Laparoscopic Hysterectomy

Hysterectomies are one of the most common surgical procedures in the United States. There has been a slow but steady decline in hysterectomies performed annually in recent years, decreasing from approximately 555,000 in 2016 to about 517,000 in 2018. ^[1] For decades, abdominal and vaginal approaches accounted for the vast majority of hysterectomies. The advent of better laparoscopic technology resulted in the first total laparoscopic hysterectomy (TLH) in 1989. Over the past 30 years, laparoscopic and robotic-assisted laparoscopic hysterectomy (minimally invasive hysterectomy or MIH) has become the most common surgical approach. TLH accounted for 9.9% of all hysterectomies in 1997 and 11.8% in 2003. ^[2]  In 2018, MIH accounted for 65.8% of hysterectomies. ^[1]

A TLH is defined by the laparoscopic ligation of the ovarian arteries and veins with the removal of the uterus vaginally or abdominally, along with laparoscopic closure of the vaginal cuff. This is in contrast to other methods of removing the uterus, fallopian tubes, and ovaries. A laparoscopic supracervical hysterectomy is completed in a similar fashion, with the exception that the cervix is amputated after occluding the ascending vascular pedicles. A laparoscopic-assisted hysterectomy (LAVH), a precursor to the TLH, is a technique to secure the ovarian and uterine vasculature via laparoscopy; the remainder of the procedure is completed vaginally.

The laparoscope is often reinserted after closure of the vaginal cuff to inspect the abdomen and vaginal cuff for adequate hemostasis at the end of the procedure. This procedure requires adequate uterine descent to safely complete the vaginal portion of the procedure. Laparoscopic radical hysterectomy has emerged as an alternative to abdominal radical hysterectomy for patients with stage I cervical cancer. ^[3] Emerging advancements include robotic-assisted laparoscopic hysterectomy, ^{[4, 5, 6]} single-incision laparoscopy, and laparoscopic pelvic reconstruction surgery.

The advantages of TLH compared to abdominal hysterectomy are well documented. Visualization of pelvic anatomy and the ability to minimize blood loss is superior with TLH. Substantial and dynamic access to the uterine vessels, vagina, and rectum is possible from many angles, especially after introduction of the uterine manipulator in 1995. The advantages of TLH have been firmly established to include reduced short-term morbidity (less blood loss, wound infections, and postoperative pain), shorter hospital stay, and faster resumption of normal activities when compared with abdominal hysterectomy. The primary focus of this chapter is to review the indications, surgical technique, and advantages of TLH for women who are candidates for a hysterectomy.

An image depicting female reproductive anatomy can be seen below.

Female reproductive organs, sagittal section.

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Indications for a total laparoscopic hysterectomy (TLH) are similar to those for total abdominal hysterectomy (TAH) and may include leiomyomata, pelvic organ prolapse, and abnormal uterine bleeding. TLH may also be indicated for resection and debulking of both malignant and premalignant disease, as noted by extensive case series in the gynecologic oncologic literature. Certainly, situations exist in which a TLH may be advantageous, primarily those in which a vaginal hysterectomy may be difficult. Frequently, access to the uterus can be complicated by adhesions, a narrow subpubic arch, a nulliparous pelvis, or leiomyomas, whether they are multiple, large, or found in the lower uterine segment. In these cases, laparoscopy can be used to free adhesions and divide the upper pedicles, allowing for a laparoscopic-assisted vaginal hysterectomy. Oophorectomies can be challenging when approached vaginally, whereas laparoscopic oophorectomies are a natural extension of TLH. 

The American College of Obstetricians and Gynecologists made the following recommendations on choosing the route of hysterectomy for benign disease ^[7] :

• Vaginal hysterectomy is the approach of choice whenever feasible.
• Laparoscopic hysterectomy is a preferable alternative to open abdominal hysterectomy for those patients in whom a vaginal hysterectomy is not indicated or feasible.
• The surgeon should account for clinical factors to determine the best route of hysterectomy for each individual patient.
• The size and shape of the vagina and uterus; accessibility to the uterus (eg, descensus, pelvic adhesions); extent of extrauterine disease; the need for concurrent procedures; surgeon training and experience; average case volume; available hospital technology, devices, and support; whether the case is emergent or scheduled, and patient preference can all influence the route of hysterectomy.
• A discussion with the patient should take place on the route of hysterectomy and advantages and disadvantages of each approach.
• Opportunistic salpingectomy usually can be safely accomplished at the time of vaginal hysterectomy.
• The role of robotic assistance for execution of laparoscopic hysterectomy has not been clearly determined, and more studies are needed to determine clinical use.

