In Search for the Best Minimally Invasive Hysterectomy Approach for the Large Uterus: A Review

Abstract

Review of literature is conducted to determine the best minimally invasive hysterectomy (MIH) route for large uterus, identify preoperative considerations and describe alternative techniques to power morcellation. Studies after 2010 revealed multiple MIH approaches. Vaginal hysterectomy is preferred over laparoscopic and laparoscopic assistance with less operative time and hospital cost. In morbidly obese patients with large uteri, total laparoscopic hysterectomy is superior to vaginal hysterectomy with lesser odds of blood transfusion and lower length of hospital stay. Although MIH for the large uterus is feasible, many questions remain unanswered. Well-designed multicenter prospective trial incorporating clinical pathways to compare outcomes is needed.

Reduced Complications Following Implementation of Laparoscopic Hysterectomy: A Danish Population-based Cohort Study of Minimally Invasive Benign Gynecologic Surgery between 2004 and 2018

“…However, laparoscopic hysterectomy (LH) evolves continuously, and concomitant salpingectomy and adhesiolysis after previous cesarean may be easier to perform laparoscopically, and the feasibility of VH decreases with increasing body mass index and uterus size [2]. LH is recommended over abdominal hysterectomy (AH), but when it comes to larger uteri, the best minimally invasive approach is still debated [3]. The removal of larger uteri through small laparoscopic incisions involves morcellation, which became controversial as cases with occult leiomyosarcoma emerged [3].…”

“…LH is recommended over abdominal hysterectomy (AH), but when it comes to larger uteri, the best minimally invasive approach is still debated [3]. The removal of larger uteri through small laparoscopic incisions involves morcellation, which became controversial as cases with occult leiomyosarcoma emerged [3]. After a warning from the United States Food and Drug Administration in 2014 against power morcellation, complications increased as AH was used instead of LH [4].…”

The Large Uterus Classification System: a prospective observational study

“…Existing studies evaluating hysterectomy outcomes in large uteri do not consider the location and relationship to the vascular pedicles. 5 Our analysis highlights the impact of these contributing factors on surgical outcomes. Compared with the other uterine types, the Type 1 uterus, approached using the standard TLH technique, was associated with less blood loss, shorter operative time, fewer complications, and fewer conversions to open surgery.…”

Recent advances in minimally invasive surgery for gynecologic indications

“…In particular, vaginal vault suture, uterine myomectomy, and LESS hysterectomy for increased uterine weight are considered challenging. In 2017, a review article suggested that minimally invasive hysterectomy for the large uterus is feasible [23]. However, only two RCTs comparing LESS and MLS were included in the analysis; moreover, women with uterine size greater than 18 weeks were excluded.…”