What Is A Total Laparoscopic Hysterectomy?

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A Total Laparoscopic Hysterectomy (TLH ) is a gynaecological surgical procedure, which involves removing the uterus (womb) and cervix using a keyhole (laparoscopic) technique. The uterus and cervix are removed without making a large abdominal incision. A woman may consider undergoing a TLH for various reasons, including treatment for certain gynaecological conditions or relief from pelvic pain or heavy menstrual bleeding.


How Does a Total Laparoscopic Hysterectomy Work?

With the aid of a small operating telescope, called a laparoscope, the uterus and cervix and removed through the vagina. The laparoscope is inserted into the abdominal wall through a small incision in your belly button and allows the doctor to examine the pelvis/abdomen. The uterus and cervix are removed through four small abdominal incisions using small operating tools. Depending on your condition, your doctor may also remove the ovaries, fallopian tubes and in some cases, especially when cancer is present, also remove pelvic lymph nodes. If your ovaries are removed, depending on your age you may start menopause.


When Do You Need A Total Laparoscopic Hysterectomy?

The most common reasons to have a TLH are:

  • Fibroids – these are non-cancerous tumours that cause pelvic pain, heavy and abnormal uterine bleeding and painful intercourse
  • Endometriosis – the growth of uterine lining in other parts of the abdomen, which may include the ovaries, fallopian tubes, bladder, and intestines.
  • Adenomyosis – this occurs when endometrial tissue (the tissue that lines the uterus) grows into the muscular wall of the uterus. The displaced tissue continues to thicken, break down and bleed during each menstrual cycle and this can cause severe pelvic pain.
  • Uterine prolapse – this causes the downward movement of the uterus into the vagina.
  • Pre-cancerous lesions and gynaecological cancers. When signs of cancer are present, your doctor may also remove your cervix, ovaries, fallopian tubes and nearby lymph nodes.


What Happens Before Surgery?

Before the procedure your doctor will conduct a full physical exam, including blood and imaging tests. During the days before the surgery, you may be asked to stop taking aspirin, warfarin and any other blood-thinning medication. You will usually be asked not to drink or eat anything for 6 – 12 hours before the surgery. You can take the medication your doctor told you to take with a small sip of water.


What Happens During Surgery?

From the beginning to the end of the procedure, understanding the intricacies of each stage can help patients and caregivers navigate the surgical process with confidence and clarity.


Anaesthesia and Cannula Insertion

Prior to the commencement of the surgery, the patient is administered general anesthesia to induce unconsciousness. A cannula, which is a narrow plastic tube, is then inserted into a vein in the patient's arm or hand using a needle. This cannula serves the purpose of delivering fluids and necessary medications to the patient's body during the surgical procedure. Additionally, a catheter, a tube used for urine drainage, may be inserted into the patient's bladder to manage urinary output during the surgery.


Incisions and Laparoscopy

Once the patient is adequately sedated from the general anesthesia, the surgeon proceeds with making small incisions to facilitate the insertion of surgical instruments. Typically, a small incision, approximately 2 cm in size, is made within the patient's navel (belly button). Carbon dioxide gas is then used to fill the patient's abdomen, creating space and providing a clear view of the internal pelvic organs. Through the initial incision, a laparoscope, a thin tube equipped with a camera and light source, is inserted to allow visualisation of the pelvic area. Additional two or three small incisions, each about 1 cm in size, are made on the patient's abdomen to accommodate the insertion of other surgical instruments required for the procedure.


Uterus Removal and Closure

With the laparoscope providing a clear view of the internal pelvic organs, including the uterus and cervix, the surgeon proceeds with the removal of these structures. An incision is made at the top of the vagina to facilitate the extraction of the uterus and cervix. Following the removal of these organs, the incision in the vagina is meticulously closed using dissolvable sutures. Additionally, any necessary blood vessels are cauterised to prevent bleeding and ensure hemostasis. It's important to note that the decision to remove the ovaries and fallopian tubes during TLH surgery depends on various factors, including the patient's medical condition and the reason for undergoing the surgery.


Recovering From A Total Laparoscopic Hysterectomy

After the procedure, you will be taken to the recovery room and monitored for a short time before going to the observation unit. Depending on the length of your surgery, you may not be able to eat or drink anything until the next morning or you will be started on a liquid diet. You may experience cramping, bloating, a sore throat (from the anaesthetic), or shoulder pain. You will be given medication for pain and the catheter (tube into your bladder) will be removed. You may be fitted with compression stockings on your legs to improve circulation. It is advised to start walking as soon as possible after the surgery to help healing and recovery.

Some patients go home the same day after surgery while others may stay one night in the hospital. TLH is a major surgery and recovery typically takes 2-4 weeks. Your doctor will discuss your pathology report and determine if any further treatment is necessary.


What Are The Benefits Of Having A Total Laparoscopic Hysterectomy?

Following the recovery from a TLH it is expected for women to have relief from pain and correction of abnormal uterine bleeding. Patients suffering with uterine prolapse prior to surgery, should have relief from vaginal pressure and pelvic pain.


What Are The Risks Of Having A Total Laparoscopic Hysterectomy?

All surgical procedures are associated with possible unforeseen problems that may be immediate or even quite delayed in presentation. These complications include:

  • Bleeding
  • The need to convert to an open surgery requiring a larger, abdominal incision.
  • Inadvertent damage to an organ in the abdomen or pelvis  including the liver, spleen, colon, intestine, bladder, stomach or ureter
  • Blood clot in the legs or lungs
  • Bowel obstruction
  • Hernia
  • Infection from the open incision or a pelvic abscess where an infection occurs at the top of the vagina where the uterus was removed from.
  • Scar tissue
  • Occasionally blood loss can be significant enough to necessitate a blood transfusion.
  • Rarely sepsis occurs when the infection enters the bloodstream and makes you very ill.
  • Cuff dehiscence occurs when the top of the vagina does not heal properly after surgery, causing the skin edges to separate. This can cause bleeding and in rare cases can allow intestines to herniate into the vagina. It is for this reason that sexual intercourse should not be resumed until given the go ahead by your surgeon.
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