Version May 2024
INTRODUCTION — Hysterectomy (surgical removal of the uterus) was first successfully performed in the 19th century using vaginal or abdominal incisions [1,2]. Innovations in technology led to the performance of the first laparoscopic hysterectomy in 1989 [3]. According to United States national surveillance data, the laparoscopic mode of access has become the most common approach to hysterectomy, with a shift toward outpatient procedures [4,5]. Additionally, laparoscopic surgery can be performed with conventional laparoscopic instruments or with computer assistance using robotic equipment and instruments.
Laparoscopic hysterectomy will be reviewed here. Other approaches to hysterectomy are discussed separately. (See "Hysterectomy: Abdominal (open) route" and "Hysterectomy: Vaginal" and "Radical hysterectomy" and "Hysterectomy (benign indications): Selection of surgical route".)
In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. We encourage readers to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.
INDICATIONS — Common indications for hysterectomy include [6]:
●Uterine leiomyomas
●Adenomyosis
●Idiopathic abnormal uterine bleeding
●Endometriosis
●Uterine prolapse
Hysterectomy is also performed for uterine, ovarian, fallopian tube, peritoneal, and cervical cancer. In some patients with gynecologic cancer, surgical staging and treatment can be performed laparoscopically [7-10]. (See "Endometrial carcinoma: Staging and surgical treatment" and "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Surgical staging", section on 'Open laparotomy versus minimally invasive surgery' and "Management of early-stage cervical cancer", section on 'Type of surgery'.)
There are no unique indications for laparoscopic hysterectomy compared with other surgical approaches to hysterectomy. Indications for hysterectomy, along with medical and surgical treatment alternatives, are discussed in detail separately.
SURGICAL PLANNING
Type of laparoscopic hysterectomy — A hysterectomy may be total (uterus and cervix are removed) or subtotal, also referred to as supracervical (uterus is removed, cervix is conserved). The choice between these approaches is discussed in detail separately.
There are several subtypes of laparoscopic hysterectomy, including:
●Total laparoscopic hysterectomy (TLH) – The uterus and cervix are removed. The entire procedure, including suturing of the vaginal vault, is performed laparoscopically. Alternately, some surgeons may prefer to suture the vaginal cuff using a vaginal approach. The uterine specimen is typically removed through the vaginal vault, either intact or after morcellation.
●Laparoscopic subtotal (supracervical) hysterectomy (LSH) – The uterus is removed; the cervix is conserved. The uterine specimen is extracted via the abdominal ports or incisions.
●Laparoscopic-assisted vaginal hysterectomy (LAVH) – A total hysterectomy is performed. Typically, the laparoscopic approach is utilized to perform any needed adnexal surgery and control the adnexal blood supply (utero-ovarian ligament if ovaries are conserved or infundibulopelvic ligament blood supply if ovaries are removed). The remainder of the procedure is performed vaginally, including entry into the peritoneal cavity and ligation of the uterine vessels from below.
There are several classification systems for types of laparoscopic hysterectomy [11-13]. The most commonly used classification is from the American Association of Gynecologic Laparoscopists (AAGL) [11].
Conventional laparoscopy is the predominant technique employed for laparoscopic hysterectomy for benign indications, although use of a robotic platform is increasingly common [14]. Alternative approaches to laparoscopic surgery include laparoendoscopic single-site surgery (LESS), natural orifice transluminal endoscopic surgery (NOTES), and hand-assisted laparoscopy. These are discussed below. (See 'Alternative techniques' below.)
Elective salpingo-oophorectomy — Oophorectomy and/or salpingectomy is indicated in some patients at the time of hysterectomy. Patients without a definite indication for adnexectomy should be counseled preoperatively about the risks and benefits of removing the ovaries and/or fallopian tubes.
Elective oophorectomy at time of hysterectomy may be associated with adverse health outcomes, particularly in premenopausal females. There is increasing interest in the role of salpingectomy for risk reduction of ovarian cancer. Data suggest that the fallopian tube may be a primary site for cancers that present with an ovarian mass [15-17]. These issues are discussed in detail separately.
●(See "Elective oophorectomy or ovarian conservation at the time of hysterectomy".)
●(See "Opportunistic salpingectomy for ovarian, fallopian tube, and peritoneal carcinoma risk reduction".)
Choice of instruments — Instrument choice varies by institution and surgeon preference. Typical equipment for a laparoscopic hysterectomy includes grasping, dissection/cutting, and hemostatic devices. A monopolar or bipolar electrosurgical device, ultrasonic dissector, and/or an advanced vessel sealing/ligation device are commonly employed. Use of multiple disposable instruments generally adds to cost.
