{"paper_id":"cd3ae6b2-9bad-453e-9287-e5c103464de8","body_text":"Abstract\nTotal laparoscopic hysterectomy (TLH) for enlarged uteri presents a significant challenge for surgeons due to limited surgical field exposure, increasing the risk of injury to the bowel, bladder, ureters, and blood vessels. To minimize these intraoperative complications, a surgical approach known as “The Ship Theory” has been developed at our center. According to this concept, the uterus is likened to a large vessel moored within the pelvis. As its supporting ligaments (“anchors”) are progressively released, the uterus gains mobility, allowing it to migrate into the abdominal cavity. This enhanced mobility improves visualization and facilitates surgical access, enabling a safer and more effective TLH for large uteri. Using this approach, we successfully performed this procedure on a 51-year-old female patient with uterine leiomyomas and metrorrhagia. Preoperative imaging revealed a uterus measuring 189 × 158 × 148 mm. Institutional review board and ethics committee approval was obtained. The total operative time was approximately 90 min, with an estimated blood loss of less than 50 mL. The patient was discharged 48 h postoperatively without complications. This technical report demonstrates that the application of a minimally invasive surgical technique for uteri with significant spatial constraints—as outlined in “The Ship Theory\"—is not only feasible but can be successfully executed when performed in a systematic and structured manner.\nIntroduction\nThe field of minimally invasive gynecologic surgery has made significant advancements over the past three decades. One of the ongoing debates concerns the feasibility and indications for total laparoscopic hysterectomy (TLH) in cases of an enlarged uterus (, ). TLH for large uteri presents considerable challenges due to restricted surgical field exposure, increasing the risk of injury to adjacent structures such as the bowel, bladder, ureters, and blood vessels. The latter are often hypertrophied, exhibiting enhanced vascularization and vessel thickening due to increased blood supply and angiogenesis (). Additionally, laparoscopic surgery has a steep learning curve, which may lead to prolonged operative time and technical difficulties in tissue extraction ().\nA uterus is generally considered large when it extends beyond the confines of the true pelvis, typically corresponding to a weight of approximately 500 g (). Leiomyomas are the main cause of significant uterine enlargement (). Training new surgeons to perform and successfully complete such complex procedures remains a significant challenge. To address these difficulties, we have developed a structured procedural framework that enables even surgeons in training to navigate and overcome the technical obstacles associated with large uteri. In this study, supplemented by our instructional video, we aim to demonstrate how adherence to the principles of “The Ship Theory” facilitates the successful execution of a step-by-step TLH for large uteri. Within the framework of The Ship Theory, each metaphorical ‘anchoring point’ is directly mapped to a specific ligamentous or vascular attachment—round ligament, adnexal pedicles, uterine vessels, and uterosacral ligaments—such that the progressive ‘unmooring’ of the uterus conceptually mirrors, step by step, its anatomical detachment and controlled mobilization into the abdominal cavity. This structured approach mitigates the complexity of the procedure, reducing the likelihood of conversion from a minimally invasive approach to open surgery.\nCase presentation and surgical technique\nIn the context of the “Ship Theory,” the metaphor is used strictly as a pedagogical tool to simplify spatial orientation and procedural sequencing. Each “anchoring point” corresponds to a specific anatomical attachment—the round ligament, utero-ovarian ligament, uterosacral ligament, and vascular pedicles—that must be sequentially released to restore uterine mobility. “Setting sail” represents progressive mobilization of the uterus into the abdominal cavity after detachment from these structures. Thus, while metaphorical in presentation, each conceptual element of the theory directly maps to a reproducible anatomical step.\nThe patient was a 51-year-old female presenting with metrorrhagia, classified as abnormal uterine bleeding (AUB) and attributed to two uterine leiomyomas. Ultrasonographic evaluation revealed two leiomyomatous nodules measuring 130 × 130 × 120 mm (color score 2/3) and 40 × 40 × 30 mm (color score 1). The overall uterine dimensions were 189 × 158 × 148 mm. The final diagnosis was AUB secondary to leiomyomas, classified according to the FIGO system.