Objective: To demonstrate improved techniques and safety measures for total laparoscopic hysterectomy for a severely enlarged uterus. Design: Technical video of the surgery, which demonstrates various techniques for improved visualization, hemostasis, and manipulation for total laparoscopic hysterectomy for a 7400 g uterus. Setting: Academic tertiary care hospital, University of Louisville Hospital, Louisville, Kentucky. Interventions: A 44-year- old woman, gravida 0, presented with a severely enlarged myoma uterus, class III obesity with a body mass index of 40.4 kg/m(2), and hypertension seeking minimally invasive hysterectomy. Magnetic resonance imaging demonstrated a uterus measuring 26 x 26 x 17 cm with multiple myomas. The patient was counseled in detail regarding minimally invasive surgery. She underwent total laparoscopic hysterectomy, bilateral salpingectomy, right oophorectomy, and cystoscopy. The total operative time was 4 hours 12 minutes, and the estimated blood loss was 700 mL. Pre- and postoperative hemoglobin was 13.3 g/dL and 11.3 g/dL, respectively. A 4-cm minilaparotomy incision was created as an extension of the umbilical port, and the specimen was extracted by scalpel morcellation using the extracorporeal C-incision tissue extraction technique. The patient was discharged home on postoperative day 1 and recovered without any complications. Conclusion: There is an increasing trend in performing laparoscopic hysterectomy for large uteri, which has a lower incidence of overall complications than laparotomy [1,2]. In addition, a cost analysis has demonstrated the superiority of laparoscopic hysterectomy for myomatous uterus accounting for the rare incidence of leiomyosarcoma [3]. Our video demonstrates improved hemostasis and visualization techniques through the use of high-cephalad camera and assistant ports, generous traditional bipolar desiccation, blunt retraction with suction irrigator in the midline umbilical port, and surgical bed rotation. We also describe in detail the scalpel morcellation technique. To date, we believe this is the largest uterine size removed laparoscopically that has been reported in the literature. In the hands of an experienced surgeon and with the demonstrated techniques, a laparoscopic approach to hysterectomy of a very enlarged uterus is safe and feasible. (C) 2020 AAGL. All rights reserved.