Regardless of instrument choice, knowledge of electrosurgical principles is essential to a safe operation; unexpected injury may result from direct or capacitive coupling, insulation failure, and lateral thermal spread. (See "Overview of electrosurgery".)
An overview of various laparoscopic instruments is discussed separately. (See "Instruments and devices used in laparoscopic surgery", section on 'Devices for hemostasis' and "Overview of gynecologic laparoscopic surgery and non-umbilical entry sites", section on 'Instrumentation'.)
Patients with obesity — Laparoscopic hysterectomy can be performed safely in patients with obesity (body mass index ≥30 kg/m2), although some studies have reported increased operative time, blood loss, complication risk, operative cost, and conversion to an open surgical route [18-22].
●Impact of Trendelenburg position – Patients with obesity may be less able to tolerate Trendelenburg position with pneumoperitoneum, and this may limit the surgeon’s ability to perform laparoscopic surgery in the pelvis [23]. It may be useful to perform a tilt test in patients with obesity prior to beginning the operation to confirm that the anesthesiologist is able to maintain safe levels of airway pressures with the patient in Trendelenburg position. If this is not possible even before abdominal insufflation has taken place, then an alternate surgical approach may be necessary. Additionally, it is recommended to screen patients for sleep apnea and refer for evaluation when indicated. Sleep apnea is often underdiagnosed and preoperative treatment can optimize cardiopulmonary status for surgery. (See "Preanesthesia medical evaluation of the patient with obesity" and "Anesthesia for the patient with obesity".)
●Surgical positioning – Additional suggestions for successful laparoscopy in the patients with obesity include extra care with positioning; liberal padding should be applied and the operative table and stirrups should support appropriate weight capacity [24].
●Intraperitoneal access – Initial entry into the peritoneum may be more difficult in patients with obesity due to the changes in anatomic landmarks in the presence of a large pannus [25,26]. The Veress needle technique may be less reliable in patients with obesity, and surgeons may need to perform open laparoscopic (Hassan) or left upper quadrant entry to obtain abdominal access. (See "Abdominal access techniques used in laparoscopic surgery", section on 'Obesity' and "Overview of gynecologic laparoscopic surgery and non-umbilical entry sites", section on 'Obesity'.)
●Instrument selection – Extra-long or bariatric length instruments are helpful in patients with obesity, as are devices to retract the bowel (bowel fan or retractor). Some surgeons favor a robotic approach to laparoscopy in patients with obesity due to advantages such as ergonomic working position for the surgeon, freedom from resistance and weight of thick anterior abdominal wall, and stable optics and wristed movements in an often narrow field, although there are no data to support superiority of this approach in benign disease [27].
Older adult patients — Older adult patients may require special attention regarding preoperative testing, positioning, and anesthesia [28]. (See "Anesthesia for the older adult".)
PREOPERATIVE EVALUATION AND PREPARATION — Preoperative issues specific to laparoscopic hysterectomy will be discussed here. The general approach to preoperative planning is discussed separately. (See "Overview of preoperative evaluation and preparation for gynecologic surgery".)
Informed consent — Treatment alternatives and operative risks should be discussed. The possible use of tissue morcellation should be discussed, including the risk of dissemination of malignant cells, if an unsuspected cancer is present. (See 'Complications' below.)
Preoperative testing — Preoperative testing includes:
●Medical, surgical, gynecologic, and obstetric history.
●Preoperative evaluation for medical comorbidities that may impact the ability to tolerate surgery.
●Evaluation and screening for gynecologic malignancies – Patients with risk factors, symptoms, and findings that suggest a possibility of a gynecologic malignancy should be evaluated preoperatively. A unique aspect of laparoscopic hysterectomy, due to small (5 to 15 mm) incision size, is the need for tissue morcellation to remove the specimen in cases of supracervical hysterectomy or total hysterectomy of large uteri. Preoperative evaluation of risk for genital tract malignancy is particularly important in these circumstances. Testing should include:
•Cervical cancer screening. (See "Screening for cervical cancer in resource-rich settings".)