\nInstitutional review board and ethics committee approval was obtained. TLH with bilateral adnexectomy was performed (step-by-step video demonstration attached VC1). Pneumoperitoneum was established using an open laparoscopic access technique with Hadson's trocar at the umbilical/supra-umbilical level or at Palmer's point, particularly in patients with multiple previous vertical midline incisions. Three ancillary trocars were placed along the line between the left anterior superior iliac spine and the supra-umbilical region.\nThe enlarged uterus was progressively mobilized and detached from its supporting ligaments, following the principles of the “Ship Theory.” According to this concept, the uterus is visualized as a large vessel moored within the pelvis. As its anchoring ligaments are systematically released, the uterus, akin to a ship setting sail, can migrate into the abdominal cavity. This maneuver enhances visualization and facilitates access to the lateral uterine walls, allowing precise identification of the ureter and uterine artery. The uterus was ultimately extracted through a mini-laparotomy after being enclosed in an endobag.\nBy applying the “Ship Theory” and adhering to a systematic yet straightforward surgical approach, TLH can be performed safely and effectively. The procedure consisted of the following steps:\n- 1.\nOpening of the peritoneum at the level of the round ligament and access to the retroperitoneum.\n- 2.\nLateral development of the vesico-uterine space.\n- 3.\nDissection of the pararectal and paravesical spaces.\nEarly identification and ligation of the uterine arteries at their origin\n- 4.\nIdentification, coagulation, and bilateral transection of the infundibulopelvic ligament.\n- 5.\nCoagulation and transection of the lateral uterine vessels.\n- 6.\nColpotomy and specimen retrieval via endobag-assisted mini-laparotomy.\n- 7.\nColporrhaphy and final hemostasis check.\nIn our attached video we give a practical demonstration of the surgical technique with explanation (\nSupplementary Video S1).\nTable 1 summarizes the intersection and similarity between The Ship Theory and surgical steps, and even more so between anatomical structures.\nTable 1\n| Ship theory concept | Anatomical structure/step | Surgical objective |\n|---|---|---|\n| Anchor 1—“Bow mooring” | Round ligament | Entry to retroperitoneum, exposure of pelvic sidewall |\n| Anchor 2—“Lateral tether” | Infundibulopelvic ligament or utero-ovarian ligament | Control of adnexal blood supply |\n| Anchor 3—“Central mooring” | Uterine artery and vein | Early devascularization, reduced blood loss |\n| Anchor 4—“Stern tether” | Uterosacral ligament | Complete mobilization and access to vaginal fornices |\n| Setting sail | Mobilization of uterus into abdominal cavity | Enhanced exposure and access for colpotomy |\nHow metaphor and surgical principles have created the ship theory.\nJust as a ship is freed from its docking points, the uterus must be progressively detached from its ligaments and vascular connections. This begins with peritoneal incision and round ligament transection, followed by systematic dissection of retroperitoneal spaces. With stepwise detachment, the uterus gains mobility and can be positioned strategically, enhancing exposure to lateral pelvic structures. This maneuver prevents excessive traction and reduces the risk of ureteral and vascular injury. Insufflation assists in maintaining a clear operative field, preventing excessive compression of adjacent organs by the enlarged uterus. Once fully mobilized, the uterus can be morcellated or removed via mini-laparotomy in an endobag, depending on size and patient factors.\nThe operative time was approximately 90 min, with an estimated blood loss of less than 50 mL. Postoperative hematological examinations were within normal limits, with a hemoglobin level of 10 g/dL. Pathological analysis confirmed the diagnosis of leiomyoma. The patient was discharged 48 h after surgery without complications. During follow-up, the patient reported no discomfort.\nDiscussion\nThe “Ship Theory” is a conceptual framework designed to facilitate TLH for enlarged uteri, a procedure traditionally considered technically challenging due to limited surgical field exposure and increased risk of complications. This theory provides a structured, stepwise approach to safely mobilize and extract a large uterus, minimizing the need for conversion to open surgery. The uterus, especially when significantly enlarged, is likened to a large vessel anchored in the pelvis. Similar to how a ship must be methodically freed from its moorings before setting sail, the uterus must be systematically detached from its supporting ligaments and vascular structures before it can be mobilized. Once released, it can “float” into the abdominal cavity, improving visualization and access to critical anatomical structures such as the ureters and uterine arteries.