Advantages

A 2009 Cochrane review evaluated 27 randomized controlled trials to determine the most appropriate type of hysterectomy for nonmalignant gynecologic conditions. This meta-analysis concluded that no differences existed between vaginal and laparoscopic hysterectomies for the following parameters: return to normal activities, conversion to laparotomy, and duration of hospital stay. Morbidity rates comparing these 2 types of hysterectomies were similar for the incidence of pelvic hematoma, vaginal cuff infection, urinary tract infection, respiratory tract infections, and venous thromboembolism. Bladder and ureteral injuries were more common with a TLH compared to a TAH; however, urinary tract injuries with TLH were similar to those with vaginal hysterectomy. This review also found that evidence is lacking in support of any benefit in choosing either single-port laparoscopic or robotic hysterectomy over traditional TLH.

This meta-analysis, however, was underpowered to detect a clinically significant increase in the incidence of bladder or ureteral injury with TLH. Most of the data regarding urinary tract injury is derived from nonrandomized studies. ^[8] Other benefits to TLH include a decreased risk of wound infection (both incisional and abdominal wall) and blood loss. The incidence of major surgical complications (hemorrhage, visceral injury, pulmonary embolism, wound dehiscence, anesthetic problems, and conversion to laparotomy) was 11% with TLH compared to 6% with TVH. ^[8] Operative times were longer for TLH compared to LAVH, TAH, or TVH, whereas LAVH and TAH had comparable operative times. The shortest operative times were noted for TVH.

Most of these studies reflect early experience with TLH. One study evaluated laparoscopy endpoints in two different time periods, which revealed a decrease in laparotomy conversion rates, the incidence of major complications, and operating time. ^[9] Another study evaluated outcomes based on the number of hysterectomies performed; it reported that, after 30 procedures, the conversion to laparotomy rate decreased from 9.2% to 2.4%. Operating time decreases with experience, but the rate of serious complications remains unchanged. ^[10]

Potential benefits of TLH include shorter hospital stays, quicker return to normal activities, and less use of postoperative pain medications in comparison to TAH. ^[11] A comparison of TVH and TLH outcomes demonstrate similar length of hospital stays and level of postoperative pain. A more recent article by Ghezzi et al noted an improved pain profile and shorter hospital stay by one day for those patients undergoing a TLH versus a vaginal hysterectomy for benign disease. Surgical outcomes, although not the primary outcome measure for this study, also favored laparoscopic hysterectomy. Operative times were 5 minutes longer for the laparoscopic cases, and similar rates of conversion to laparotomy, intraoperative complications, and intraoperative blood loss existed. ^[12]

However, according to the American College of Obstetricians and Gynecologists 2009 Committee Opinion, TVH appears to be the overall preferred approach for a hysterectomy in the appropriate patient based on the well-documented advantages and lower complication rates. ^[13] Future studies will likely continue to examine the benefits of TLH versus conventional hysterectomy approaches, but some benefits of laparoscopy to the patient seem clear at this time.

Some conflicting evidence regarding the cost-effectiveness of TLH exists. A meta-analysis of 12 randomized controlled studies reviewed the cost of TAH compared to TLH. The total direct costs for TLH were 6.1% higher than TAH, whereas total indirect cost for TLH was half the cost of TAH. The study concluded that the shorter hospital stay and decreased morbidity in the laparoscopic group compensates for the increased operating cost compared to TAH. ^[14] A quality of life study in 2008 indicated TLH performed equally or better in terms of postoperative health and quality of life in the first weeks after surgery. ^[15] In the decision for the approach to hysterectomy, these published benefits of shorter hospital stay and higher quality of life must be weighed with the possibility of increased risk of complications, although the literature has yet to come to a conclusion regarding current complication risks.

In recent years, TLH as a planned outpatient surgical procedure with same-day discharge has increased in popularity. Several studies have found that this is a safe, lower cost approach with comparable postoperative readmission rates. ^{[16, 17]}  Approximately 100,000-200,000 outpatient hysterectomies are performed annually, and the number is increasing. ^[18]

Some investigators believe there is no absolute contraindications to a total laparoscopic hysterectomy (TLH) for benign gynecologic diseases. ^[19] The experience of the surgeon and the patient's pelvic anatomy remain the limiting factors for most laparoscopic hysterectomies. The most common reason for a surgeon to abandon a TLH is insufficient knowledge or training in laparoscopic procedures.