•Endometrial sampling. This should be performed for women with abnormal uterine bleeding, a uterine mass or significant risk factors for endometrial cancer or uterine sarcoma (eg, postmenopausal status, history of ≥2 years of tamoxifen therapy, history of pelvic irradiation, history of childhood retinoblastoma, or personal history of hereditary leiomyomatosis and renal cell carcinoma [HLRCC] syndrome) (table 1 and table 2). If there is a suspicion of uterine sarcoma, follow-up imaging studies should be performed. (See "Uterine fibroids (leiomyomas): Differentiating fibroids from uterine sarcomas".)
•The ovaries and tubes are not typically morcellated, but if there is an ovarian mass or symptoms or risk factors for ovarian cancer, further evaluation should be performed (table 3 and table 4).
Antibiotic prophylaxis — Antibiotic prophylaxis is given for all surgical approaches to hysterectomy (table 5). (See "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Surgical site infection prevention'.)
Thromboprophylaxis — Patients undergoing laparoscopic hysterectomy (major surgery, defined as >45 minutes duration) are at least at moderate risk for venous thromboembolism and require appropriate thromboprophylaxis, whether mechanical or pharmacologic. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients" and "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Thromboprophylaxis'.)
Bowel preparation — Routine mechanical bowel preparation is not necessary [29,30]. However, antibiotic bowel preparation may be employed if there is a high suspicion that colorectal surgery will be necessary at the time of hysterectomy [31]. (See "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Bowel preparation'.)
PROCEDURE — Laparoscopic hysterectomy is discussed here, with a focus on aspects that are specific to a laparoscopic approach. The procedure for hysterectomy is discussed in detail separately. (See "Hysterectomy: Abdominal (open) route", section on 'Operative technique'.)
Anesthesia — Laparoscopy is typically performed under general anesthesia. Regional anesthesia (spinal, epidural) is not as commonly employed during advanced gynecologic laparoscopy due to pulmonary concerns which arise with the combination of abdominal insufflation and Trendelenburg positioning. Enhanced recovery protocols are also beneficial to employ. (See "Overview of anesthesia" and "Enhanced recovery after gynecologic surgery: Components and implementation".)
Positioning and preparation — The patient is positioned in the dorsal lithotomy position (picture 1). It is important to position the patient carefully on the operating room table to avoid neurologic injury, provide for ergonomic surgeon positioning, and allow adequate access to the vagina.
Further details on patient positioning for gynecologic laparoscopy are discussed separately. (See "Overview of gynecologic laparoscopic surgery and non-umbilical entry sites", section on 'Patient positioning and preparation' and "Nerve injury associated with pelvic surgery", section on 'Prevention of nerve injury'.)
An examination under anesthesia is performed to confirm the size, position, and mobility of the uterus and adnexa. (See "Pelvic examination under anesthesia".)
Shaving hair with razors at the planned operative site should be avoided. If necessary, hair removal can be performed with clippers or depilatory agents. (See "Overview of control measures for prevention of surgical site infection in adults", section on 'Hair removal'.)
Routine application of antiseptics to the skin should be performed to reduce the burden of skin flora. Vaginal preparation is performed prior to hysterectomy. Surgical skin preparation with chlorhexidine is superior to use of povidone-iodine based solutions, and chlorhexidine can also be utilized for vaginal preparation [32].
After the patient’s abdomen and vagina have prepared and draped in sterile fashion, a bladder catheter is placed into the bladder and left to drain by gravity. (See "Urogynecologic surgery: Perioperative care issues", section on 'Bladder catheter'.)
Uterine manipulator — A uterine manipulator is typically placed at the beginning of the procedure to aid with mobilization and surgical exposure. Disposable, partially reusable, and reusable devices are available. (See "Overview of gynecologic laparoscopic surgery and non-umbilical entry sites", section on 'Uterine cannula and manipulators'.)
Uterine manipulators are placed in the vagina and typically have a cannula that is inserted into the cervix. These devices allow visualization of the boundaries of the vaginal cuff with a cup that fits around the cervix, injection of dye (chromopertubation), and maintenance of pneumoperitoneum after the vaginal incision. Two examples of these systems for laparoscopic hysterectomy that are commonly employed are the RUMI Uterine Manipulator (Cooper-Surgical) and the VCare Uterine Manipulator/Elevator (ConMed Endosurgery). Use of a manipulator may also increase the distance between surgical structures and the ureters [33]. (See 'Identification of the ureter' below.)
Alternately, some surgeons choose to forgo advanced uterine manipulation systems and rely on deviation of the uterus with instruments inserted through the abdominal ports, such as a tenaculum or myoma screw.
