Skip to main content Accessibility help
  • Print publication year: 2018
  • Online publication date: February 2018

12 - Laparoscopic Hysterectomy

from Section 2 - Gynecologic Surgery



Laparoscopic hysterectomy (LH) encompasses a range of laparovaginal procedures for the removal of the uterus and its adnexa. It is a powerful and broadly applicable surgical technique. It provides a minimally invasive alternative to total abdominal hysterectomy (TAH) while allowing full visualization of the pelvis impossible with vaginal hysterectomy (VH). In this chapter, the various forms of LH, indications, technique, and complications are described.

Scope of the Problem

Hysterectomy is one of the most common surgical procedures in the United States. The majority of hysterectomies continue to be performed abdominally, despite recommendations for a vaginal approach, where feasible. Laparoscopic hysterectomy is a minimally invasive procedure which can effectively replace a substantial number of abdominal hysterectomies, as detailed in the sections that follow. Like all surgeries, technical considerations substantially improve outcomes and broaden the settings within which a minimally invasive approach can be used.


The first literature description of LH was by Dr. Harry Reich in 1989 [1]. Ten years later, Reich and colleagues classified laparovaginal hysterectomy based on the level of dissection required (see Table 12.1 and Figure 12.1) [2]. The essential difference between LH and laparoscopically assisted vaginal hysterectomy (LAVH) is that the uterine vessels are dissected and divided laparoscopically in LH. Further extent of dissection below the uterine vessels is a matter of surgeon choice rather than of procedure conception.

As early as 1996, total laparoscopic hysterectomy (TLH) was sufficiently well developed to generate literature describing its utility [3]. For this procedure the essential difference is the vaginal cuff is dissected laparoscopically, with the specimen typically removed vaginally. Cuff closure is then accomplished either laparoscopically or vaginally.

Indications and Choice of Procedure

The American College of Obstetricians and Gynecologists has addressed the issue of procedure choice [4]. Vaginal hysterectomy is preferred when feasible. Laparoscopic hysterectomy of any type is preferred when pure vaginal surgery is not reasonable. Open abdominal hysterectomy is reserved for pathology or patient conditions that make laparoscopic procedures impossible or inadvisable. The technical skill and experience of the operator will also influence the choice of procedure.