Patient-specific contraindications to laparoscopy may involve a pelvis with severe adhesive disease, obstructive leiomyomata, or any other anatomic limitation that prevents safe entry into or inadequate working space in the abdomen. Patients with a history of repeat cesarean deliveries, multiple laparotomies, or midline incisions have up to a 50% chance of organ adhesion in the umbilical area. Risk factors for conversion to laparotomy include elevated BMI, increased uterine width greater than 10 cm, lateral or lower uterine segment fibroids over 5 cm, and previous adhesion-forming abdominopelvic surgery. ^[9] The obese patient may be a challenge for the gynecologist, as both the Veress and open technique for trocar entry and establishment of pneumoperitoneum can be difficult. ^[20] Longer instruments and appropriate trocar placement can help ensure adequate manipulation of pelvic structures.

Any medical condition that limits patient anesthesia selection or proper positioning makes gynecologic laparoscopy difficult to safely perform. Anesthesia during a total laparoscopic hysterectomy (TLH) can be complicated by the steep Trendelenburg position after abdominal insufflation to improve visualization of the pelvic structures. Ventilation, especially in the obese patient, is a challenge. The Trendelenburg position itself lowers vital pulmonary capacity, which may result in improper ventilation, perfusion, and a decrease in functional capacity. ^[9]

In addition to the physiologic changes associated with the change in patient position, the actual insufflation of CO₂ gas may account for anesthetic complications in the cephalad displacement of the diaphragm. This can decrease functional residual capacity, total lung volume, and pulmonary compliance, contributing to ventilation perfusion mismatch. This latter problem may result in the development of atelectasis and hemodynamic compromise, including decreased cardiac output, elevation of arterial pressure and an increase in systemic, and pulmonary vascular resistance. ^[21] Given these challenges unique to gynecologic laparoscopy, communication between the surgical and anesthesia teams is essential to a safe and successful outcome of a TLH.

The surgeon must familiarize himself or herself with the appropriate room set-up, patient positioning, and laparoscopic equipment to facilitate a successful surgery. The patient is placed in the dorsal supine modified lithotomy position with arms tucked securely to the patient's side. Positioning the arms as close to the patient as possible allows the surgeon and the assistant adequate operating room on either side of the patient's head and shoulders, optimizing the angle toward the pelvis.

Shoulder holders or pads are routinely used to protect the patient during the 20-30 º Trendelenburg that is required during gynecological laparoscopy. The patient is positioned in the modified dorsal lithotomy position during placement of the uterine manipulator, while the legs are lowered during laparoscopy. Placement of the uterine manipulator requires a bivalve speculum or vaginal retractors, a tenaculum, and cervical dilators. A mild degree of Trendelenburg is helpful during this part of the procedure. After successful placement of the manipulator and the bladder catheter, the legs are repositioned in the low lithotomy position for the remainder of the procedure.

The surgeon and assistant operate toward the foot of the patient, rather than facing each other, as in traditional laparotomy. The assistant operates the camera while the surgeon operates with laparoscopic instruments in both hands, one of which generally serves as a retractor, while the other may be a monopolar, bipolar, harmonic, or sealing device for cutting and coagulating tissue. The assistant has various graspers to use, including atraumatic, Maryland, or bowel graspers. Depending upon the tissue angle, the assistant may have the more effective angle of operation. A suction irrigator can also be an invaluable addition to assist with a TLH, although some surgeons find that several instruments on the field can be cumbersome and inhibit economy of movement. Options for tissue removal include durable bags that are rolled into or around a laparoscopic extender, released to open inside the abdomen, and cinch prior to removal through a larger port site or hand port.

Please see the Equipment section.

After completing a pelvic examination under anesthesia, the first step is to properly position and drape the patient as previously described. The patient is placed in the modified lithotomy position during placement of the uterine manipulator. Currently, several manipulators are marketed. The manufacturer’s directions for assembly and application should be reviewed prior to use. Correct application of the uterine manipulator is key to a successful TLH, as many of these manipulators facilitate identification of important anatomical structures.