Trocar placement — For multi-port laparoscopic hysterectomy (as opposed to a single port technique), port placement typically involves a primary port at the umbilicus with two accessory ports in the bilateral lower quadrants (figure 1). To avoid injury to nerves or blood vessels in the abdominal wall (notably the ilioinguinal and iliohypogastric nerves, superficial and inferior epigastric arteries), the lower quadrant ports are placed approximately 2 cm medial and 2 cm cranial to the anterior superior iliac spine, lateral to the border of the rectus [34].
A fourth port may be useful, particularly in cases involving extensive dissection or laparoscopic suturing, and can be placed suprapubically or in the lateral abdominal wall at the level of the umbilicus. In cases of enlarged uteri where the fundus approaches the level of the umbilicus, it may be necessary to place the ports higher on the abdominal wall to ensure proper distance for visualization and instrument operation.
Techniques for abdominal access in laparoscopy are discussed in detail separately. (See "Abdominal access techniques used in laparoscopic surgery" and "Overview of gynecologic laparoscopic surgery and non-umbilical entry sites", section on 'Trocar placement'.)
Adhesiolysis — If pelvic or intraabdominal adhesions are present, adhesiolysis is performed. Restoring normal anatomy allows for visualization of important pelvic structures (eg, ureter, blood vessels).
Identification of the ureter — The ureter should be identified and kept in view throughout critical portions of the hysterectomy procedure. It may be possible to identify the ureter transperitoneally along the lateral pelvic sidewall. If this cannot be seen, then a retroperitoneal dissection to identify the ureter is performed by incising the peritoneum parallel to the infundibulopelvic ligament at the level of the pelvic brim. A combination of sharp and blunt dissection is performed until the ureter is in view, and the dissection may be continued inferiorly toward the ischial spine as needed.
Techniques to ease identification of the ureters include:
●Ureteral catheters (stents) – Prophylactic ureteral catheters (stents) may be placed if challenging surgery is anticipated (see "Urinary tract injury in gynecologic surgery: Epidemiology and prevention", section on 'Prophylactic ureteral catheters (stents)').
●Dye or contrast – Some surgeons inject indocyanine green (ICG) dye into bilateral ureters in order to allow for visualization with near infrared fluorescence [27]; this technique may be particularly useful in cases of severely distorted anatomy for example due to advanced endometriosis. (See "Urinary tract injury in gynecologic surgery: Identification and management", section on 'Intraoperative detection'.)
●Uterine manipulator – Use of a uterine manipulator appears to increase the surgical distance (and thus potentially increase ease/safety of dissection) between the ureter and cervix/vagina. In a study of six fresh-frozen cadavers, advancement of a uterine manipulator increased the distance in 55 percent of pelvises and an average increase of 0.8 cm for the cervical-ureteral distance and 0.6 cm for the cervical-parametrial and vaginal-ureter distances [33].
Key portions of the procedure where the surgeon should identify the ureter and ensure it is well away from planned cautery or dissection include division of the infundibulopelvic ligament and uterine vascular pedicle. (See "Urinary tract injury in gynecologic surgery: Epidemiology and prevention", section on 'Surgical technique'.)
Adnexa — The surgical treatment of the adnexa depends upon whether the ovaries and/or tubes will be conserved or removed. It is our practice to routinely remove bilateral fallopian tubes in the majority of cases due to the role of fallopian tubes in future development of epithelial carcinoma. (See "Opportunistic salpingectomy for ovarian, fallopian tube, and peritoneal carcinoma risk reduction" and "Risk-reducing salpingo-oophorectomy in patients at high risk of epithelial ovarian and fallopian tube cancer".)
●Tube removal with ovary preservation – To remove the fallopian tube but preserve the ovary, the fallopian tube is first elevated with an atraumatic grasper and the mesosalpinx is divided. Care must be taken to remove the entirety of the fimbriated portion of the tube, as this is the site most implicated with future development of epithelial carcinoma. Additionally, it is important to perform the dissection close to the tube itself and avoid damaging collateral vessels that also supply the ovary. The fallopian tubes can be left attached to the cornua of the uterus or can be amputated and removed as separate specimens. Tubal amputation may be useful in cases of large pathology or when uterine tissue morcellation will be performed).
●Ovary and tube conservation – If ovaries and tubes are conserved, the utero-ovarian ligament is divided using an electrosurgical instrument to cauterize and incise the pedicle (figure 2). To avoid bleeding from the ascending uterine vasculature, we transect the ligament close to the ovary (picture 2) [35]. (See "Instruments and devices used in laparoscopic surgery", section on 'Electrosurgery'.)