Related content

Powered by UNSILO
1. Reich, H, DeCaprio, J, McGlynn, F. Laparoscopic hysterectomy. J Gynecol Surg 1989;5:213–16.
2. Reich, H,Rahmanie, N. Laparoscopic Hysterectomy. In Kavic MS, Levinson CJ, Wette PA eds Prevention and Management of Laparoendocscopic Surgical Complications 1st Edition Miami Florida, Socisey of Laparoendoscopic Surgones, 1999.
3. Lee, PI, Lee, YT, Lee, SH, Chang, YK. Advantages of total laparoscopic hysterectomy. J Am Assoc Gynecol Laparosc 1996 Aug;3(4, Supplement):S24–5.
4. American College of Obstetricians and Gynecologists. Choosing the Route of Hysterectomy for Benign Disease. Committee Opinion 444, November 2009, reaffirmed 2011.
5. Johns, DA, Carrera, B, Jones, J, DeLeon, F, Vincent, R, Safely, C. The medical and economic impact of laparoscopically assisted vaginal hysterectomy in a large, metropolitan, not-for-profit hospital. Am J Obstet Gynecol 1995;172:1709–19.
6. Stovall, TG, Summitt. Laparoscopic hysterectomy – is there a benefit? N Engl J Med 1996;335:512–13.
7. Nieboer, TE, Johnson, N, Lethaby, A, Tavender, E, Curr, E, Garry, R et al. Surgical approach to hysterectomy for benign gynaecological disease. Coch Dat Sys Rev 2009;3 (CD003677).
8. Jennings, AJ, Spencer, RJ, Medlin, E, Rice, LW, Uppal, S. Predictors of 30-day readmission and impact of same-day discharge in laparoscopic hysterectomy. Am J Obstet Gynecol 2015 Sep;213(3):344.e1-7.
9. Lassen, PD, Moeller-Larsen, H, Nully, P DE. Same-day discharge after laparoscopic hysterectomy. Acta Obstet Gynecol Scand 2012 Nov;91(11):1339–41.
10. Tsaltas, T, Dassow, JD. Advanced surgical care for a rural outreach population. American College of Obstetricians and Gynecologists, poster presentation at 2015 Annual Clinical Meeting.
11. Alperin, M, Kivnick, S, Poon, KY. Outpatient laparoscopic hysterectomy for large uteri. J Minim Invasive Gynecol. 2012 Nov–Dec;19(6):689–94.
12. Donaldson, M, Gizzarelli, G, Chanpong, B. Oral sedation: a primer on anxiolysis for the adult patient. Anesth Prog 2007;54(3):118–29.
13. Slim, K, Vicaut, E, Launay-Savary, MV, Contant, C, Chipponi, J. Updated systematic review and meta-analysis of randomized clinical trials on the role of mechanical bowel preparation before colorectal surgery. Ann Surg 2009;249:203–9.
14. Bretagnol, F, Panis, Y, Rullier, E, Rouanet, P, Berdah, S, Dousset, B et al. Rectal cancer surgery with or without bowel preparation: the French GRECCAR III multicenter singleblinded randomized trial. Ann Surg 2010;252:863–8.
15. Reichman, DE, Greenberg, JA. Reducing surgical site infections: a review. Rev Obstet Gynecol 2009;2(4):212–21.
16. Nygren, J, Thorell, A, Jacobsson, H, Larsson, S, Schnell, PO, Hylén, L, Ljungqvist, O. Preoperative gastric emptying: effects of anxiety and oral carbohydrate administration. Ann Surg 1995 Dec;222(6):728–34.
17. Hunt, JN. Some properties of an alimentary osmoreceptor mechanism. J Physiol 1956 May;132(2):267–88.
18. Sutherland, AD, Stock, JG, Davies, JM. Effects of preoperative fasting on morbidity and gastric contents in patients undergoing day-stay surgery. Br J Anaesth. 1986 Aug;58(8):876–8.
19. Lindqvist, P, Dahlback, B, Marsal, K. Thrombotic risk during pregnancy: a population study. Obstet Gynecol 1999;94:595–9.
20. James A. American College of Obstetricians and Gynecologists Practice Bulletin no. 123 Thromboembolism in Pregnancy. Obstetrics and Gynecology 2011;118(3):718–29.
21. Bates, SM. VTE, thrombophilia, antithrombotic therapy, and pregnancy. antithrombotic therapy and prevention of thrombosis . In: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest, 9th ed. 2012 Feb;141(2 Suppl):e691S–736S.
