In a total laparoscopic hysterectomy, the uterus is detached from its blood supply, supporting ligaments, and the vaginal wall entirely through small abdominal incisions, then pulled out through the vagina or, when the uterus is too large for that route, broken into smaller pieces inside a containment bag. The whole process relies on specialized instruments inserted through narrow ports, a camera that magnifies the surgical field, and energy devices that simultaneously cut tissue and seal blood vessels. What sounds straightforward in summary actually involves a carefully sequenced series of steps, each designed to control bleeding and protect nearby structures like the ureters and bladder.
The Surgical Steps From Start to Finish
The operation begins with the surgeon placing several small ports, usually between three and four, through the abdominal wall. One goes near the navel for the camera, and the others are positioned on the lower abdomen to give working angles for instruments. A uterine manipulator is inserted vaginally to move the uterus during the procedure, which helps the surgeon see and access structures that would otherwise be hidden.
Once the view is established, the round ligaments on each side are sealed with an energy device and cut. This opens the path into the tissue layers behind the uterus, where the surgeon needs to identify the ureter before going any further. Locating the ureter early is a safety step that runs throughout the entire procedure, because it lies dangerously close to several structures that must be cut or sealed.
With the ureters identified, the surgeon works on the blood supply. The uterine arteries can be sealed at different points depending on the technique. In one widely described approach, the surgeon enters the space between the ureter and the internal iliac artery, finds where the uterine artery branches off, and seals it at its origin using a vascular stapler or bipolar device. This cuts blood flow early and reduces bleeding for the remaining steps.1Journal of Minimally Invasive Gynecology. Step by Step Total Laparoscopic Hysterectomy with Uterine Arteries Ligation at the Origin In another common approach, the ascending uterine vessels are sealed closer to the uterus at the level of the internal cervical opening, using a bipolar grasper to heat the tissue until it is fully desiccated before cutting.2PubMed Central. Total Laparoscopic Hysterectomy: 10 Steps Toward a Successful Procedure
Next, the ovarian ligaments and fallopian tubes are dealt with. If the ovaries are being kept, the connection between the ovary and the uterus is sealed and cut while staying close to the uterine side to avoid the pelvic sidewall. If the ovaries are being removed, the infundibulopelvic ligament, which carries the ovarian blood vessels, is sealed instead. The surgeon then separates the front and back layers of the broad ligament, the sheet of tissue draping over the uterus like a curtain.2PubMed Central. Total Laparoscopic Hysterectomy: 10 Steps Toward a Successful Procedure
The uterosacral and cardinal ligaments, which anchor the cervix to the pelvis, are sealed and divided last. These are the final structural connections holding the uterus in place. Once they are cut, the surgeon performs a colpotomy: cutting around the cervix where it meets the top of the vagina, guided by the ring of the uterine manipulator. This frees the uterus entirely.3PubMed Central. Total Laparoscopic Hysterectomy with Prior Uterine Artery Ligation at Its Origin
Getting the Uterus Out of the Body
Once the uterus is completely detached, it needs to exit the body. For a normal-sized or moderately enlarged uterus, the simplest route is through the vagina. The surgeon pushes the specimen down, and an assistant retrieves it vaginally. This approach works well even in women who have never given birth, and studies suggest that transvaginal retrieval using a containment bag is safe and effective as a first-line option in that population.4PubMed Central. Safety of Transvaginal Specimen Retrieval in Total Laparoscopic Hysterectomy for Nulliparous Women: A Retrospective Study
When the uterus is too large to fit through the vagina intact, the surgeon has to reduce its size. This is where morcellation comes in. The specimen is placed inside a containment bag within the abdomen, the bag is inflated, and either a power morcellator or manual cutting with a scalpel breaks the tissue into smaller strips that can be extracted through a port site or the vagina.5PubMed. Open power morcellation versus contained power morcellation within an insufflated isolation bag: comparison of perioperative outcomes In-bag morcellation has become the standard approach in centers that still use power morcellation, because it prevents tissue fragments from scattering inside the abdomen.