●Ovary and tube removal – If salpingo-oophorectomy is performed, the infundibulopelvic ligament is divided using the electrosurgical tool of choice (figure 2). In general, it is useful to ligate the ligament close to the ovary to preserve a longer infundibulopelvic ligament pedicle and avoid sidewall structures. The ureter should be identified either transperitoneally or by retroperitoneal dissection prior to dividing the infundibulopelvic ligament. However, when performing oophorectomy for risk-reduction due to genetic susceptibility to malignancy (eg, in cases of BRCA gene mutation or Lynch syndrome), pelvic washings are obtained and a 2 cm segment of the proximal infundibulopelvic ligament is removed along with adnexa [36].
Round ligament — The round ligament is ligated and divided with the electrosurgical tool of choice, with attention to avoiding parametrial vessels that may be present in the mesosalpinx and mesovarium (picture 3). The broad ligament is opened by separating the anterior and posterior leaves of this peritoneum (picture 4). In open procedures, division of the round ligament is typically the first step in hysterectomy; this order of steps may also be applied to laparoscopic hysterectomy. It may be particularly useful to divide the round as an initial step with a larger fixed uterus in order to gain mobility.
Uterine vessels — The bladder is mobilized off the lower uterine segment to prepare for amputation of the uterus by a combination of sharp and blunt dissection with laparoscopic instruments. The anterior leaf of the broad ligament is incised, continuing along the line of the vesicouterine peritoneal reflection (picture 5). If perivesicular fat is encountered, this indicates proximity to the bladder and should guide the surgeon to avoid that area. If bladder adhesions are present, it may be helpful to divide the round ligament more laterally and perform bladder flap dissection from a more lateral approach. When dealing with difficult bladder adhesions, electrosurgical instruments should be avoided in favor of dissection with laparoscopic scissors in order to limit potential thermal damage to the bladder. In some cases, the full bladder flap dissection can be delayed until after transection of the cardinal ligament/uterine vascular complex in order to gain access to the plane along the pubocervical fascia. Additionally, it may be useful to back-fill the bladder via the Foley catheter to help delineate bladder boundaries.
The uterine vessels are identified and are skeletonized by incising the posterior broad ligament peritoneum and dissecting away surrounding adventitia (picture 6). After confirming the position of the ureter, the uterine vasculature is desiccated at the level of the internal cervical os. It is important to elevate the uterus in a cephalad direction using the uterine manipulator or laparoscopic instruments in order to increase distance from the electrosurgical instrument to the ureter (picture 7). An incision is made in the desiccated uterine vasculature, and this area is lateralized to create a discrete vascular pedicle that can be cauterized safely in the event of inadequate hemostasis (picture 8).
Uterus — The cervix is removed in a total laparoscopic hysterectomy or conserved in a subtotal laparoscopic hysterectomy. (See 'Type of laparoscopic hysterectomy' above.)
Subtotal hysterectomy — For subtotal hysterectomy, the cervix is amputated at the level of the internal os (picture 9). Instruments that can be used for this step include ultrasonic scalpel, monopolar hook, or loop. The residual cervical stump is then inspected. Many surgeons fulgurate or excise the endocervical canal to decrease the possibility of postoperative cyclic bleeding, but the efficacy of this technique has not been proven [37,38].
The uterine specimen must then be removed. Options include:
●Morcellation (cutting into pieces) with a power morcellator to remove through the laparoscopic incisions.
●Mini-laparotomy incision to remove the specimen intact or with scalpel morcellation. The size of the incision depends upon the size of the specimen.
One risk of power morcellation is that it can disseminate malignant cells if an unsuspected malignancy is present. An alternative technique is to morcellate after the specimen has been contained in a specimen bag, either with a power morcellation device or using manual scalpel morcellation [39]. Preoperative evaluation should include evaluation for gynecologic malignancy, as noted above. (See 'Preoperative testing' above.)
If morcellation is planned, the risks and benefits should be part of informed consent. The issue of power morcellation of a uterine specimen is discussed in detail separately. (See "Uterine tissue extraction by morcellation: Techniques and clinical issues".)
Total hysterectomy — For total hysterectomy, a colpotomy is made in a circumferential fashion around the cervix, typically using an ultrasonic scalpel or monopolar instrument. When using a uterine manipulator cervical cup, the rim is a useful guide (picture 10). Cephalad elevation on the manipulator will help to delineate vaginal fornices and distance the ureter from the colpotomy site. Care is taken to avoid excessive thermal damage to the vaginal cuff so that the tissue can heal properly.