\nTLH for an enlarged uterus has consistently posed a challenge for gynecologists due to the inherent spatial constraints, which hinder mobilization and manipulation. These limitations increase the difficulty in identifying anatomical structures, thereby elevating the risk of vascular, intestinal, and ureteral injury.\nUccella et al. has designed Large Uterus Classification System (LUCS) which could predict surgical outcomes and complication rates in women undergoing TLH for large uteri. The LUCS categorizes large uteri into three types based on intraoperative findings of vascular pedicle displacement (uterine and adnexal vessels):\n- •\nType 1: No significant displacement of uterine or adnexal vascular pedicles [essentially large fundal fibroid(s) without major anatomical shift].\n- •\nType 2: Cephalad (upward) displacement of the adnexal vascular pedicles, but uterine vessels remain at approximately normal level.\n- •\nType 3: Displacement of the uterine vessels (with or without adnexal pedicle displacement), often associated with large cervical or lower-segment fibroids; more distorted anatomy.\nAuthors found type 2 and 3 uteri were independently associated with a greater risk of total complications and concluded this classification could help the surgical team anticipate technical difficulty, guide trocar placement, choice of surgical steps (for example strategies for Type 3 uteri where ureter/uterine vessel displacement is pronounced) and improve planning (\n).\nThe rationale behind our surgical approach lies precisely here in the pre-planning definition on type 2 and 3 uteri by proposing a useful surgical approach to reduce complications risks.\nVarious other strategies have been proposed to overcome the technical challenges of TLH in large uteri, including the use of mini-laparotomy-assisted TLH, in situ morcellation, and robotic assistance.\nCompared with these approaches, The Ship Theory emphasizes anatomical dissection and mobility rather than device-dependent solutions. Its primary advantage lies in its structured reproducibility and educational potential for trainees. However, unlike robotic systems, which compensate for limited pelvic space with enhanced dexterity, The Ship Theory depends entirely on systematic dissection and precise identification of landmarks, making anatomical understanding paramount.\nThe medical literature demonstrates that TLH is feasible even for uteri exceeding 6,000 g, as reported by Siedhoff et al., who currently hold the record for the largest uterus removed laparoscopically (). However, in routine clinical practice, open abdominal hysterectomy remains the preferred approach worldwide when the uterine fundus reaches the umbilical level (). Several studies have highlighted that factors such as obesity, prior abdominal surgery, and a large uterus (>500 g) were previously considered absolute contraindications for TLH (10). Twijnstra et al. reported that a uterine weight exceeding 500 g, a BMI >35, and an age >65 years are associated with an increased conversion rate to open surgery (11). Conversely, other researchers have found no correlation between uterine weight and conversion rate (12). Notably, the only factor independently associated with a reduction in complication rates for uteri >1,000 g is the minimally invasive surgical approach (13). An intriguing aspect emerging from the literature on large uteri is the concept of “surgical skills,” which encompasses a combination of im-measurable “environmental” factors related to the surgeon, operating room team, and institutional organization (11). Studies indicate that the only independent predictor of con-version to open surgery is lower surgeon experience (14). In high-volume referral centers, where surgical expertise is continuously refined, experienced surgeons are capable of overcoming technical challenges. Multiple studies confirm the efficacy of the laparoscopic approach for large uteri. However, comparisons among studies are complicated by the frequent reporting of uterine size in gestational weeks rather than weight. Additionally, different cut-off values for relative contraindications to TLH have been suggested, ranging from 250 g to 1,500 g.\nBeyond uterine size, one of the primary factors influencing the complexity of TLH for a large uterus is its lateral dimension or the presence of massive subserosal leiomyomas, both of which impede uterine manipulation and limit retroperitoneal access. Our findings support the assertion that uterine weight alone is not a predictor of conversion to open surgery. Instead, multiple authors suggest that the key determinant is the residual intra-abdominal volume (RIAP), which is influenced by factors such as anterior abdominal wall flexibility, ventilation pressure, patient positioning, proper use of uterine manipulators, uterine mobility, surgical expertise, and the preparedness of the operating room (OR) staff (15, 16).