Total Laparoscopic Hysterectomy (TLH)

Medically reviewed by Dr Manan Boob, MS ObGyn (Gold Medalist), DNB — Consultant Gynaecologist & Laparoscopic Surgeon

What it is

A total laparoscopic hysterectomy (TLH) is an operation to remove the entire uterus — the body of the womb together with the cervix — through three or four openings of half to one centimetre in the abdomen, rather than through one long cut.

The word “total” describes what is removed, not how big the operation is. It means the cervix comes out along with the uterus, as opposed to a subtotal hysterectomy in which the cervix is left behind. The ovaries and fallopian tubes are a separate decision altogether, and one we take with you rather than for you.

In a TLH the whole operation, including the final stitching, is done from inside using a telescope and slim instruments. The uterus is freed from its attachments, delivered out through the vagina, and the top of the vagina — the vault — is closed with absorbable sutures under laparoscopic vision. Nothing on your abdomen ends up longer than about a centimetre. The 3D laparoscopy system in our advanced laparoscopy and hysteroscopy unit helps here, because so much of this operation is about staying in the right plane close to the ureter and the bladder.

Who needs it

A hysterectomy is a big decision and it should be the answer to a specific problem, not a general tidying-up. The situations where it genuinely earns its place:

• Fibroids causing heavy bleeding or pressure symptoms, in a woman who has completed her family or in whom removing the fibroids alone is not a sensible option.
• Adenomyosis — where the lining grows into the muscle of the womb, producing painful, heavy periods that medicines have stopped controlling.
• Abnormal uterine bleeding that has not responded to tablets, a hormonal intrauterine device or hysteroscopic treatment.
• Severe endometriosis with a painful, involved uterus, usually as part of a larger operation.
• Uterine prolapse, in selected cases, together with a repair to support the vault.
• Pre-cancerous changes in the lining of the uterus, such as atypical hyperplasia, and certain early cancers.
• Chronic pelvic pain where investigation points clearly at the uterus and nothing else.

“My periods are heavy and my neighbour had her uterus removed for the same thing. Should I just get it done?” Please don’t decide that way. Heavy bleeding has many causes, and quite a few of them are treated with a tablet, a hormonal device or a twenty-minute hysteroscopy. We would rather spend one consultation and one scan finding out which you have than remove an organ you did not need to lose.

How it is done

You come to theatre fasting. Once you are asleep, a urinary catheter is passed and an instrument called a uterine manipulator is placed through the cervix — it lets us move the uterus about from below, which is what makes the keyhole approach possible at all.

A small opening is made near the navel and the abdomen is filled gently with carbon dioxide gas to create working space. The telescope goes in there, and two or three more ports are placed low on the abdomen.

The surgeon then works down each side of the uterus in a set order: the round ligament is sealed and divided, then either the tube and ovarian ligament (if the ovaries are staying) or the ovarian vessels (if they are coming out). The layer of tissue in front is opened and the bladder is pushed gently downwards off the cervix. The uterine arteries are sealed on each side — this is the step that stops the bleeding, and it is done with the ureter clearly identified.

The vagina is then opened around the cervix, following the rim of the manipulator’s cup, and the uterus is delivered out through the vagina. A large uterus may need to be reduced in size first inside a protective bag. The vaginal vault is stitched closed laparoscopically, the pelvis is washed, the gas pressure is dropped so that any bleeding point shows itself, and the small cuts are closed.

Anaesthesia, duration and hospital stay

The operation is done under general anaesthesia. You are fully asleep and will remember none of it.

A straightforward TLH takes 60 to 120 minutes. A very large uterus, dense adhesions from previous caesareans, or severe endometriosis can push that to two to three hours — and in that situation slower is safer.

Most women are admitted on the morning of surgery and go home after one to two nights. The catheter usually comes out the next morning. You will be allowed sips of water within a few hours, a light meal the same evening, and we will have you up and walking to the bathroom before you sleep. Early walking prevents clots and helps clear the gas that causes that odd shoulder ache.

Recovery

Day 1. Sore around the small cuts, a bit bloated, sometimes an ache in one shoulder tip. Regular painkillers handle it. Short walks, normal food, catheter out.

The first week. Tiredness, more than pain, is what most women notice. Light bleeding or a brownish discharge from the vagina is expected and can come and go for two to four weeks. Keep the dressings dry; showering is usually fine from day three. Do not push yourself to prove a point.

Weeks 2 to 4. Desk work is realistic. Driving once you can brake hard without flinching. Nothing heavier than a full water bottle, no squatting to scrub floors, no gym.

By six weeks. The vaginal vault has healed and life goes back to normal, including exercise and intercourse. Nothing goes into the vagina before that — no intercourse, no tampons. Call us straight away if you have a sudden gush of bright red bleeding, offensive discharge, fever, or pain that is getting worse instead of better.

Why keyhole rather than open surgery

The uterus that comes out is the same. What differs is what your body goes through on the way there.

