, Harmonic™ scalpel)
General anesthesia with endotracheal intubation. TIVA preferred. Maintain CO₂ at 12–15 mmHg.
0° or 30° Hopkins rod lens, 10mm diameter. 4K HD camera head.
Spring-loaded safety needle for initial CO₂ insufflation (Palmer's point or umbilical)
5mm, 10mm, 12mm — bladed or bladeless (Optiview™). Primary 10–12mm umbilical port.
Curved Metzenbaum scissors for sharp dissection of peritoneum and adhesions
Atraumatic bowel graspers, toothed tissue graspers for uterine manipulation
5mm suction-irrigator for haemostasis, field clearing, and hydrodissection
Ultrasonic energy — simultaneous cutting and coagulation up to 5mm vessels. Minimal thermal spread.
Advanced bipolar vessel sealing — reliable haemostasis of vessels up to 7mm diameter
Laparoscopic needle drivers for vault closure. Barbed suture (V-Loc™) or Vicryl 0 on CT-1 needle.
VCare™, RUMI II™, or Clermont-Ferrand — provides anteversion, retroversion, and colpotomy cup delineation
Delineates vaginal fornix for safe colpotomy; maintains pneumoperitoneum during uterine removal
Veress needle inserted at umbilicus (or Palmer's point). Confirm intraperitoneal placement: saline drop test, low opening pressure (<8 mmHg), free gas flow. Insufflate to 15 mmHg.
10–12mm umbilical trocar inserted with controlled thrust. Alternatively, Hasson open technique with purse-string suture for secure seal. Camera introduced.
Systematic inspection: liver, gallbladder, stomach, bowel, appendix, omentum, pelvic organs. Document adhesions, endometriosis, unexpected pathology. Assess feasibility.
Under direct laparoscopic vision, insert 5mm working ports bilaterally in iliac fossae. Transilluminate to avoid inferior epigastric vessels. Confirm triangulation.
Assistant manipulates uterus via vaginal manipulator — anteversion for posterior dissection, retroversion for anterior. Confirm colpotomy cup position.
Grasp and divide round ligament bilaterally using energy device (LigaSure/Harmonic) at its midpoint. This opens the broad ligament and provides access to the retroperitoneal space.
Open the broad ligament leaf. Develop the pararectal and paravesical spaces. Identify the ureter on the medial leaf of the broad ligament — confirm peristalsis. This is the most critical safety step.
If BSO planned: divide IP ligament (ovarian vessels) after confirming ureter is safe. If ovaries conserved: divide utero-ovarian ligament and fallopian tube close to uterus.
Incise vesicouterine peritoneum transversely. Develop the vesicovaginal space using sharp and blunt dissection. Push bladder inferiorly off the cervix and upper vagina — expose the colpotomy cup.
Open posterior broad ligament. Develop rectovaginal space if needed (especially in endometriosis). Identify and protect rectum and ureters posterolaterally.
Dissect the uterine artery and vein from surrounding areolar tissue at the level of the internal os. The ureter must be visualized and displaced laterally before proceeding. "Skeletonize" the vessels for 1–2 cm.
Apply energy device (LigaSure/Harmonic) directly on the uterine vessels at the level of the internal os, close to the uterus. Seal and divide. Confirm haemostasis. Repeat contralaterally.
Divide the cardinal ligaments (Mackenrodt's) and uterosacral ligaments using energy device. These provide the main uterine support. Ensure ureter is safe — it runs close to the uterosacral ligament.
Reduce pneumoperitoneum to 5–8 mmHg and inspect all pedicles for bleeding. Irrigate and aspirate. Apply additional energy or clips as needed before proceeding to colpotomy.
Using monopolar hook or energy device, incise the vaginal fornix circumferentially along the colpotomy cup of the uterine manipulator. The cup provides a safe guide and maintains pneumoperitoneum. Incise anteriorly first, then posteriorly.
Once vagina is entered, pneumoperitoneum is maintained by the colpotomy cup or by packing the vagina with a wet swab. Alternatively, use a vaginal occluder balloon. Prevent CO₂ loss.
Uterus delivered vaginally by the assistant. For large uteri: in-situ morcellation within a contained bag system (FDA-approved), or bisection/coring technique. Ensure complete specimen retrieval.
Send uterus, cervix, and adnexa (if removed) for histopathological examination. Document weight, dimensions, and macroscopic findings. Frozen section if malignancy suspected intraoperatively.
Inspect vaginal cuff edges for bleeding. Apply bipolar diathermy to bleeding points. Irrigate pelvis thoroughly. Reduce pneumoperitoneum to 5 mmHg to check for venous ooze.
Close vaginal vault laparoscopically using continuous or interrupted sutures. Options: Vicryl 0 on CT-1 needle (figure-of-8 or running), or barbed suture (V-Loc™ 0) for easier intracorporeal suturing. Include full thickness of vaginal wall.
Incorporate uterosacral ligament stumps into the vault closure angles to provide apical support and reduce risk of vault prolapse. This is the McCall culdoplasty principle applied laparoscopically.
Systematic inspection of all pedicles, vault, bladder, ureters, and bowel. Irrigate until clear. Reduce CO₂ and remove ports under vision. Close 10–12mm port fascial defects (Vicryl 1 J-needle). Skin closure.
Causes: Uterine vessel injury, IP ligament bleeding, port-site vessel injury, trocar injury to iliac vessels
Management: Direct pressure, additional energy/clips, suture ligation. If uncontrolled → immediate conversion to laparotomy. Activate massive transfusion protocol.
Causes: Thermal injury during vessel sealing, suture ligation, kinking, transection. Most common at uterine artery crossing and uterosacral ligament.
Management: Intraoperative: ureteric stent, primary repair, ureteroneocystostomy. Postoperative: CT urogram, urology referral, percutaneous nephrostomy if needed.
Causes: Bladder dissection, energy injury, trocar entry in undrained bladder
Management: Intraoperative repair in 2 layers (Vicryl 2-0). Foley catheter 7–14 days. Cystogram before removal.
Causes: Trocar entry, adhesiolysis, thermal spread from energy devices
Management: Small bowel: primary repair or resection. Colon: primary repair ± diversion. General surgery involvement. Delayed thermal injuries present 3–7 days post-op.
Indications: Uncontrolled bleeding, dense adhesions, poor visualization, organ injury, equipment failure
Principle: Conversion is NOT a failure — it is sound surgical judgment. Consent patients pre-operatively.
Causes: Veress needle in vessel, excessive pressure, prolonged surgery
Management: Immediate desufflation, Durant's maneuver (left lateral decubitus), 100% O₂, aspiration via CVP line. Anaesthetic emergency.
Laparoscopic vs open/vaginal hysterectomy. Laparoscopic: longer OR time but faster recovery, less pain, better QoL.
Minimally invasive vs open radical hysterectomy for cervical cancer. Open surgery superior — MIS associated with lower disease-free survival.