Gynecological surgery removal of the uterus (
Total laparoscopic hysterectomy is a safe and effective procedure for women needing a hysterectomy. We enjoy a high operative volume and perform approximately 200 laparoscopic hysterectomy cases annually with a conversion rate of 1 in every 400 cases. The 10 steps described herein are not meant to be an absolute truth, but rather a true and tested method that has served us well to safely accomplish this procedure.

If the uterus is large and requires manipulation with a tenaculum, consider injecting dilute vasopressin subserosally prior to applying traction to the uterus. This can reduce bleeding associated with pulling and tearing of the uterine serosa.
In cases with poor exposure, we routinely use sutures to retract organs away from the surgical field. A redundant sigmoid can be retracted by taking a series of bites with a 0 prolene suture through the epiploica and pulling the suture through the lower quadrant port. The port is removed to get the sutures out and then reinserted. The sutures are then secured to the skin with a hemostat. Take care to include a number of epiploica to avoid tearing.
Alternatively, ovaries or other structures can be tacked away using a 6-inch suture (0 Quill PDO or 0 vicryl) with a LapraTy on the end. The needle is passed through the structure and then a bite is taken through the inside of the anterior abdominal wall. This end of the suture is then secured with another LapraTy and the needle is cut away and removed.
If access to the uterine vessels is difficult, take the uterine vessels up high initially to secure the blood supply to the upper uterus and then gradually work down, staying medially to the vessels.
Maintain exposure at all times-do not dig yourself into a hole-always be ready to deal with a sudden onset of bleeding.
The combination of a prior cesarean delivery and a large uterus is a set up for bladder injury-stay high on the vesicouterine peritoneum, respect any fat that you see, and watch out for air in the Foley balloon.
In severely distorted anatomy consider entering the retroperitoneum sooner rather than later. The easiest starting point is usually at the round ligament.