Compared with an open hysterectomy, TLH means less blood loss, considerably less pain afterwards, a shorter hospital stay, a much lower rate of wound infection and hernia, small scars instead of one long one, and a return to normal life in two to six weeks rather than two to three months. Because the bowel is handled less and the abdomen stays sealed, things also start moving again sooner.

That said, open surgery has not been abolished, and any surgeon who tells you otherwise is overselling. A uterus that fills the abdomen, a frozen pelvis from repeated surgery, or a suspected cancer that needs a different kind of clearance may be better and safer done open. Sometimes a laparoscopic operation is converted to open partway through. That is a decision taken in your favour, not a failure.

Risks and complications

TLH is safe in experienced hands, but it is major surgery and you deserve the honest list.

• Bleeding, occasionally needing a blood transfusion.
• Injury to the bladder or ureter. Uncommon, and the reason the ureter is identified deliberately at every step. Previous caesareans and endometriosis raise this risk.
• Bowel injury, rare, more likely where adhesions are dense.
• Infection — of a port site, the urinary tract, or the vaginal vault.
• Vault haematoma, a collection of blood at the top of the vagina, which sometimes needs drainage.
• Vault dehiscence — the healed vault opening up, usually after intercourse too soon. Rare, and the reason we insist on the six-week rule.
• Conversion to open surgery, for the reasons above.
• Clots in the legs or lungs, which early walking and, where needed, blood-thinning injections are used to prevent.
• Earlier menopause, even with the ovaries retained, in a minority of women; immediate menopause if the ovaries are removed.
• Anaesthetic risks, which the anaesthetist will discuss with you separately.
• An unexpected finding on the histopathology report. Every uterus we remove is sent for examination, and occasionally the report changes the follow-up plan.

Alternatives

Medical treatment. Tranexamic acid and non-hormonal measures reduce heavy bleeding. A hormonal intrauterine device controls bleeding well in many women with adenomyosis or a normal-shaped cavity, and it can be tried for years before anyone talks about surgery.

Hysteroscopic treatment. A polyp, a submucous fibroid or a thickened lining can often be dealt with through the cervix with no abdominal cuts at all. Our simple guide to hysteroscopy explains what that involves.

Laparoscopic myomectomy, if fibroids are the problem and you want to keep your uterus — whether for fertility or simply because you would rather keep it.

Uterine artery embolisation, done by an interventional radiologist, for fibroids in selected women.

Vaginal or open hysterectomy, which remain the better choice in particular situations — a prolapsed uterus, for instance, often comes out beautifully through the vagina.

“Should I have my ovaries taken out at the same time, just to be safe?” Usually not, if you are below about 45 and there is nothing wrong with them. Healthy ovaries keep doing useful work for your bones, heart and general wellbeing long after periods stop. We remove them when there is a genuine reason — disease, a strong family history, or a specific risk we have discussed. Removing the tubes alone, however, is often sensible and costs you nothing hormonally.

What it costs

Total laparoscopic hysterectomy at Shubham Hi-Tech Hospital: ₹60,000 – ₹99,000. If both tubes and ovaries are removed at the same sitting (with BSO): ₹63,000 – ₹1,06,000. These are all-inclusive figures — surgeon’s fee, operation theatre, anaesthesia, room rent for a typical stay, medicines and routine investigations.

Please note: The figures above are indicative estimates for a typical case. The final cost depends on your individual condition, the complexity of the surgery, the room category you choose, how long you stay, and any complications that arise. Deluxe and super-deluxe rooms are charged higher. Emergency admissions and night or holiday surgery attract additional charges. These charges are subject to change without prior intimation. Please call us on +91-8668954915 for a written estimate for your own case before you decide anything.

Preparing for your surgery

• Bring every scan, blood report, biopsy result and old operation note you have. Previous caesarean records matter more than most people realise.
• List all your medicines, especially blood thinners, aspirin and diabetes tablets. Some are stopped in advance — never stop them on your own.
• If your haemoglobin is low from months of heavy bleeding, we will usually build it up with iron first, and control the bleeding medically while we do.
• Nothing to eat for six hours and nothing to drink for two hours before surgery, unless told otherwise.
• Leave jewellery, nail polish and contact lenses at home.
• Arrange one attendant to stay overnight and someone to drive you home.
• Plan six clear weeks away from heavy lifting and hard physical work, and organise help at home for the first two.
• If the decision has been troubling you, write your questions down and bring the list. Nobody has ever annoyed us by asking too much before a hysterectomy.

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A hysterectomy is one of the few operations that changes something a woman has lived with her whole adult life, and it deserves an unhurried conversation. If heavy bleeding, pain or fibroids have brought you to this page, come and discuss it with the gynaecology and laparoscopy team at Shubham Hi-Tech Hospital, Amravati — bring your reports, and we will tell you plainly whether surgery is the right answer for you or whether something smaller will do. Call +91-8668954915, get in touch here, or see all the procedures we perform.

Disclaimer: This article is for general information only and is not a substitute for professional medical advice. Please consult a qualified doctor for guidance specific to your situation.