The Enlarged Uterus and Total Laparoscopic Hysterectomy
Charles H. Koh, M.D.
As gynecologists become increasingly experienced in
performing total laparoscopic hysterectomy (TLH), there is a growing trend to expand its
indications to include significantly enlarged and distorted myomatous uteri. While several
months of down-regulation with Gn-RH-agonists and placement of the laparoscopic port above
the umbilicus are key in such cases, I have found that The RUMI Systemâ Uterine Manipulator and the KOH
Colpotomizerä System also
confer many benefits when performing laparoscopic hysterectomy on patients with enlarged
uteri, including those women who have associated pelvic adhesions, endometriosis, or other
adnexual pathologies.
Chief among those benefits are the ability of the KOH and
RUMI systems to enhance visualization of critical anatomical landmarks as the laparoscopy
is insinuated anteriorly and posteriorly around the myoma, thus allowing safe uterine
desiccation and colpotomy incisions.
The use of a 30-degree or 45-degree laparoscope is key.
Otherwise, the anterior, posterior, and lateral bulging fibroids will obscure the anterior
and posterior fornices and lateral uterine vessels, respectively. Occasionally, the
broad-ligament fibroid must be enucleated before the lateral pedicles can be approached.
Although I usually like to use smaller ports, an additional 12-mm port may be required
when dealing with large uteri because of the need to employ a morcellator. This port is
best placed in a parumbilical position (usually to the right) to aid in manipulation of
the uterus using a 10-mm tenaculum. The use of this tenaculum is crucial, as no
manipulator is able to mobilize a large uterus.
With the 45-degree laparoscope, after division of the
uterovesical peritoneum and the upper pedicles, the 10-mm tenaculum allows one to move the
uterus laterally so that the uterine vessels are highlighted against the cup. They now can
be desiccated satisfactorily, although division is not necessary at this point.
At his point, one can begin to morcellate the fibroid to
create more room to operate. It also should be possible, after a while, for the RUMI
manipulator to elevate the posterior, lower uterus so that posterior colpotomy can be
performed. Because the laparoscope can be inserted into this area, the rest of the uterine
mass does not have to be elevated. In the case of the massive uterus lying on the pelvis,
the posterior fornix is the most difficult area to approach. Once this job is done, the
anterior colpotomy can be completed and the desiccated uterine vessels divided.
Hysterectomy is now complete. The reduced uterine mass can be delivered vaginally or the
morcellation completed vaginally. The vaginal vault is then sutured laparoscopically, as
previously described.
Using this technique, we have successfully performed total
laparoscopic hysterectomy on women with uterine sizes up to 24 weeks' (1500 g).