Why Morcellation Became Controversial
Power morcellation drew intense scrutiny after a highly publicized case in which a woman’s uterine fibroid turned out to be a leiomyosarcoma, a rare uterine cancer. Morcellating it spread cancer cells throughout the abdomen. The U.S. Food and Drug Administration issued a safety communication discouraging the use of power morcellators on presumed fibroids, and for a time many hospitals stopped the practice entirely.6PubMed. Power morcellators: a review of current practice and assessment of risk
The concern is real but statistically uncommon. Leiomyosarcoma lurking inside what looks like a benign fibroid is rare, and no reliable preoperative test can distinguish the two with certainty. If the tissue is morcellated uncontained, any malignant cells can disseminate and potentially worsen survival outcomes.7Critical Reviews in Oncology/Hematology. Morcellation of undiagnosed uterine sarcoma: A critical review Contained in-bag morcellation was developed to address this risk, keeping all fragments sealed away from the abdominal cavity. Studies evaluating in-bag systems have successfully contained specimens without spillage.8PubMed Central. Safety and feasibility of contained uterine morcellation in women undergoing laparoscopic hysterectomy Still, some surgeons and patients prefer to avoid morcellation entirely by converting to a small open incision when the uterus is very large, which trades minimal-access benefits for the certainty that tissue stays intact for pathology analysis.
Closing the Vaginal Cuff
After the uterus is out, the surgeon must close the opening at the top of the vagina, known as the vaginal cuff. This is one of the most technically demanding steps, because a poorly closed cuff can later separate, a complication called cuff dehiscence. There are several closure methods, and the debate over which is best has generated a fair amount of research.
Interrupted sutures tied by hand inside the body (intracorporeal knotting) or outside the body (extracorporeal knotting) are traditional techniques. A newer option is a barbed suture, which has tiny hooks along its length that grip tissue without requiring knots. A laboratory comparison found that barbed suture closed the cuff in about half the time of interrupted sutures and held up better under tension, with significantly less gap formation when pulled.9Scientific Reports. Comparison of different suture techniques for laparoscopic vaginal cuff closure
As for the colpotomy itself, surgeons can use either monopolar coagulation or cutting mode to make the vaginal incision. A randomized trial comparing the two energy modes found that cuff dehiscence rates were similarly low in both groups, around one percent or less, suggesting that either approach is acceptable.10PubMed. Vaginal cuff dehiscence following total laparoscopic hysterectomy by monopolar cut vs coagulation mode during colpotomy: A randomized controlled trial Some surgeons have also experimented with two-layer closures, suturing the vaginal lining first and then a second muscular layer on top, in an effort to add strength to the repair.11PubMed Central. Two-Layer Compared With One-Layer Vaginal Cuff Closure at the Time of Total Laparoscopic Hysterectomy to Reduce Complications
Total Laparoscopic Versus Laparoscopic-Assisted Vaginal Hysterectomy
Not every laparoscopic hysterectomy is performed entirely through the scope. In a laparoscopic-assisted vaginal hysterectomy (LAVH), the surgeon uses the laparoscope for the upper portion of the procedure, such as freeing the ovarian ligaments and upper blood supply, then switches to a vaginal approach for the lower dissection, colpotomy, and specimen removal. A total laparoscopic hysterectomy (TLH) completes every step, including the colpotomy and cuff closure, through the abdominal ports.
Randomized comparisons between the two have shown trade-offs rather than a clear winner. TLH tends to have a longer operating time. One trial reported a median of 111 minutes for TLH compared with 85 minutes for LAVH.12PubMed. A prospective randomized comparison of vaginal hysterectomy, laparoscopically assisted vaginal hysterectomy, and total laparoscopic hysterectomy in women with benign uterine disease LAVH, on the other hand, tends to have higher blood loss and, in at least one comparison, a higher overall complication rate than TLH or a supracervical laparoscopic approach.13PubMed. Comparison of classic intrafascial supracervical hysterectomy with total laparoscopic and laparoscopically-assisted vaginal hysterectomy Hospital stay, cost, and long-term complication rates are generally comparable between the two. The choice often depends on surgeon training and the patient’s anatomy.
What Robotic Assistance Adds
A robotic hysterectomy follows the same surgical steps as a standard laparoscopic one, but the surgeon sits at a console and controls wristed instruments that offer a wider range of motion than straight laparoscopic tools. The robot does not operate autonomously; it translates the surgeon’s hand movements into finer, tremor-free motions inside the patient.