After successful placement of the uterine manipulator, the legs are repositioned in the low lithotomy position. The abdomen is prepped and draped. A periumbilical incision is used to introduce pneumoperitoneum. Several techniques are available to enter the abdominal cavity including the following techniques: open, direct, direct vision, radically expanding trocar, or the Veress needle. There is no clear advantage of one technique being safer than another. The open technique is rarely associated with major organ or vascular injury, but care should be taken regardless of the method of entry. Trocar selection, number, and location may depend on several factors, including patient habitus, surgical history, uterine or pelvic mass size, indications for oncologic staging, available instruments, and degree of assistant participation.

Traditionally, a larger 10-12 mm trocar is placed at or above the umbilicus to provide a panoramic view of the pelvis though a 5-mm camera via a 5-mm trocar, which is usually adequate for uncomplicated cases. Once placed successfully through the peritoneum, pneumoperitoneum is developed with high flow CO₂ at 25-30 mm Hg. After  adequate pneumoperitoneum is established, the gas flow is reduced to 15 mm Hg and the laparoscope is introduced. An initial survey of the pelvis is performed, noting the size and mobility of the uterus and adnexal structures. Careful inspection for adhesive disease or endometriosis should be performed at this time to assess for appropriate trocar placement. Under direct visualization, a 5-mm or 8-mm trocar is inserted in the lower quadrants, approximately 2-3 cm superior and 2-3 cm medial to the anterior superior iliac spine.

A conscious effort should always be made to avoid the inferior epigastric vessels and perforating arteries of the anterior abdominal wall during trocar placement. The inferior epigastric arteries usually can be visualized with the laparoscope while the abdomen is palpated from above prior to trocar placement. Transabdominal illumination of the anterior abdominal wall may also facilitate vessel identification and proper trocar placement. During insertion of a trocar, the camera operator should follow the pointed trocar tip throughout its entry and removal from the abdomen in order to immediately identify any vascular or visceral injury that may occur.

Additional trocars may be placed in superior or lateral to the umbilicus to facilitate adequate instrument use, visualization, and mobilization of intra-abdominal structures (see video below). Once one or two trocars are placed, adhesiolysis may facilitate safe placement of additional trocars. Careful and meticulous technique during development of pneumoperitoneum and trocar placement cannot be overemphasized, as injuries associated with this initial part of the procedure account for both recognized and unrecognized vessel and organ injury as well as the vast majority of medicolegal claims with laparoscopic surgery.

Once proper access into the abdomen is obtained, the round ligaments on both sides are identified, grasped, and divided with bipolar or monopolar cautery. This allows for subsequent development of the retroperitoneal space, both cephalad toward the iliac vessels and into the lateral avascular space. Laparoscopy provides a strikingly detailed view of the retroperitoneal anatomy, and time should be taken at this point to identify the course of the ureters and the major vasculature of the pelvis. The ureter courses a mere 1 cm lateral to the cervix at the level of the uterine arteries and is the most common location of laparoscopic ureteral injury.

After ureteral identification, further retroperitoneal dissection allows the ureter to fall laterally and away from active ligation and coagulation. Energy sources used during laparoscopy should always be kept in the camera view at all times to help avoid risks of accidental activation and subsequent injury, especially while operating near the ureter and the iliac vessels. Observation of ureteral peristalsis should accompany every laparoscopic procedure at least once during active retroperitoneal dissection and preferably again prior to trocar removal and closure. Entry and development of the bladder flap peritoneum allows for anterior mobilization of the bladder early in the procedure (see video below).

Thorough development of the posterior leaf of the broad ligament allows for skeletonization of the infundibulopelvic ligaments. The infundibular and utero-ovarian ligaments contain the two upper vascular supplies of the adnexal structures and the uterus. The second most common location of ureter injury is found at the level of the infundibulopelvic ligaments during oophorectomy, emphasizing the importance of careful attention to identify the ureters. A window is developed in the medial leaf of the broad ligament, and the infundibulopelvic ligaments are sealed with suture, bipolar electrocautery, or surgical clips. If the ovaries are to be preserved, the utero-ovarian ligament may be sealed and ligated in a similar fashion. Sealing of the uterine side of these pedicles is recommended to protect against excessive back bleeding (see the video below).

