Total Laparoscopic Hysterectomy (TLH)

Indication

  • Benign gynecological conditions
    • Uterine fibroids causing serious symptoms (with exception of small, singular intracavitary fibroids FIGO I or II).
    • High suspicion of adenomyosis uteri interna resistant to endocrine therapy.
    • Dysfunctional uterine bleeding resistant to endocrine therapy or endometrial ablation.
  • Gynecological malignancy
    • Endometrial cancer.
    • Precancerous lesions of the cervix when CIN 2/3 persists even after conization.
    • Borderline ovarian tumor.
  • Urogynecological conditions

Technique

  • Preoperative antibiotic prophylaxis (single shot, second generation cephalosporine).
  • Patient in lithotomy position.
  • Desinfection of the abdomen, thighs, vulva and vagina.
  • Sterile surgical drapes.
  • Urinary catheter.
  • Examination under anesthesia.
  • Uterine Manipulator.
  • Change of surgical gloves, start of laparoscopy.
  • Placement of a drainage.
  • Removal of instruments and trocars under direct visualization.
  • Suturing of the skin.

Contraindications

  • Patient not fit for surgery.
  • Patient has further plans for bearing children.

Complications

  • Injury of nearby organs (ureter, bladder, bowel).
  • Bleeding.
  • Thromboembolism.
  • Infection.

Postoperative Management

  • Removal of bladder catheter within the first 24 hours.
  • Removal of drainage on 1st postoperative day.
  • Routine blood test on 1st postoperative day (Hemoglobin).
  • Early patient discharge (usually 3-5 days).
  • Venous thromboembolism prophylaxis with low molecular weight heparin for 7 days.

Bibliography

  • Neis, K. J., Zubke, W., Fehr, M., Römer, T., Tamussino, K., & Nothacker, M. (2016). Hysterectomy for Benign Uterine Disease. Deutsches Arzteblatt international113(14), 242–249. https://doi.org/10.3238/arztebl.2016.0242
  • Sandberg, E. M., Hehenkamp, W., Geomini, P. M., Janssen, P. F., Jansen, F. W., & Twijnstra, A. (2017). Laparoscopic hysterectomy for benign indications: clinical practice guideline. Archives of gynecology and obstetrics296(3), 597–606. https://doi.org/10.1007/s00404-017-4467-9
  • Encke, A., Haas, S., & Kopp, I. (2016). The Prophylaxis of Venous Thromboembolism. Deutsches Arzteblatt international113(31-32), 532–538. https://doi.org/10.3238/arztebl.2016.0532

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