What to know about Total Laparoscopic Hysterectomy?



As you would all agree that changing trends is the way for Life. Long back the conventional phone was the best way of communication for all of us, but with the advent of mobile phone it seems to become obsolete. Similarly for Hysterectomy, before abdominal and vaginal route were enough to tackle all our cases. But with changing trends and the advent of minimally invasive surgery TLH is the need for today. May be in future it will replace the conventional methods.

Who decides the route for hysterectomy? The patient, the relatives or the doctor? Ofcource the doctor, so as to give best options to the patient.

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In laparoscopic surgical anatomy the ureter lies close to the internal cervical os where the uterine artery is coagulated. The distance is 2-2.5cms. The distance between uterine artery and ureter is too less for safe coagulation and section of uterine artery without causing risk of thermal damage to ureter. To offset this concern, the technique of TLH employs primarily, uterine manipulators with vaginal fornix delineators.

This is the core basic principle: - Strech of cervicovaginal junction with strong cephalad traction of the uterus, with adequate bladder dissection. This will cause upward movement of vaginal fornix thereby lengthening the vagina and pushing the uterine arteries upwards, and pushing the ureter laterally, thereby increasing the distance of uterine artery from ureter.

The technical innovation of various types of manipulators have been instrumental in wide acceptance of TLH. The manipulators also have pneumo-occluder which prevents leakage of gas while doing colpotomy.

Several uterine manipulators have been devised.

• Dr KOH has devised KOH manipulator.

This has three different sized cups to fit on cervix. Cups are disposable. Expensive.

• Clermont-ferrand manipulator

Economical. All parts are reusable and autoclevable. Also with half cup so easy to introduce in vagina.

• Silicon tube

By Greg of Australia-Sydney. Most simple and economical.

• Myoma screw

Good manipulator when the size of uterus is big more then 14 wks size

• Proper selection of patient
• Patient counseling
• Fitness for GA is must
• Routine Lab Ix
• Bowel preparation
• NBM for 8 hrs


Patient position

• Modified lithotomy position
• Upper limbs are alongside the body

Position of trocars

• Empty bladder
• Position of trocar will depend on the size of uterus and associated pathology • Routine is two five mm lower lateral ports with one five mm central port and one infraumbical ten mm trocar for telescope.
• Central port should be above the line joining the two lateral trocar.
• Previous surgery – palmer’s point entry is preferred.

Surgical procedure

• Division of round ligament, ovarian ligament and infundibulopelvic ligament
• Opening of broad ligament and bladder dissection
• Skelatanization and division of uterine arteries
• Coplotomy
• Vault closure
• Cystoscopy

Post-op care

• Diclogesic suppository
• Monitor vital data
• No indwelling catheter is required
• Keep patient in hospital for 48 hrs.
• Routine antibiotics
• Oral fluids after 6-8 hrs

• One step laparoscopic approach
• Uterosacrals are not cut, so vaginal vault support is good.
• No shortening of vagina.
• No inversion of vaginal mucosa, so negligible chance of vault granulation.
• Other pelvic floor procedures like Burch colposuspension, paravaginal defect repair etc.can be done.
• True intrafacial technique. So blood supply and nerve supply of ligaments and supporting facial of vault is preserved.
• There is no crushing and clamping of tissue with ligation with sutures. So there is less tissue necrosis and inflammation. So less post operative pain.
• Less chances of injury to other organs as done under vision.
• Pericervical ring remains intact so no post-op prolepse.
• Patient is out of bed in 6-8 hrs and home in 48 hrs.

• Anesthesia complication
• Operative complication

Bladder injury (0.9%)
Uretaric injury (0.1%)
Brachial plexus injury

• D V thrombosis

• Time consuming
• Expensive
• Req.high tech equipments
• Technically more difficult
• Safe

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Our Clinic offers Laparoscopic Surgeries, Hysteroscopic Surgeries, Gynecological Care and Infertlity Guidance

WINGS Hospital is a state of art specialty hospital/clinic in India for Laparoscopy, infertility treatment IVF, Endoscopy, Surrogacy, Fetal Medicine, Gynecology, Wellness, situated at Ahmedabad, Gujarat. We have separate dedicated Endoscopy Department & dedicated Endoscopy Consultant team to perform various difficult Gynaec surgeries.

Recent Event
Venue: WINGS Hospital Date: 22/02/2015
Operative Faculty :
Laparoscopy - Dr.Devang Kanuga
Obstetrics - Dr.Mahesh Gupta
SUI - Dr.Darshan Shah
Co-ordinate by - Dr.Jayesh Amin