From the posterior aspect of the developed peritoneal edge, the incision is made across the posterior aspect of the upper vagina, as identified by the ring located on most uterine manipulators. Development of either the anterior or posterior colpotomy with monopolar or bipolar cautery releases the ureter inferiorly as it maintains its attachment to the peritoneum. If not already completed, the bladder flap may be developed at this time, allowing the bladder to fall below and away from the site of the anterior colpotomy.

Once the anterior and posterior colpotomies are opened, the uterine vessels are skeletonized, sealed, and divided with a sealing device or vessel clips. The remainder of the colpotomy is completed using monopolar or bipolar cautery. Prior to this maneuver, the ureters should again be identified, and if necessary, skeletonized up to the entry into the bladder to ensure their safety. If a supracervical hysterectomy is planned, the cervix can be amputated after skeletonization, sealing, and division of the uterine vessels.

After division of the uterus and cervix from the upper vagina, the specimens are removed from the abdomen (see video below). The abdomen is desufflated, the legs elevated, and attention is turned to the perineum for transvaginal removal. As there are many indications for a TLH, the specimens themselves may also be varied in their size or origin. If the procedure is being performed as part of an oncologic staging procedure, morcellation of the specimen is contraindicated. In most instances, the cervix, uterus, tubes, and ovaries are removed transvaginally en bloc while still attached to the uterine manipulator. Use of a tenaculum to grasp the uterine body may facilitate removal of a fibroid or otherwise enlarged uterus. The US Food and Drug Administration (FDA) in 2020 recommended that laparoscopic power morcellation for hysterectomy or myomectomy only be performed with a tissue containment system.  

After specimen removal, attention is turned to the closure of the vaginal cuff. Several methods and materials are available for intra-abdominal cuff closure. Interrupted or continuous sutures may be tied intra-corporeally with a needle driver and grasper or extra-corporeally with a knot pusher. Closure of the vaginal cuff using a barbed suture does not require knot tying and is favored by many surgeons. Vaginal cuff closure requires time and practice to become proficient, and some surgeons prefer traditional transvaginal cuff closure. 

If the TLH was performed for oncologic staging, pelvic and peri-aortic lymph node dissection is undertaken at this time. Laparoscopy holds a distinct advantage for the gynecologic oncologist, as it allows for meticulous visualization, dissection, and hemostasis of the pelvic and peri-aortic lymph node beds. Abdominal washings, omentectomy, and bowel resection can be completed often with the assistance on a small hand port.

The abdomen should be inspected at the completion of the laparoscopic procedure. We recommend setting the intra-abdominal CO₂ at 8 mm Hg. This allows for identification of both arterial bleeding as well as venous bleeding, which may only be discovered with lower abdominal pressure. All ports should be removed under direct visualization and their entry sites observed for hemostasis. The laparoscope is removed and as much CO₂ is expelled through the umbilical trocar site as possible before removal. Removal of intra-abdominal CO₂ is recommended to decrease postoperative abdominal pain and minimize the incidence of referred shoulder pain.

Fascial closure of the larger 10 or 12 mm ports is recommended to prevent an umbilical hernia. All of the smaller 5 or 8 mm ports can be closed directly at the skin, either with suture or with skin adhesion products. Injection of local anesthesia at all port sites is believed to decrease immediate postoperative pain.

Some surgeons opt to perform a cystoscopy at the conclusion of a TLH. Both indigo carmine dye injected intravenously or methylene blue injected in a retrograde fashion into the bladder may be used to evaluate ureteral patency and bladder integrity at the completion of the procedure.

Preoperative assessment of the bony pelvis and uterine size should be determined when the surgeon is considering a total laparoscopic hysterectomy (TLH). Preoperative ultrasound is useful to measure uterine length and width in relation to the pelvis.

Patients with a suspected uterine malignancy should undergo TLH only if the uterus can be removed intact via the vagina or abdominal incision.

Do not hesitate to use a 5-mm port site to insert a laparoscope to improve visualization for lysis of adhesions to the abdominal wall.

A 30º 10-mm laparoscope is useful to assist with the anterior colpotomy in the presence of a large lower uterine segment leiomyoma.

Use a suction irrigator to clean smudge marks from the laparoscope. This technique significantly decreases the number of times the laparoscope has to be removed from the abdomen.

Removal of the ovaries and tubes from the uterus often can facilitate visualization during the hysterectomy.

Dissection of the bladder several centimeters below the manipulator ring allows for safe closure of the vaginal cuff.