A large meta-analysis pooling randomized trials, prospective studies, and database studies found that the robotic and laparoscopic approaches had similar complication rates, mortality, and reoperation rates. Robotic cases showed lower conversion rates to open surgery in database studies and modestly lower blood loss in some analyses, though those differences shrank or disappeared in the higher-quality randomized trials. Hospital stays were similar in the randomized data.14PubMed Central. Robotic-assisted benign hysterectomy compared with laparoscopic, vaginal, and open surgery: a systematic review and meta-analysis
The financial picture tilts against the robot. A propensity-matched analysis of thousands of cases found that hospital costs were roughly $2,500 higher for robotic hysterectomy, with complication rates that were essentially identical to standard laparoscopy.15PubMed Central. Comparison of Robotic and Laparoscopic Hysterectomy for Benign Gynecologic Disease An experienced laparoscopic surgeon can also complete the procedure faster. One study found a mean operative time of about 111 minutes for TLH compared with 151 minutes for robotic hysterectomy performed by the same surgical team.16PubMed Central. Total laparoscopic hysterectomy versus da Vinci robotic hysterectomy: is using the robot beneficial? The robot’s greatest advantages appear in complex cases where the extra wrist articulation matters and for surgeons still building their laparoscopic skills, where the instrument control can flatten the learning curve.
When the Uterus Is Very Large
A large, fibroid-filled uterus was once considered a reason to go straight to open surgery. That thinking has shifted considerably. Studies of laparoscopic hysterectomy for uteri larger than 16 weeks’ gestational size show that the procedure is feasible and safe in experienced hands, with conversion rates linked to excessive bleeding or bladder injury rather than to uterine size alone.17PubMed Central. Laparoscopic hysterectomy for large uteri: Outcomes and techniques A prospective series of over 460 procedures found that larger uteri meant longer operating times and more blood loss, but intraoperative and postoperative complication rates did not differ significantly by uterine weight.18PubMed. Surgical outcome and complications of total laparoscopic hysterectomy for very large myomatous uteri in relation to uterine weight: a prospective study in a continuous series of 461 procedures
Surgeons sometimes shrink a large uterus before operating. A three-month course of a GnRH agonist, a hormone-suppressing medication, has been shown to reduce uterine volume by roughly a quarter, which can lower operative time and blood loss during the subsequent laparoscopic procedure.19The Journal of the American Association of Gynecologic Laparoscopists. GnRH Agonist Treatment before Total Laparoscopic Hysterectomy for Large Uteri Whether to use this strategy depends on the patient’s symptoms, the timeline for surgery, and the side effects of temporary medical menopause.
Complications Worth Knowing About
The most talked-about risk specific to laparoscopic hysterectomy is ureteral injury. The ureter runs within centimeters of the uterine artery and the cardinal ligament, and it can be accidentally cut, clipped, or burned by energy devices. In laparoscopic surgery, the points of greatest risk are near the infundibulopelvic ligament, the ovarian fossa, and where the ureter passes under the uterine artery.20PubMed Central. Ureteral Injury in Laparoscopic Gynecologic Surgery
An analysis of 31 ureteral injuries during laparoscopic hysterectomy in the Netherlands found that predisposing factors split roughly between patient anatomy (deep endometriosis, fibroids embedded in the ligaments) and surgeon-related factors like insufficient experience. In several cases, a nearby blood vessel was mistaken for the ureter, and the actual ureter was then inadvertently injured.21PubMed. Causes and prevention of laparoscopic ureter injuries: an analysis of 31 cases during laparoscopic hysterectomy in the Netherlands Thermal injuries, where heat from a bipolar or ultrasonic device damages the ureter without directly touching it, accounted for several of those cases as well.22PubMed Central. Ureter Injury in Total Laparoscopic Hysterectomy These injuries are uncommon overall, but they underline why identifying the ureter early and repeatedly checking its position matters at every stage of the procedure.
