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Laparoscopic challenges: The large uterus

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Total laparoscopic hysterectomy is possible when the uterus is larger than 14 weeks’ gestational size—if you incorporate several novel techniques and use the right instruments



The authors report no financial relationships relevant to this article.

CASE: Large fibroid uterus. Is laparoscopy feasible?

A 41-year-old woman known to have uterine fibroids consults you after two other gynecologists have recommended abdominal hysterectomy. She weighs 320 lb, stands 5 ft 2 in, and is nulliparous and sexually inactive. Pelvic ultrasonography reveals multiple fibroids approximating 18 weeks’ gestational size. Although she has hypertension and reactive airway disease, these conditions are well controlled by medication. Her Pap smear and endometrial biopsy are negative.

Because her professional commitments limit her time for recovery, she hopes to bypass abdominal hysterectomy in favor of the laparoscopic approach.

Is this desire realistic?

Twenty years have passed since Reich performed the first total laparoscopic hysterectomy,1 but only a small percentage of hysterectomies performed in the United States utilize that approach. In 2003, 12% of 602,457 hysterectomies were done laparoscopically; the rest were performed using the abdominal or vaginal approach (66% and 22%, respectively).2

Yet laparoscopic hysterectomy has much to recommend it. Compared with abdominal hysterectomy, it involves a shorter hospital stay, less blood loss, a speedier return to normal activities, and fewer wound infections.3 Unlike vaginal hysterectomy, it also facilitates intra-abdominal inspection.

Although the opening case represents potentially difficult surgery because of the size of the uterus, the laparoscopic approach is feasible. When the uterus weighs more than 450 g, contains fibroids larger than 6 cm, or exceeds 12 to 14 cm in size,4-7 there is an increased risk of visceral injury, bleeding necessitating transfusion, prolonged operative time, and conversion to laparotomy. This article describes techniques that simplify laparoscopic management when the uterus exceeds 14 weeks’ size. By incorporating these techniques, we have performed laparoscopic hysterectomy in uteri as large as 22 to 24 weeks’ size without increased complications.

In Part 2 of this article, we address techniques that simplify laparoscopy when extensive intra-abdominal adhesions are present.

Why do some surgeons avoid laparoscopy?

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Major complications occur in approximately 5% to 6% of women who undergo total laparoscopic hysterectomy.8,9 That is one of the reasons many surgeons who perform laparoscopic procedures revert to the more traditional vaginal or abdominal approach when faced with a potentially difficult hysterectomy. These surgeons cite uteri larger than 14 weeks’ size, extensive intra-abdominal adhesions, and morbid obesity as common indications for a more conservative approach. Others cite the limitations of working with inexperienced surgeons or residents, inadequate laparoscopic instruments, and distorted pelvic anatomy. Still others avoid laparoscopy when the patient has medical problems that preclude use of pneumoperitoneum or a steep Trendelenburg position.

In some cases, laparoscopic hysterectomy is simply not practical. In others, however, such as the presence of a large uterus, it can be achieved with attention to detail, a few key techniques, and proper counseling of the patient.

Success begins preop

All surgical decisions begin with the patient. A comprehensive preoperative discussion of pertinent management options allows both patient and surgeon to proceed with confidence. Easing the patient’s preoperative anxiety is important. It can be achieved by explaining what to expect—not only the normal recovery for laparoscopic hysterectomy, but also the expected recovery if it becomes necessary to convert to laparotomy. If the patient has clear expectations, unexpected outcomes such as conversion are better tolerated. When it comes down to a choice between the surgeon’s ego or patient safety, the patient always wins. Conversion is not failure.

Another important topic to discuss with the patient is the risk of bowel injury. Mechanical bowel preparation is not essential for every patient who undergoes laparoscopic hysterectomy, but the risk of injury to the bowel necessitating colorectal surgical assistance may be heightened in women who have a large uterus or extensive intra-abdominal adhesions. Because of this risk, mechanical bowel preparation with oral polyethylene glycol solution or sodium phosphate should be considered. Most patients prefer the latter.10


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