Total Laparoscopic Hysterectomy in Bicornuate Uterus: A Case Series with 10 Surgical Steps

Total Laparoscopic Hysterectomy (TLH) is a minimally invasive and safe procedure commonly performed today for various gynaecological conditions. Mullerian anomalies include a wide range of congenital malformations that arise from changes occurring in the embryogenesis of Müllerian ducts, which alter the morphology of the uterus, cervix, fallopian tubes, and vagina. This case series emphasises the difficulties encountered during TLH in patients with a bicornuate uterus and the approach to overcome those difficulties. Our first case was a 46-year-old female P3L2 with previous two c-sections, who presented with a complaint of heavy menstrual bleeding for 2 months. Her ultrasound showed bicornuate/septate uterus with a subserosal fibroid of 60*53*45 mm and a complex left ovarian cyst of 44*40 mm. Intraoperatively, the bladder could be pushed down with difficulty due to a tough band connecting the bicornuate uterus in the midline and the previous two c-sections. The second patient was a 52-yearold female P3L3 with previous three vaginal deliveries and presented with abdominal pain. Her ultrasound showed a bicornuate uterus with endometrial hyperplasia. Endometrial biopsy suggested endometrial hyperplasia without atypia. She was taken up for TLH with bilateral salpingo-oophorectomy. The third patient was a 16-year-old girl who presented to the Outpatient Department (OPD) with primary amenorrhoea and recurrent episodes of abdominal pain, not relieved even by injectable pain killers, for 6 months. Clinical and radiological findings suggested a diagnosis of uterus didelphys bicollis with unilateral left haematometra with left haematosalpingx with left ovarian endometriotic cyst and right rudimentary uterine horn. Diagnostic laparoscopy was done and followed by drainage of the left haematosalpinx and left ovarian endometriotic cystectomy. Laproscopic hysterectomy of such cases is challenging at each step. Most commonly faced difficulties were inserting the uterine manipulator and specimen retrieval. Delineating the anatomy carefully during the surgery in patients with Müllerian anomalies and meticulous dissection are key to the prevention of urinary tract or Gastrointestinal (GI) injuries.