Total Laparoscopic Intrafascial Hysterectomy

Bladder and ureteral injuries are associated with several types of hysterectomies performed laparoscopically. Subtotal hysterectomy is said to cause fewer complications and provide better pelvic support by preserving the uterosacral and cardinal ligaments, but there are also arguments against it. A new technique, total laparoscopic intrafascial hysterectomy (TLIH) has all the benefits of total and subtotal hysterectomies, but fewer complications. Conventionally, uterosacral ligaments are cut at or just below their junction with the cervix, and the remaining vagina and cardinal ligaments are cut at the same level. With TLIH, using a uterine manipulator and colpotomizer, the incision is made at a much higher level. The cervix is circumcised while preserving the entire uterosacral and cardinal ligaments and full length of the vagina, except in cases of malignancy or severe pelvic endometriosis. The ureter is mobilized farther from the cervix. A longer vagina and excellent pelvic support can be achieved with maximum preservation of the vagina and pelvic supporting structures. A modified McCall culdoplasty and reinforcement of the cardinal ligaments are done, and the vaginal cuff is closed with everted mattress sutures either vertically or transversely. Less granulation tissue is formed on the vaginal vault and postoperative leukorrhea or postcoital vaginal bleeding is reduced. Moschcowitz culdoplasty or high McCall culdoplasty can be done at the same time to correct or prevent an enterocele or prolapsed vagina.