Total Laparoscopic Hysterectomy for Enlarged Uteri (300g-1000g): Procedural Analysis and Optimization

Abstract Background: The goal of the study was to analyze different aspects of Total Laparoscopic Hysterectomy (TLH) in cases involving enlarged uteri with myomas and to additionally identify surgical phases that significantly impact longer operation durations. The assumption was that the standard operative time for enlarged uteri with myomas should be less than 150 minutes. Methods: Data was collected from video recordings of surgical procedures. Two groups were distinguished: fast (F) with a duration less than 150 minutes and slow (S) with a duration greater than 150 minutes. The time was calculated from the beginning skin cutting to the extraction of specimen. The study predominantly included enlarged uteri with myomas weighing between 300 and 1000 grams. Results: Erythrocytes, hemoglobin, and hematocrit were significantly lower in the S group (p < 0.01). The S group had significantly higher BMI values (p = 0.036). No significant differences were found in age and parity. Significant differences in the short surgical phases between the F and S groups were observed in the time for coagulation and cutting of the right round ligament (p = 0.006), as well as cutting and coagulation of the left ligamentum proprium with the left uterine tube (p = 0.001). Multiple regression analysis with the duration of surgery showed a positive correlation with cutting the vagina, time for morcellation of uterus, time for suturing the vagina and time for cleaning instruments and suction (p < 0.001). The Kruskal-Wallis test indicated a significant association between uterine shape and duration of operation (p < 0.001). Conclusion: The surgical phases most significantly affecting the duration of TLH procedures in S group were: vaginal cutting, vaginal morcellation of uterus, cleaning instruments and suction. These phases are the most significant contributors to the duration of operation. Surgeons aiming for a duration of surgery less than 150 min (median uterine weight 658 g) must expedite these longer phases. For faster vaginal cutting phases, surgical gauze can be used to push the rectum away from the monopolar hook, while suction can be used simultaneously for smoke evacuation. During vaginal morcellation of the uterus, a surgical knife could be more efficient than scissors for faster cutting and specimen evacuation. Shortening the cleaning time for the bipolar tip, optics and suction is possible by minimizing bleeding through precise dissection of blood vessels before coagulation, though this may be challenging with large fragile veins.