22. Clarke-Pearson, DL, Elizabeth, J. Geller, EJ. Complications of hysterectomy. Obstet Gynecol 2013;121:654–73.
23. Bhattacharya, S. The facts about penicillin allergy: a review. J Adv Pharm Technol Resv 2010 Jan–Mar;1(1):11–17.
24. Jacob, M, Chappell, D, Conzen, P, Finsterer, U, Rehm, M. Blood volume is normal after pre-operative overnight fasting. Acta Anaesthesiol Scand 2008;52(4):522.
25. Lambert, KG, Wakim, JH, Lambert, NE. Preoperative fluid bolus and reduction of postoperative nausea and vomiting in patients undergoing laparoscopic gynecologic surgery. J A Assoc Nur Anesth 2009;77:110–4.
26. Maharaj, CH, Kallam, SR, Malik, A, Hassett, P, Grady, D, Laffey, JG. Preoperative intravenous fluid therapy decreases postoperative nausea and pain in high risk patients. Anesth Analg 2005;100:675–82.
27. Zhang, J, Ho, K-Y, Wang, Y. Efficacy of pregabalin in acute postoperative pain: a meta-analysis, Br J Anaesth 2011;106 (4):454–62.
28. Alayed, N, Alghanaim, N, Tan, X, Tulandi, T. Preemptive use of gabapentin in abdominal hysterectomy: a systematic review and meta-analysis. Obstet Gynecol 2014;123:1221–9.
29. Loring, M, Morris, SN, Isaacson, KB. Minimally invasive specialists and rates of laparoscopic hysterectomy. J Soc Laparasc Surg 2015;19(1):e2014.00221. doi: 10.4293/JSLS.2014.00221
30. Ferguson, D. Therbligs: the key to simplifying work. The Gilbreth network,
31. Allen, K, Blascovich, J. Effects of music on cardiovascular reactivity among surgeons. J Am Med Assoc 1994;272(11):882–4.
32. Persoon, MC, Broos, HJHP, Witjes, JA, Hendrikx, AJM, Scherpbier, AJJM. The effect of distractions in the operating room during endourological procedures. Surg Endosc 2011;25(2):437–43.
33. Reichman, DE, James, A, Greenberg, JA. Reducing surgical site infections: a review. Rev Obstet Gynecol 2009;2(4):212–21.
34. Nezhat, CH, Dun, EC, Katz, A, Wieser, FA. Office visceral slide test compared with two perioperative tests for predicting periumbilical adhesions. Obstet Gynecol 2014;123:1049–56.
35. Hefni, MA, Bhaumik, J, El-Toukhy, T et al. Safety and efficacy of using the LigaSure vessel sealing system for securing the pedicles in vaginal hysterectomy: randomised controlled trial. B J Obstet and Gynaecol 2005 Mar;112(3):329–33.
36. Buller, JL, Thompson, JR, Cundiff, GW, Sullivan, L Krueger, Ybarra, MA Schön, Bent, AE. Uterosacral ligament: description of anatomic relationships to optimize surgical safety. Obstet Gynecol 2001 Jun;97(6):873–9.
37. Chin, K, Smith, BC, Maldonado, PA, Corton, M. Variability in ureteral distance to uterosacral ligament and uterine vessels with and without cervical traction. J Minim Invasive Gynecol 2014 Mar–Apr;21(2):Supplement, S8
38. Hur, HC, Donnellan, N, Mansuria, S, Barber, RE, Guido, R, Lee, T. Vaginal cuff dehiscence after different modes of hysterectomy. Obstet Gynecol 2011 Oct;118(4):794–801.
39. Perron-Burdick, M, Yamamoto, M, Zaritsky, E. Same-day discharge after laparoscopic hysterectomy, Obstet Gynecol 2011 May;117(5):1136–41.
40. Gilmour, DT, Das, S, Flowerdew, G. Rates of urinary tract injury from gynecologic surgery and the role of intraoperative cystoscopy. Obstet Gynecol 2006;107:1366–72.
41. Carley, ME, McIntire, D, Carley, JM, Schaffer, J. Incidence, risk factors and morbidity of unintended bladder or ureter injury during hysterectomy. Int Urogynecol J Pelvic Floor Dysfunct 2002;13:18–21.
42. Navarro, LHC, Bloomstone, JA, Auler, JOC, Cannesson, M, Rocca, G Della, Gan, TJ et al. Perioperative fluid therapy: a statement from the international Fluid Optimization Group Perioper Med. 2015; 4: 3.Published online, Apr 10, 2015.
