Overcoming the Complexity of Total Laparoscopic Hysterectomy and Bilateral Salpingo-Oophorectomy in a Patient With Uterine Didelphys and Dual Endometrial Pathology: A Surgical Approach in a Complex Anatomical Variant

Uterine didelphys is a rare Müllerian anomaly occurring in approximately 0.1-0.5% of women. It is characterised by duplicated uterine and cervical structures and presents significant diagnostic and surgical challenges. The coexistence of atypical endometrial hyperplasia, a premalignant lesion with malignant potential, adds further complexity to management. We report a woman in her late 40s with uterine didelphys who had persistent atypical endometrial hyperplasia in one uterus and hyperplasia without atypia in the other despite a hormonal therapy trial. Preoperative imaging, including renal ultrasonography, excluded associated urological anomalies. Definitive management with total laparoscopic hysterectomy and bilateral salpingo-oophorectomy was performed. Intraoperatively, two uteri and cervices were confirmed. The surgery was technically challenging due to the altered pelvic anatomy; however, meticulous dissection with careful ureteric identification enabled safe mobilisation and vascular control. A McCartney tube was utilised to aid fornix identification, maintain pneumoperitoneum after colpotomy, and facilitate secure laparoscopic vault closure. The patient tolerated the procedure well, recovered uneventfully, and was discharged home in good condition. At the six-week follow-up, she remained well with no postoperative complications. Histopathological examination confirmed atypical hyperplasia confined to one uterine cavity and benign endometrium in the other, with no evidence of malignancy. This case highlights the importance of thorough preoperative planning and precise surgical technique in managing Müllerian anomalies. It also highlights the rare coexistence of dual endometrial pathology in uterine didelphys, failure of conservative therapy. It highlights that definitive management can be safely and effectively achieved using a laparoscopic approach, despite the challenges of complex pelvic anatomy.