When possible, the specimen is delivered through the vagina. A pneumo-occluder device (such as a sterile glove packed with surgical sponges or plastic bulb) is placed in the vaginal canal to prevent loss of pneumoperitoneum (picture 11). If the specimen is too large to deliver through the vagina, scalpel morcellation (via either the colpotomy site or a minilaparotomy incision) or contained power morcellation is performed. (See 'Subtotal hysterectomy' above.)
Vaginal cuff — The vaginal cuff is then sutured closed with the technique and suture of the surgeon's choice (picture 12). In our practice, we use a laparoscopic suturing technique with barbed suture in a continuous fashion for two-layer closure due to increased efficiency and possible benefits with regard to tissue healing [40]. A two-layer closure may be associated with lower postoperative complications related to the cuff [41]. Randomized trials of barbed versus conventional suture closure have demonstrated no difference in adverse events, although, given the relative rarity of vaginal cuff dehiscence, this is difficult to study in a prospective fashion [42-45]. (See "Vaginal cuff dehiscence after total hysterectomy", section on 'Surgical techniques and materials'.)
It is important to ensure that adequate margins of tissue are included in the sutures, incorporating vaginal mucosa and pubocervical/rectovaginal connective tissue, to avoid dehiscence of the vaginal cuff. Additionally, uterosacral and cardinal ligament tissue near the vaginal cuff should be incorporated into the closure to enhance apical vaginal support. Factors that may be associated with cuff dehiscence include excessive thermal destruction of vaginal cuff tissue or insufficient margins of tissue incorporated into the closure, although no one method of colpotomy incision or cuff closure has been shown to be superior [46,47]. Some surgeons prefer to suture from a vaginal approach due to increased comfort with vaginal suturing and initial study data supporting reduced infection risk [47], although a subsequent trial reported reduced rates of cuff dehiscence and complication with laparoscopic closure [48]. (See "Vaginal cuff dehiscence after total hysterectomy".)
Final examination and closure — The surgical field is inspected for hemostasis. Observation under low intraperitoneal pressure may be useful to remove the hemostatic effect of high intraabdominal pressure.
Abdominal wall fascial defects over 10 mm are typically sutured closed to avoid port-site herniation [49]. The skin incisions are closed.
After desufflation of the abdomen, it is useful to have the anesthesiologist administer five forced respirations to encourage carbon dioxide expulsion, as residual carbon dioxide in the peritoneal cavity can lead to irritation and referred pain in the shoulder [50].
COMPLICATIONS — The potential complications of laparoscopic hysterectomy and their management are generally the same as those for abdominal hysterectomy. (See "Hysterectomy: Abdominal (open) route", section on 'Complications'.)
●Overall complication rates and risk factors – Reported overall complication rates for laparoscopic hysterectomy for benign disease range from 4 to 14 percent [51-53]. An English database study evaluating laparoscopic and abdominal hysterectomies performed between 2011 and 2018 reported adhesions and adenomyosis were associated with increased risk of major complications during laparoscopic hysterectomy (adjusted odds ratios of 1.92, 95% CI 1.73-2.13 and 1.46, 95% CI 1.36-1.60, respectively) [53].
●Risk of specific complications – Data from large studies and systematic reviews [54] of laparoscopic hysterectomy report the following estimates of specific complications:
•Infection – Laparoscopic hysterectomy is associated with a three percent risk of surgical site infection, predominantly wound infection, with <1 percent risk of deep space infection or abscess [55]. Laparoscopic, compared with abdominal route of hysterectomy, is associated with lower odds of febrile episodes, wounds, or abdominal wall infections [54]. Posthysterectomy infection is reviewed in detail separately. (See "Posthysterectomy pelvic abscess".)
•Conversion to laparotomy – 3.9 percent [56]. The risk of conversion varies by degree of surgical complexity, patient comorbid conditions, and surgeon expertise.
•Urinary tract injury –
-Incidence – 1.2 to 2.6 percent [57]. Compared with abdominal or vaginal hysterectomy, the risk of urinary tract injury has traditionally been reported to be greater with a laparoscopic approach. However, it is possible that this discrepancy has decreased with time and advances in laparoscopic technique. For example, a review of 10 years of hysterectomy data in Norway reported an overall ureter injury rate of 1.2 percent and was highest in the laparotomy group (1.9 percent) [58].