43. Kaye, AD, Riopelle, JM. Miller's Anesthesia. Missouri: Churchill Livingstone, 2009. Ch. Intravascular fluid and electrolyte physiology, pp. 1705–37.
44. Holte, K, Klarskov, B, Christensen, DS, Lund, C, Nielsen, KG, Bie, P et al. Liberal versus restrictive fluid administration to improve recovery after laparoscopic cholecystectomy: a randomized, double-blind study. Ann Surg 2004;240:892–9.
45. Yee, JP, Koshiver, JE, Allbon, C, Brown, CR. Comparison of intramuscular ketorolac tromethamine and morphine sulfate for analgesia of pain after major surgery. Pharma 1986 Sep–Oct;6(5):253–61.
46. Balestrieri, P, Simmons, G, Hill, D, Brown, J, Jackson, A, Brull, SJ, Maneatis, TJ, Shefrin, A, Bynum, L, O'Hara, DA. The effect of intravenous ketorolac given intraoperatively versus postoperatively on outcome from gynecologic abdominal surgery. J Clin Anesth 1997 Aug;9(5):358–64.
47. Nakayama, M, Ichinose, H, Yamamoto, S et al. Perioperative intravenous flurbiprofen reduces postoperative pain after abdominal hysterectomy Acta Anesthesiol Scand 1999;43:13–18.
48. Rittenhouse, BE, Choiniere, M. An economic evaluation of pain therapy after hysterectomy: patient-controlled analgesia versus regular intramuscular opioid therapy. Int J Tech Assess 1999 15(3):548–62.
49. Everett, B, Salamonson, Y. Differences in postoperative opioid consumption in patients prescribed patient-controlled analgesia versus intramuscular injection. Pain Manag Nurs 2005 Dec;6(4):137–44.
50. Bayar, U. Basaran, M. Atasoy, N. Ayoglu, H. Sade, H. Altunkaya, H. Comparison of satisfaction and pain relief between patients-controlled analgesia and interval analgesia after laparoscopic ovarian cystectomy. J Psychosom Obstet Gynaecol 2008 Jun;29(2):139–45.
51. McPherson, K, Metcalfe, MA, Herbert, A, Maresh, M, Casbard, A, Hargreaves, J et al. Severe complications of hysterectomy: the VALUE study. B J Obstet Gynecol 2004 111(7):688–94.
52. Makinen, J, Johansson, J, Tomas, C et al. Morbidity of 10,110 hysterectomies by type of approach. Hum Reprod 2001;16: 1473–8.
53. Wright, KN, Jonsdottir, GM, Jorgensen, S, Shah, N, Einarsson, JI. Costs and outcomes of abdominal, vaginal, laparoscopic and robotic hysterectomies. J S Laparosc Surg 2012 Oct–Dec;16(4):519–24.
54. Walsh, CA, Walsh, SR, Tang, TY, Slack, M. Total abdominal hysterectomy versus total laparoscopic hysterectomy for benign disease: a meta-analysis. Eur J Obstet Gynecol Reprod Biol 2009 May;144(1):3–7.
55. Berker, MD Bulent, Taskin, MD Salih, Taskin, MD. Elif Aylin Complications of laparoscopic gynecologic surgery chapter 60 in prevention and management of laparoendoscopic surgical complications. In: S Laparoendosc Surg, 3rd ed, 2012.
56. Vilos, GA, Ternamian, A, Dempster, J et al. Laparoscopic entry: a review of techniques, technologies, and complications. The Society of Obstetricians and Gynaecologists of Canada. J Obstet Gynaecol Can 2007 29:433–65.
57. Leron, E, Piura, B, Ohana, E, Mazor, M. Delayed recognition of major vascular injury during laparoscopy. Eur J Obstet Gynecol Reprod Biol 1998 Jul;79(1):91–93.
58. Hur, HC, Donnellan, N, Mansuria, S, Barber, R, Guido, R, Lee, T. Vaginal cuff dehiscence after different modes of hysterectomy. Obstet Gynecol 2011;118:794–801.
59. Uccella, SU, Ceccaroni, M, Cromi, A, Malzoni, M, et al. Vaginal cuff dehiscence in a series of 12,398 hysterectomies: effect of different types of colpotomy and vaginal closure. Obstet Gynecol 2012;120:516–523.