Laparoscopy, like any other surgery, has associated complications; however, complications reported in the early years of total laparoscopic hysterectomy (TLH) tended to be higher than in more recent reports. Reported complications in gynecologic laparoscopy range from 0.1-10%, with over 50% of injuries occurring at the time of entry and 20-25% not recognized until the postoperative period. The incidence of entry access injury has been reported as 5-30 occurrences per 100,000 procedures, with bowel and retroperitoneal vascular injuries comprising almost 76% of all injuries. ^[22]

The safest entry technique, open or closed, is unclear based on multiple studies. Approximately half of small and large bowel injuries are not recognized at the time of surgery. Usually within 24 hours most bowel injuries are recognized as patients experience increasing abdominal pain, fever, and prolonged ileus. Vascular injury is less common in laparoscopy but certainly occurs and can have significant morbidity and mortality. The iliac artery is the most common site of vascular injury, involving 19% of all laparoscopic injuries. Injury to the iliac vein or other retroperitoneal veins constitute 9% of vascular injuries during laparoscopy. ^[22] Although the aorta and inferior vena cava are the vessels most commonly injured in fatal occurrences, fortunately, large vessel injury comprises a very small percentage of all laparoscopic injuries, with the aorta and inferior vena cava injured in just 6% and 4% of total injuries, respectively. ^[22]

Several risk factors increase the complication rate of laparoscopy. Patients with a significant surgical history including one or more laparotomies or abdominal wall hernias are at risk for significant adhesive disease, especially involving the anterior abdominal wall. Patients with a history of intra-abdominal disease, including pelvic inflammatory disease, endometriosis, or diverticulitis, are also at an inherently higher risk of complications secondary to adhesive disease. Other risk factors involved with laparoscopy include large pelvic masses, bowel distention, cardiopulmonary disease, and high BMI. The surgeon’s laparoscopic experience may play a role in the rate of complications, and a learning curve of approximately 30 procedures for TLH is recognized. ^[10]

Avoidance of entry injuries requires a cautious approach for every procedure, regardless of the patient’s risk factors for complications. For Veress needle placement, the needle should be inserted at a 45º angle through the base or the lower aspect of the umbilicus to minimize direct extension into the intra-abdominal vasculature. Decompression of the stomach with an orogastric or nasogastric tube prior to Veress needle placement may help prevent perforation of the stomach. Placing the laparoscopic trocar directly into the peritoneal cavity and then insufflating is possible. If the open technique is to be used, the fascia and peritoneum are grasped and incised directly, allowing for direct visualization upon entry to the abdomen.

In order to avoid the inferior epigastric vessels, the lateral trocars should be placed no closer than 8 cm from the midline and at least 5 cm above the symphysis and lateral to the rectus abdominis muscles. Alternatively, once inside the peritoneum, the inferior epigastric vessels can be visualized just medial to the site where the round ligament exits the abdomen and palpation of the skin overlying the anterior wall may assist with safe lateral trocar placement.

If vascular injury to the inferior epigastric vessels does occur, mild bleeding may be controlled with coagulation. If moderate or heavy bleeding occurs, a damp sponge can be placed into the cavity for pressure application. The vessels may be able to be suture ligated if the bleeding persists. If major vascular injury occurs, the inflicting instrument should be removed, and in most cases, a vertical laparotomy is made to explore the abdomen. Bleeding should be controlled with pressure, packing, or vascular clamps while awaiting a vascular surgery consult.

Bowel injury is one of the more common and most serious complications of laparoscopy. These injuries are often undetected at the initial surgery or during the initial postoperative period. Peritonitis from a bowel perforation may first present after laparoscopy as increasing abdominal pain or distention, nausea and vomiting, ileus, fever, hypotension, or tachycardia. Patients who have undergone laparoscopy should improve hourly after surgery. Patients who have increased abdominal pain in the immediate postoperative period should be carefully examined to rule out occult bowel injury. The estimated incidence of bowel injury in TLH is between 0.34-0.45%. ^[23]

Intraoperatively, small penetrating injuries to the bowel may be managed conservatively, as with those from a Veress needle. Others, including those from a 5-mm trocar, usually require suture reapproximation, which may be performed with interrupted 3-0 silk or Vicryl suture in a transverse fashion. Electrosurgical injuries are notorious for late manifestation and usually require 1-2 centimeters of resection surrounding the burn to ensure that only healthy bowel remains. Colostomy formation is rarely necessary. Routinely, the presence of free air in an upright abdominal film is a diagnosis of a perforated viscus; however, after laparoscopy, up to 40% of patients have more than 2 cm of free air 24 hours postoperatively. Free air has been documented up to 1 week after laparoscopy, but increasing amounts of air should be further evaluated. ^[10]