-Prevention – Avoiding urinary tract injury depends upon meticulous surgical technique and knowledge of anatomy. The ureter should be identified prior to surgical management of the adnexa and the uterine vessels. Universal cystoscopy at the time of laparoscopic hysterectomy is cost-effective in most cases, although some surgeons choose to perform it selectively in complex cases [59]. The American Association of Gynecologic Laparoscopists (AAGL) advises liberal use of cystoscopy with laparoscopic hysterectomy but states that the level of evidence and the limited available data preclude recommendation for making cystoscopy an integral component of laparoscopic hysterectomy [60]. There is no need for prolonged bladder catheterization after laparoscopic hysterectomy unless indicated by an intraoperative complication.
(See "Urinary tract injury in gynecologic surgery: Epidemiology and prevention".)
(See "Urinary tract injury in gynecologic surgery: Identification and management".)
•Vaginal cuff dehiscence – 0.64 to 1.64 percent [45].
Vaginal cuff dehiscence is an uncommon complication, and historically the incidence was reported to be highest following laparoscopic procedures, including robot-assisted surgeries [61]. An updated systematic review and meta-analysis found incidence of cuff dehiscence after total laparoscopic hysterectomy to be between 0.64 to 1.35 percent, with robotic hysterectomy associated with incidence of 1.64 percent. (See "Vaginal cuff dehiscence after total hysterectomy".)
•Bowel injury – 0.34 to 0.45 percent [62,63]. (See "Complications of laparoscopic surgery", section on 'Bowel injuries'.)
•Hemorrhage – Management of surgical hemorrhage is discussed in detail separately. (See "Management of hemorrhage in gynecologic surgery".)
OUTCOME — Laparoscopic hysterectomy results in decreased morbidity, shorter hospital stay, and faster return to normal activities compared with an abdominal approach. Surgical approaches for hysterectomy are compared separately. (See "Hysterectomy (benign indications): Selection of surgical route".)
A comparison of outcomes after hysterectomy versus medical therapy for abnormal uterine bleeding can be found separately. (See "Managing an episode of acute uterine bleeding".)
POSTOPERATIVE CARE — Patients are typically seen for a postoperative visit in the office within three to four weeks after surgery.
Hospital discharge — Patients may have a laparoscopic hysterectomy and be discharged home on the same day or stay in the hospital overnight, typically for one night.
Observational studies have consistently found that same-day discharge is safe, less costly, and may be associated with fewer postoperative complications [64,65]. However, this finding may be the result of patient selection or bias based on degree of case complexity.
Patient satisfaction and quality of life measures have been assessed by two randomized trials on outpatient versus inpatient laparoscopic hysterectomy for benign indications. In the earlier study, quality of life was significantly worse in the outpatient group on postoperative days 2 and 4; the updated trial showed similar outcomes of satisfaction and health-related quality of life. However, roughly a third of patients randomized to outpatient surgery elected to stay overnight in hospital without a medical indication [66,67].
Given the available evidence, same-day discharge after hysterectomy appears to be a safe option for patients without perioperative complications or comorbidities that require inpatient observation and care [68]. A longer hospital stay after laparoscopic hysterectomy is a reasonable option for patients who do not have sufficient support at home to manage care during the first postoperative day.
Postoperative instructions — There is limited evidence on which to base postoperative activity recommendations. Patients are advised to avoid heavy lifting/straining while the abdominal incisions are healing and to increase other activities as tolerated. Patients may expect a recovery period of two to four weeks before resumption of the majority of daily activities. Pelvic rest (avoidance of intercourse, tampons) is typically recommended for six to eight weeks after total hysterectomy and three to four weeks after subtotal hysterectomy, in part to reduce the risk of vaginal cuff dehiscence.
Routine discharge instructions for patients can be found separately. (See "Patient education: Care after gynecologic surgery (Beyond the Basics)".)
ALTERNATIVE TECHNIQUES
Robot-assisted laparoscopic surgery — Given the available data, we suggest conventional rather than robot-assisted laparoscopy for patients undergoing hysterectomy for benign indications, unless dictated by patient characteristics or surgeon preference. Studies suggest similar outcomes for the two approaches, including frequency of complications, length of stay, conversion, and blood loss [69-72]. However, operative times and equipment costs associated with robotic surgery are higher [70-72]. The equipment cost may be mitigated in centers with greater volumes of robotic surgery [70].
●The American College of Obstetricians and Gynecologists states that when choosing a robot-assisted approach, consideration should be given to the likelihood of improved outcomes compared with other approaches with consideration of costs [73].
