Large uterus: what is the limit for a laparoscopic approach?

Large uterus: what is the limit for a laparoscopic approach?



Hysterectomy is the most common gynecologic surgical procedure performed in the United States, accounting for 600,000 procedures per year.1 The most common indication for a hysterectomy is abnormal uterine bleeding, which is frequently caused by uterine leiomyoma,2 which is present in 25-50% of reproductive-aged women.3 In 2003, approximately 66.1% of hysterectomies performed in the United States were via the abdomen; 21.8% were via the vagina; and 11.8% were laparoscopically undertaken.4

A meta-analysis by the Cochrane Library showed that both the vaginal and the laparoscopic hysterectomies were associated with a shorter hospital stay, fewer infections, and a more rapid return to normal activities compared with abdominal hysterectomies.5 Furthermore, the former is associated with less postoperative pain, a faster recovery, and a better cosmetic result.6 Wattiez et al.7 concluded that “the rationale for hysterectomy is to convert abdominal hysterectomy into a laparoscopic procedure and thereby reduce trauma and morbidity.”

In 1989, Reich and DiCaprio8 performed the first total laparoscopic hysterectomy (LH). Since then, several authors have reported their experience with this operation, so much that LH is currently accepted as a safe procedure for the treatment of benign uterine pathology.9

The term “large uterus” has been overused. In several publications, this term was used to define the weight of a uterus > 300 g or > 500 g.10-12 Giant myomas usually obstruct the pelvis and become extremely difficult to be mobilized and manipulated, reducing the availability to identify the surrounding anatomic structures, and hampering the correct development of the spaces by the surgeon. In the study by Uccella et al.13 comprising more than 1,500 hysterectomies, the prevalence of uteri weighing > 1 kg was 5.7%.

Studies involving the laparoscopic procedure for the treatment of a uterus weighing > 1 kg are scanty and involve a small number of patients,14-16 and the procedure via the vagina has been limited to sporadic reports.17 The case reported herein presents the removal of a 2,800 g uterus via laparoscopic-assisted vaginal hysterectomy (LAVH) by skilled surgeons using minimally invasive techniques. The report was approved by the ethics committee of the hospital (ZNA Stuivenberg/ Antwerp - Belgium), and was formally consented by the patient. This intervention was part of a routine treatment–hysterectomy–-hysterectomy. The informed consent had been obtained from the patient.



A 43-year-old woman born in the Middle East presented to the medical facility complaining of a “large ball” in the abdomen for 2 years, which was associated with nocturia. She denied abnormal uterine bleedings, but eventually presented pain. She was obese (body mass index = 34.5kg/m2) but no other comorbidity was present. Physical examination revealed a mobile, painless, pelvic-abdominal mass extending 3 cm above to the umbilicus.

Abdominal and vaginal ultrasonography was performed showing a large mass in the uterine topography that was scarcely vascularized and sized 13.9 × 16.4 cm.

The magnetic resonance images showed a mass with areas of hyperintense signal intermingled with areas of hypointense signal in T2 in the fundus and the posterior wall of the corpus uteri partially subserous and intramural. The mass measured 18.7 × 16.3 × 21 cm. The endometrial cavity was normal (Figure 1). These findings were consistent with the diagnosis of uterine myomatosis without any sign of malignancy.