\nConsidering the impact of these factors on the laparoscopic surgeon's visibility and dexterity, several authors advocate performing these procedures in specialized referral centers, where gynecologists, anesthesiologists, and nurses can optimize their technical proficiency (17–19). We propose that the surgical team must achieve complete synchronization of movements and standardize surgical techniques. Once the learning curve for nor-mal-sized uteri is mastered, these skills can be effectively adapted for larger uteri (20).\nThe technique described is easily reproducible, but in our report it corresponds to a single application. In any case, before describing the technique, the team of surgeons applied and tested it in various situations, establishing its effectiveness.\nConclusions\nThe application of minimally invasive surgical techniques for uteri with significant spatial constraints is not an impossible task. When performed systematically, following and completing a series of simple and precise surgical micro-steps, this approach can be successfully implemented. The Ship Theory may offer a structured, reproducible method to overcome technical challenges in TLH for large uteri. It enhances surgical efficiency, reduces blood loss, and minimizes conversion rates.\nThis report however, actually represents just a proof of concept demonstrating that the “Ship Theory” framework can guide a safe and reproducible approach to TLH in cases of markedly enlarged uteri. While the findings are encouraging, they are limited to a single clinical case. Further validation through larger prospective studies is necessary to assess reproducibility, learning curve impact, and comparative safety vs. conventional approaches.\nFuture perspectives would be to validate this proof-of-concept on larger cohorts, including proposed outcome measures (conversion rate, operative time, complication rate) allowing to eventually standardize this surgical procedure.\nIn conclusion, by implementing The Ship Theory and demonstrating its generalisable applicability on a large sample, surgeons could navigate the complexities of large uterus hysterectomy in a systematic, controlled, and minimally invasive manner, much like a ship being set free from its moorings and guided safely out to sea.\nStatements\nData availability statement\nThe original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.\nEthics statement\nThe studies involving humans were approved by Institutional Review Board of Udine. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.\nAuthor contributions\nSR: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing – review & editing. GP: Formal analysis, Writing – original draft. AF: Methodology, Writing – original draft. AG: Conceptualization, Formal analysis, Writing – original draft. MA: Methodology, Writing – review & editing. SC: Data curation, Writing – review & editing. FP: Funding acquisition, Writing – review & editing. AP: Funding acquisition, Writing – review & editing. SU: Data curation, Validation, Writing – review & editing. GS: Project administration, Writing – review & editing. LD: Resources, Writing – review & editing. GV: Validation, Visualization, Writing – review & editing. SG: Investigation, Methodology, Project administration, Resources, Software, Writing – original draft.\nFunding\nThe author(s) declare that no financial support was received for the research and/or publication of this article.\nConflict of interest\nThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.\nGenerative AI statement\nThe author(s) declare that no Generative AI was used in the creation of this manuscript.\nAny alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.\nPublisher’s note\nAll claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.\nSupplementary material\nThe Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fsurg.2025.1681831/full#supplementary-material\nSupplementary Video S1The accompanying instructional video (VC1) illustrates the key operative stages of The Ship Theory technique. It highlights trocar placement, stepwise dissection of retroperitoneal spaces, early identification of uterine arteries, and visualization of the uterus “floating” into the abdominal cavity after sequential detachment. The video also demonstrates ergonomic positioning, uterine manipulation techniques, and safety checks, serving as a visual complement for surgical education.\nReferences\n1.\nFerrariMMBerlandaNMezzopaneRRagusaGCavalloMPardiG. Identifying the indications for laparoscopically assisted vaginal hysterectomy: a prospective, randomised comparison with abdominal hysterectomy in patients with symptomatic uterine fibroids. BJOG. (2000) 107(5):620–5. 10.1111/j.1471-0528.2000.tb13303.x\n2.\nSalmanliNMaherP. Laparoscopically-assisted vaginal hysterectomy for fibroid uteri weighing at least 500 grammes. Aust N Z J Obstet Gynaecol. (1999) 39(2):182–4. 10.1111/j.1479-828X.1999.tb03367.x\n3.