●The American Association of Gynecologic Laparoscopists (AAGL) states that robot-assisted laparoscopy should not replace conventional laparoscopic or vaginal procedures for benign gynecologic disease [74].
Robotic surgery techniques are described in more detail separately. (See "Robot-assisted laparoscopy".)
Laparoendoscopic single-site surgery — Laparoscopic hysterectomy performed through a single incision site, typically at the umbilicus, is referred to as laparoendoscopic single-site surgery (LESS). Robotic surgery may also be combined with single-port access [75].
Hysterectomy via LESS appears to have surgical outcomes similar to traditional laparoscopic hysterectomy, although benefits over a conventional laparoscopic approach remain to be seen [76]. The main benefit of LESS is the use of one abdominal incision rather than several incisions. However, it is uncertain whether patients find that this improves cosmesis. As an example, in one study, patients reported a preference for traditional laparoscopic incisions [77]. Similarly, a randomized trial of postoperative pain profiles found no difference with LESS compared with multi-port laparoscopic hysterectomy [78].
Natural orifice transluminal endoscopic surgery — Natural orifice transluminal endoscopic surgery (NOTES) represents a merging of endoscopic and laparoscopic techniques. In the field of gynecology, transvaginal endoscopic surgery (vNOTES) has been applied to adnexal and uterine procedures [79], and a hybrid technique involving minimized abdominal incisions has been reported for benign and oncologic laparoscopic hysterectomy [80]. (See "Hysterectomy: Vaginal", section on 'Use of vaginal laparoscopy'.)
Hand-assisted laparoscopy — In cases of extreme uterine enlargement, an alternative to pubis-to-xiphoid laparotomy is hand-assisted laparoscopy. In these cases, a small laparotomy is created (either in vertical midline or transverse lower abdominal location) through which a gloved hand can be placed with use of an access port. Pneumoperitoneum is maintained to permit laparoscopic portions of the operation, while the hand port is used to aid with retraction, visualization, and specimen retrieval. In addition to reports of hand-assisted laparoscopic hysterectomy and myomectomy [81-84], this technique has also been employed in the fields of general surgery and urology [85,86].
SUMMARY AND RECOMMENDATIONS
●Description and benefits – Laparoscopic hysterectomy is a minimally invasive approach that has decreased morbidity, shorter hospital stay, and quicker return to normal activities compared with an abdominal approach. (See 'Outcome' above.)
●Procedure variations – There are several types of laparoscopic hysterectomy, including: total laparoscopic hysterectomy, subtotal (supracervical) laparoscopic hysterectomy, and laparoscopic-assisted vaginal hysterectomy. (See 'Type of laparoscopic hysterectomy' above.)
●Role of oophorectomy and/or salpingectomy – Oophorectomy and/or salpingectomy is indicated in some patients at the time of hysterectomy. Patients without a definitive indication for adnexectomy should be counseled preoperatively about the risks and benefits of removing the ovaries and/or fallopian tubes. (See 'Elective salpingo-oophorectomy' above.)
●Preoperative preparation – Antibiotic prophylaxis is given for all surgical approaches to hysterectomy. Patients undergoing laparoscopic hysterectomy (major surgery, defined as >30 minutes duration) are at least at moderate risk for venous thromboembolism and require appropriate thromboprophylaxis, whether mechanical or pharmacologic. (See 'Preoperative evaluation and preparation' above.)
●Instruments and uterine manipulator – The choice of instrumentation varies by surgeon and institution. Many surgeons use a uterine manipulator, which is a device that is placed in the vagina and cervix and allows visualization of the boundaries of the vaginal cuff with a cup that fits around the cervix, injection of dye (chromopertubation), and maintenance of pneumoperitoneum after the vaginal incision. (See 'Uterine manipulator' above.)
●Complications – Conversion to laparotomy occurs in up to 4 percent of laparoscopic hysterectomies. Potential complications include hemorrhage, urinary tract injury, vaginal cuff dehiscence, and bowel injury. (See 'Complications' above.)
●Postoperative discharge – Same-day discharge from the hospital after laparoscopic hysterectomy is a safe option for women without perioperative complications or comorbidities that require inpatient observation and care. A longer hospital stay is a reasonable option for women who do not have sufficient support at home to manage care during the first postoperative day. (See 'Hospital discharge' above.)
ACKNOWLEDGMENTS — The UpToDate editorial staff acknowledges Dr. Thomas Lyons, MS, MD, and Jon Ivar Einarsson, MD, PhD, MPH, who contributed to earlier versions of this topic review.
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