Total laparoscopic hysterectomy is a minimally invasive and safe alternative to total abdominal hysterectomy, providing benefits such as rapid recovery, shorter hospitalization, minimal blood loss, and fewer minor complications. This procedure is particularly suitable for patients who are not eligible for vaginal hysterectomy. TLH is a laparoscopic surgery in which the entire surgical procedure, including vault closure, is carried out through a laparoscope. The procedure requires skilled hands and a longer learning curve, but if safety is confirmed, more surgeons would be attracted to learn and perform laparoscopy.



Many studies are done to evaluate the safety and advantages of TLH, particularly in a government hospital setting, for various gynecological conditions. The total complication rate was found to be around 8%, with a major complication rate of less than 1%. Hemorrhage was the most common complication, followed by bladder injury, vaginal cuff infection, and trocar site infection. Patients with a greater risk of laparotomy may be identified by preoperative patient evaluation and fibroid mapping in lower uterine segment fibroids.

While the study has limitations, such as being a retrospective record review from a single center, TLH is relatively risk-free and provides good access to the whole abdomen, making it beneficial for patients with a pelvic mass, endometriosis, adhesions, or cancer. With proper case selection and skilled hands, complications from this technique will be minimal. Therefore, TLH should be a part of the basic knowledge of a gynecological surgeon.

TLH is being increasingly adopted by gynecologists as a type of minimally invasive surgery due to its many advantages over open surgery, such as less pain, decreased hospital stay, and early recovery. Unlike vaginal hysterectomy, TLH is independent of vaginal size or capacity.

The technique used for TLH in the hospital involves a modified lithotomy position, bimanual inspection, and the use of a Mangeshikar-style uterine manipulator with a cupping device to delineate the cervicovaginal junction. A thorough abdominopelvic survey is done to identify the ureters, and the round ligament, infundibulopelvic (IP) ligament, and utero-ovarian ligament are coagulated and incised. The uterine arteries are coagulated and incised, and the cervicovaginal margin is laparoscopically "palpated" to delineate the posterior margin, lateral edges, and anterior margin of the cervical stroma. The vagina is incised at the precise margin of the cervix and vagina, and the uterus is removed.

The study has found that TLH is a safe and effective procedure for treating various gynecological conditions, including leiomyomata uteri, abnormal uterine bleeding, endometrial hyperplasia, adenomyosis, and ovarian and endometrial cancer. The average hospital stay is only 2 days, and the procedure is beneficial in obese, nulliparous, and diabetic women.

In conclusion, TLH is a valuable alternative to total abdominal hysterectomy, with fewer complications and shorter recovery times. It requires skilled hands and a longer learning curve, but with proper case selection and an experienced surgeon, complications can be minimized. TLH should be an integral part of the basic knowledge of a gynecological surgeon, and its safety and effectiveness should be confirmed in larger retrospective series to attract more surgeons to learn and perform laparoscopy.