Total laparoscopic hysterectomy (TLH), left adnexectomy with right parametrectomy due to right sciatic nerve entrapment

We present the case of a 34-year-old woman with severe pelvic pain. Antecedents include one cesarean section and three previous laparoscopic surgeries for endometriosis. Clinical examination and MRI were both normal. In this video, we demonstrate how new technologies can also be used to perform a total laparoscopic hysterectomy in a safe and simple way. Although new surgical instruments help simplifying the procedure, one should not forget the importance of classical dissection rules.

Hysterectomy when managing a big adnexal mass has always been a challenging situation for laparoscopic surgeons. Complete preoperative assessment, surgical experience and strategy are fundamental to address adnexal pathology laparoscopicallly, both for benign and malignant conditions. Adequate trocar placement, full inspection of the abdominal cavity, comprehensive evaluation of the tumor’s surface, cytology and definition of the nature of the adnexal mass are truly essential. In addition, proper identification of standard anatomical landmarks is fundamental to perform hysterectomy with adnexectomy, which helps to prevent damage to surrounding structures. Final assessment of the vaginal cuff may lead to the diagnosis of pelvic floor disorders that should be repaired during vaginal cuff closure. In this video, we present a case of hysterectomy and adnexectomy by laparoscopy in a 46-year-old patient complaining of abdominal pain secondary to the presence of a 13cm simple adnexal cyst with normal CA 125 values.

We present the case of a 65-year-old patient, diagnosed with uterine fibroids that have increased in volume over the last months. The patient had previously undergone a rectosigmoid resection and an appendectomy due to an adenocarcinoma. This surgery was streamed live worldwide, and it provides a unique opportunity to learn how to assess, diagnose, and treat intraoperative unexpected complications.

Total laparoscopic hysterectomy has gradually assumed an important part in gynecologic practice. The described “10-step” technique is the most followed strategy to be successful in this procedure. Technological innovation has brought in new devices which combine a safe use of bipolar (vessel-sealing) energy with monopolar current (hook) in the same instrument. In this didactic video, we aim to show the advantages (with some technical tips) of using this new versatile instrument.

Nowadays, hysterectomy is, after cesarean section, the most common surgical intervention performed in fertile women. Laparoscopic hysterectomy remains a safe and reproducible intervention that should be in any’s gynecologists therapeutic armamentarium.