Systematic Approach for Cold Knife Morcellation of Large Uterus in Total Laparoscopic Hysterectomy

Following the completion of the TLH and before vault closure, the uterus is flipped upside down to resemble a flask and is grasped by the assistant from the cervix. The endoknife is advanced carefully through a 10 mm trocar and an incision is started from the level of the isthmus and advanced sagittally towards the fundus to bisect this uterus into two hemiuteri connected at the fundus. The incision is stopped 1-2 cm before the fundus to keep the specimen intact. The uterus (which is grasped from the cervix) is then rotated 90 degrees and another incision is started in the hemiuterus containing the cervix coronally towards the fundus again bisecting this hemiuterus. The incision is advanced through the connecting fundus bisecting the other hemiuterus. The incision is stopped 1-2 cm before the specimen is split into two. The end result is a long, connected strip of uterus formed of the bisected hemiuteri. The cervix is guided through the colpotomy and is grasped vaginally with a tenaculum and pulled exteriorly. The vault is then closed with a continuous suture.

Inclusion criteria

• Women candidates for total laparoscopic hysterectomy
• Uterus size >/= 20 weeks gravid uterus
• Benign uterine disease

Exclusion criteria

• • Malignant or premalignant uterine disease
• Bleeding disorders
• Unfit for surgery
• Contraindications for laparoscopy