Recovery and Going Home the Same Day
Compared with open abdominal hysterectomy, a laparoscopic approach generally means less pain, a shorter hospital stay, and faster return to daily activities. A large randomized trial found that patients who had laparoscopic hysterectomy reported less pain at six weeks and had a hospital stay about a day shorter than those who had open surgery.23PubMed. The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy Open hysterectomy patients also required more days of pain medication.24PubMed. Comparison of total laparoscopic, vaginal and abdominal hysterectomy
An increasingly common practice is sending patients home the same day they have surgery. A multicenter randomized trial found that same-day discharge after laparoscopic hysterectomy was non-inferior to an overnight stay in terms of physical function at one week, and quality of life scores at one, three, and 42 days were equivalent between the two groups.25PubMed. Same-day discharge after laparoscopic hysterectomy for benign/premalignant disease: A multicentre randomised controlled trial In one protocol implementation, about 80 percent of patients went home the same day without any increase in complications or readmissions.26PubMed. Implementation of a Same-Day Discharge Protocol Following Total Laparoscopic Hysterectomy Same-day discharge is not appropriate for everyone. Patients with complicated procedures, significant blood loss, or poor pain control are kept longer. But for uncomplicated cases in healthy patients, it appears to be a safe option.27PubMed. Same-day discharge after laparoscopic hysterectomy
Pelvic Floor and Sexual Function After Surgery
A common worry is that removing the uterus will weaken the pelvic floor or change sexual sensation. Prospective data paint a more reassuring picture than many people expect. At six months after hysterectomy, women in a large cohort study reported significant improvement in pelvic floor symptoms, including urinary and bowel symptoms, regardless of whether they had laparoscopic or open surgery. Sexual function scores also improved at the six-month mark.28PubMed Central. Effects of hysterectomy on pelvic floor function and sexual function—A prospective cohort study
The longer view is slightly more nuanced. A three-year follow-up of the same cohort found that pelvic floor improvements held up, but sexual function among sexually active women showed some decline compared with baseline scores. Importantly, when the entire cohort was analyzed, including women who were not sexually active before surgery, overall sexual function remained unchanged. The surgical route, whether laparoscopic, robotic, or open, made no difference to these outcomes at three years.29PubMed Central. Pelvic floor and sexual function 3 years after hysterectomy – A prospective cohort study
Single-Incision Surgery
Some surgeons perform the entire hysterectomy through a single cut hidden inside the belly button, inserting all instruments through one multi-channel port. The cosmetic appeal is obvious: when the incision heals, there is essentially no visible scar. Early reports showed the technique is feasible, with one series of 30 patients completing the procedure with a median operative time of 100 minutes and no conversions to open surgery.30PubMed. The feasibility of scarless single-port transumbilical total laparoscopic hysterectomy: initial clinical experience
Patients who had single-port hysterectomy reported less postoperative pain at every measured time point and higher cosmetic satisfaction scores over the following weeks compared with those who had conventional multi-port surgery.31PubMed. Single-port Access Subtotal Laparoscopic Hysterectomy: A Prospective Case-Control Study The trade-off is a steeper learning curve and longer operating times, because the instruments crowd together and lose the triangulation that standard laparoscopy relies on.32PubMed Central. Single-incision total laparoscopic hysterectomy For now, single-port hysterectomy remains a niche offering, performed primarily at high-volume centers with dedicated experience in the technique.
Laparoscopic Hysterectomy in Gender-Affirming Care
Transgender men and nonbinary individuals assigned female at birth sometimes pursue hysterectomy as part of gender-affirming care. Laparoscopic hysterectomy is generally the preferred approach in this population, because it allows faster recovery, smaller scars, and preservation of structures that may be needed for future genital reconstruction.33International Journal of Impotence Research. Single center experience of laparoscopic hysteroannessiectomy and histopathological outcomes in transgender men
Long-term testosterone therapy can alter pelvic anatomy in ways that create unique surgical challenges. Tissues may become atrophic, less elastic, and more prone to tearing. The vaginal walls tend to thin, and the cervix can become more friable. Surgeons working with this population note that preoperative planning, gentle tissue handling, and customized instrumentation are especially important to reduce complications.34PubMed Central. Intraoperative complications during gender-affirming laparoscopic hysterectomy in transgender men receiving testosterone: a case series When a colpectomy (removal of the vaginal canal) is added to the hysterectomy, the technical difficulty increases substantially, and complication rates rise accordingly, though most complications tend to be minor and self-limiting.35PubMed Central. Robotic assisted hysterectomy and colpectomy as gender affirming surgery in trans men: an instructional video and perioperative considerations