Tips and Tricks for the Massive Hysterectomy

INTRODUCTION: Despite the advantages of laparoscopy, open surgery remains the most common approach for hysterectomy of a massive uterus. Enlarged uteri complicate access to vascular pedicles, making laparoscopy challenging and high risk (1–4). Offering a minimally invasive approach for a hysterectomy of a massive uterus grants patients the benefits of laparoscopy, including lower blood loss, faster recovery, less postoperative pain, and shorter hospital stays. OBJECTIVE: To demonstrate the technical key steps, as well as tips and tricks for a robotic-assisted laparoscopic hysterectomy of the massive uterus. METHODS: This is a case of a 45-year-old G1P1001 with abnormal uterine bleeding secondary to fibroids undergoing definitive surgical management. Exam was notable for a 24-week-sized uterus, and ultrasound revealed multiple large fibroids. This video shows the surgical techniques utilized to perform a robotic-assisted total laparoscopic hysterectomy of a massive uterus. RESULTS: The first key step is optimal port placement. Ports are placed in the M formation with a 30-degree camera in the umbilicus. Lateral ports are placed at the level of the umbilicus and superior ports are placed 8 cm equidistant from the umbilical and lateral ports. At the start of the case, address the anatomy as it presents itself. As safe and steady progress is made, increased mobility will improve the visibility of the critical anatomy. Given that massive pathology can obscure visualization of posterior anatomy, utilize an anterior approach to posterior structures, including the uterine artery. Another tip for improving visualization and access with a massive uterus is to utilize “port-hopping.” The camera can be moved laterally for better visualization, and the surgical instruments redistributed to enable optimal position to seal pedicles. When the posterior colpotomy cup is difficult to access, a staged colpotomy is used. The anterior uterine body is separated from the cervix until the uterine manipulator tip is visible. The manipulator is inserted through the anterior incision to lift the neck of the uterus away from inferior anatomy, allowing for the safe removal of the uterine body. Once the upper bulk of the uterus has been released, the colpotomy cup is freely mobile and a trachelectomy performed for a safe completion of the hysterectomy. CONCLUSIONS: Laparoscopic hysterectomy of a massive uterus offers patients the benefits of a minimally invasive approach. Given that enlarged pathology can complicate surgical management, utilizing the outlined key steps can make laparoscopy a feasible option. To review, these are the key steps summarized for this case: port placement, working with the anatomy as it displays itself, the use of “port-hopping” for better visualization and access to vascular pedicles and planes, an anterior approach to the uterine vessels and staged colpotomy.