Total laparoscopic hysterectomy for severe endometiosis (adenomyosis, bilateral ovarian endometriomas, completely obliterated cul-de-sac)
Cul-de-sac was completely obliterated and dense adhesion was found among the uterus, bilaterl ovarian endometriomas and the rectum.
Retroperitoneal dissection (posterior approach)
After separating sigmoid colon and pelvic sidewall, left ovarian vessels was identified. They were separated from peritoneum. Care should be taken not to injure ovarian vessels.
Identification of ureter by posterior approach
Left ureter runs inside of the ovarian vessels. The ureter was identified at the pelvic inlet.
Ligation of left uterine artery
Because of dense adhesion, the posterior space was so small that left uterine artery was identified by transverse approach. After coagulationa and incision of round ligament, the uterine was found and ligated.
Coagulation and incision of pelvic infundibulo ligament
Harmonic scalpel was used. Pelvic side of the ligament was ligated before incision.
Right ureter was identified at the pelvic inlet.
Transverse approach (right)
The right posterior space of the uterus was also small because of dense adhesion.
Coagulation of right uterine artery
Right uterine artery was coagulated and cut with harmonic scalpel.
Dissection of lateral side was finished.
The uterus and the rectum was attached. The blood flow to the uterus is only from vaginal artery.
Lysis of the adhesion between the uterus and the rectum
The uterus is upper right of the image and the rectum is left side. Lysis were done by needle tip monopolar using cutting current 60watts.
Lysis of the adhesion between the uterus and the rectum 2
Cul-de-sac is opened after lysis
Vagina was closed in two layers.
The surgery finished after irrigation.
The advantage of total laparoscopic hysterectomy for severe endometriosis
1. low risk of ureteral injury
2. less blood loss
3. fewer relapse of pelvic pain after excision of deep infiltrated endometriosis
The disadvantage of TLH for severe endometriosis
1. The technique is very compricated and difficult.
2. time-consuming surgery