Total laparoscopic hysterectomy (TLH) is a minimally invasive surgical procedure that has become the gold standard for the removal of the uterus. With advancements in surgical techniques, instrumentation, and training, TLH has gained widespread acceptance as the preferred approach over traditional open hysterectomy.

Benefits of Total Laparoscopic Hysterectomy: TLH offers several significant advantages compared to open hysterectomy. Firstly, it is a minimally invasive technique that involves making small incisions in the abdomen to insert a laparoscope and surgical instruments. This results in reduced trauma to the surrounding tissues, less pain, and faster recovery times. Additionally, TLH offers improved cosmetic outcomes due to smaller incisions and reduced scarring.

Another benefit of TLH is decreased blood loss during the procedure, leading to lower rates of transfusion requirements. The magnification provided by the laparoscope enhances visualization, enabling the surgeon to achieve precise dissection, leading to reduced surgical complications. Moreover, TLH allows for better preservation of pelvic anatomy and pelvic support, resulting in reduced risk of urinary incontinence and pelvic organ prolapse post-surgery.

Procedural Steps of Total Laparoscopic Hysterectomy: The TLH procedure involves several key steps. The patient is positioned in a modified lithotomy position, and general anaesthesia is administered. The surgeon initiates the procedure by creating a pneumoperitoneum, achieved by insufflating carbon dioxide into the abdominal cavity. This creates the necessary working space for the laparoscopic instruments.

Next, the surgeon makes several small incisions, typically ranging from 5 to 12 mm, for trocar placement. Trocars are specialized ports through which the laparoscope and other instruments are inserted. The surgeon then visualizes the pelvic structures using the laparoscope, assessing the anatomy and identifying any potential pathologies.

The uterus is then detached from its supporting ligaments and blood vessels using specialized laparoscopic instruments. The uterus is than cut off at the vaginal margin and the surgeon usually proceeds with removal of the intact uterus or smaller fragments of uterus through the vagina. Bilateral tubes and ovary may also be cut and removed if indicated.

Once the uterus and adnexa are removed, the surgeon examines the surgical site for any bleeding or other complications. Vaginal stump is closed from the abdominal side by laparoscopic suturing which preserves significant vaginal length and provides adequate vault support. The small abdominal incisions are closed, often with absorbable sutures or adhesive strips. A drain may be placed temporarily to allow any residual fluid to drain.

Patient Selection and Considerations: Patient selection for TLH involves careful consideration of various factors. TLH is suitable for most women who require hysterectomy for benign conditions such as fibroids, abnormal uterine bleeding, or pelvic organ prolapse. However, certain patient factors, such as previous lower abdominal surgery and extensive pelvic adhesions may pose challenges and make TLH less feasible. In such cases, alternative approaches like robotic-assisted laparoscopic hysterectomy or traditional open hysterectomy may be considered.

It is important to evaluate each patient individually, considering their medical history, body habitus, and the extent of the pathology. Proper preoperative assessment, including imaging studies, can help identify potential contraindications or complications that may necessitate an alternative approach.

Complications and Other Considerations: Like any surgical procedure, TLH carries potential risks and complications. However, when performed by experienced surgeons in appropriate patient selection, the overall complication rate is relatively low. However, it is important to be aware of potential complications and considerations associated with the surgery. Possible complications include bleeding, infection, injury to surrounding structures such as the bladder or ureters, and postoperative pain.

Conclusion: Total Laparoscopic hysterectomy gives the best possible short- and long-term results with minimum pain and early return to job. It is usually the most sought-after treatment for benign diseases of uterus needing its removal and should be done by trained surgeons at advanced minimal access surgery centres having modern gadgets in their operation theatres.