Urinary tract injury is also a recognized complication of laparoscopy. Bladder injury has been noted at the time of secondary trocar placement, and is usually instantly recognized and repaired. If not, blood or air within the catheter bag should raise suspicion of bladder or ureteral injury. Placing a catheter to depress the bladder and entering the abdomen under direct visualization can help decrease the incidence of bladder injury. Similar to repair of bowel injuries, blunt bladder injury from a Veress needle may be managed conservatively, while larger cystotomies should be suture repaired. Thermal injury to either the bladder or ureters may go unrecognized. This usually occurs during the development of the bladder flap and dissection in the retroperitoneal space, especially if there is significant adhesive disease or endometriosis. Traditionally, the risk of urinary tract injury has been reported to be higher with laparoscopic versus abdominal hysterectomy. However, it is likely that this complication has decreased in prevalence over time given improvements and mastery in laparoscopic surgical techniques. Specifically, incidence of ureteral injury is estimated to be 1.2-2.6% during TLH. ^[24]

Complete knowledge of the pelvic anatomy and constant vigilance in the identification and location of the ureter is the best method of prevention or early recognition of ureteral injury. Thermal ureteral injuries are caused by excessive use of an energy source adjacent to or directly onto the ureter. These types of injuries result in constriction, hydronephrosis, or fistula formation if unrepaired. Management depends on the location of the ureteral injury. Ureteral injury near the pelvic brim can be repaired by resection and primary reanastomosis over a ureteral stent. Injuries near the bladder are best repaired by direct ureteral reimplantation.

Wound complications may also develop after laparoscopy, but the incidence is less when compared with laparotomy incisions. Patients with skin infections present with erythema, induration, or purulent discharge. There is a 3% incidence of surgical site infections during TLH, making this one of the more common complications. ^[25]  Vaginal cuff dehiscence is also a known risk; a meta-analysis found this complication to occur at an incidence of 1.64%. ^[26]

Trocar site or abdominal wall hematomas may develop postoperatively, with varying degrees of severity. Small local ecchymoses are not uncommon around individual trocar sites, but large abdominal or flank hematomas may also develop and result in a significant drop in hemoglobin. Large abdominal wall hematomas have been diagnosed by computed tomography and may be managed conservatively if clinically stable and nonexpanding. Rarely, surgical intervention and evacuation is necessary. An incisional hernia can develop through larger port sites, with an incidence of 21 per 100,000 procedures. ^[10] Fascial closure of the larger 10- or 12-mm ports decreases but does not eliminate the incidence of an incisional hernia. Clinical signs of a hernia include wound disruption, bulging, increasing pain, and signs of bowel obstruction. 

Complications associated from pneumoperitoneum rarely occur, although pneumothorax, mediastinal emphysema, and diaphragmatic rupture may result from high insufflation pressures. Leal et al reported the case of a patient with massive pneumothorax after a total laparoscopic hysterectomy. ^[27] Vascular absorption of CO₂ gas may also cause an acidosis or even be fatal, as with gas emboli. Not uncommonly, patients may experience subcutaneous emphysema, and crepitus may be noted upon examination. Referred shoulder pain originates from diaphragmatic irritation from gas, blood, or fluid. These minor adverse effects generally resolve within 24 hours but can concerning to the patient.

The risk of intraperitoneal dissemination of malignant tissue led to a 2014 FDA black box warning against the use of laparoscopic power morcellation to remove uterine fibroid tumors. ^[28]

A retrospective cohort study that included 75,487 women who underwent hysterectomy for benign gynecologic indications reported that major complication rates increased from 1.9% to 2.4% in the subset of 25,571 women who underwent hysterectomy for uterine fibroids after the 2014 FDA black box warning against the use of laparoscopic power morcellation. ^[29]

Madhvani et al found that among patients who underwent laparoscopic hysterectomy for benign disease, the presence of adhesions was associated with the greatest risk of major complications (adjusted odds ratio, 1.92). In their study, major complications occurred in 4.4% of laparoscopic hysterectomies. ^[30]