\nUccellaSCasarinJMarconiNCromiAMorosiCGisoneBet alLaparoscopic versus open hysterectomy for benign disease in women with giant Uteri (≥1500 g): feasibility and outcomes. J Minim Invasive Gynecol. (2016) 23(6):922–7. 10.1016/j.jmig.2016.05.002\n4.\nWattiezASorianoDFiaccaventoACanisMBotchorishviliRPoulyJet alTotal laparoscopic hysterectomy for very enlarged uteri. J Am Assoc Gynecol Laparosc. (2002) 9(2):125–30. 10.1016/S1074-3804(05)60119-3\n5.\nUccellaSCromiASeratiMCasarinJSturlaDGhezziF. Laparoscopic hysterectomy in case of uteri weighing ≥1 kilogram: a series of 71 cases and review of the literature. J Minim Invasive Gynecol. (2014) 21(3):460–5. 10.1016/j.jmig.2013.08.706\n6.\nStewartEA. Uterine fibroids. Lancet. (2001) 357(9252):293–8. 10.1016/S0140-6736(00)03622-9\n7.\nUccellaSKhoRMGarzonSCasarinJZorzatoPCGhezziF. The large uterus classification system: a prospective observational study. BJOG. (2021) 128(9):1526–33. 10.1111/1471-0528.16753\n8.\nSiedhoffMTLouieMMisalMMoulderJK. Total laparoscopic hysterectomy and bilateral salpingo-oophorectomy for a 6095-g myomatous uterus in a patient of the Jehovah’s witness faith. J Minim Invasive Gynecol. (2019) 26(1):25–8. 10.1016/j.jmig.2018.02.018\n9.\nAartsJWNieboerTEJohnsonNTavenderEGarryRMolBWet alSurgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. (2015) 2015(8):CD003677. 10.1002/14651858.CD003677.pub5\n10.\nKluiversKBHendriksJCMolBWBongersMYBremerGLde VetHCet alQuality of life and surgical outcome after total laparoscopic hysterectomy versus total abdominal hysterectomy for benign disease: a randomized, controlled trial. J Minim Invasive Gynecol. (2007) 14(2):145–52. 10.1016/j.jmig.2006.08.009\n11.\nTwijnstraARBlikkendaalMDvan ZwetEWJansenFW. Clinical relevance of conversion rate and its evaluation in laparoscopic hysterectomy. J Minim Invasive Gynecol. (2013) 20(1):64–72. 10.1016/j.jmig.2012.09.006\n12.\nAlperinMKivnickSPoonKY. Outpatient laparoscopic hysterectomy for large uteri. J Minim Invasive Gynecol. (2012) 19(6):689–94. 10.1016/j.jmig.2012.06.007\n13.\nUccellaSMorosiCMarconiNArrigoAGisoneBCasarinJet alLaparoscopic versus open hysterectomy for benign disease in Uteri weighing >1 kg: a retrospective analysis on 258 patients. J Minim Invasive Gynecol. (2018) 25(1):62–9. 10.1016/j.jmig.2017.07.005\n14.\nCianciSGueli AllettiSRumoloVRosatiARossittoCCosentinoFet alTotal laparoscopic hysterectomy for enlarged uteri: factors associated with the rate of conversion to open surgery. J Obstet Gynaecol. (2019) 39(6):805–10. 10.1080/01443615.2019.1575342\n15.\nLouieMStrasslePDMoulderJKDizonAMSchiffLDCareyET. Uterine weight and complications after abdominal, laparoscopic, and vaginal hys-terectomy. Am J Obstet Gynecol. (2018) 219(5):480.e1–e8. 10.1016/j.ajog.2018.06.015\n16.\nKrentelHDe WildeRL. Factors for a successful laparoscopic hysterectomy in very large Uteri. Case Rep Med. (2017) 2017:1637472. 10.1155/2017/1637472\n17.\nBretschneiderCEFrazzini PadillaPDasDJelovsekJEUngerCA. The impact of surgeon volume on perioperative adverse events in women undergoing minimally invasive hysterectomy for the large uterus. Am J Obstet Gynecol. (2018) 219(5):490.e1–e8. 10.1016/j.ajog.2018.09.003\n18.\nBirkmeyerJDStukelTASiewersAEGoodneyPPWennbergDELucasFL. Surgeon volume and operative mortality in the United States. N Engl J Med. (2003) 349(22):2117–27. 10.1056/NEJMsa035205\n19.\nVreeFECohenSLChavanNEinarssonJI. The impact of surgeon volume on perioperative outcomes in hysterectomy. JSLS. (2014) 18(2):174–81. 10.4293/108680813X13753907291594\n20.\nMcGurkLOliverROdejinmiF. Laparoscopic supracervical hysterectomy for the larger uterus (>500 g): a case series and literature review. Arch Gynecol Obstet. (2017) 295(2):397–405. 10.1007/s00404-016-4237-0\nSummary\nKeywords\nhysterectomy, minimally invasive surgery, fibroid uterus, enlarged uteri, laparoscopy\nCitation\nRestaino S, Pellecchia G, Finelli A, Gioè A, Arcieri M, Cianci S, Paparcura F, Poli A, Uccella S, Scambia G, Driul L, Vizzielli G and Gueli Alletti S (2025) A systematic approach to laparoscopic hysterectomy for enlarged uteri: The Ship Theory. Front. Surg. 12:1681831. doi: 10.3389/fsurg.2025.1681831\nReceived\n07 August 2025\nRevised\n17 November 2025\nAccepted\n19 November 2025\nPublished\n02 December 2025\nVolume\n12 - 2025\nEdited by\nVito Andrea Capozzi, University Hospital of Parma, Italy\nReviewed by\nGiorgio Bogani, National Cancer Institute Foundation (IRCCS), Italy\nSusumu Fukahori, University of South Florida, United States\nUpdates\nCopyright\n© 2025 Restaino, Pellecchia, Finelli, Gioè, Arcieri, Cianci, Paparcura, Poli, Uccella, Scambia, Driul, Vizzielli and Gueli Alletti.\nThis is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.\n*Correspondence: Stefano Restaino restaino.stefano@gmail.com\nDisclaimer\nAll claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.","source_license":"CC0","license_restricted":false}