Large cervical uterine leiomyoma represent a serious technical challenge in case of hysterectomy. Distortion of the pelvic anatomy, compression of the urinary tract organs, and limited ability to mobilise the uterus make the laparoscopic approach difficult.  This surgical video presents a total laparoscopic hysterectomy (TLH) for a large cervical leiomyoma causing menorrhagia and anemia.

A 47-year-old G3P0 lady, with a background of secondary infertility, presented with menorrhagia, anemia (Hb= 10.6) and an immobile 20-week-sized uterus. Ultrasound scan showed a bulky uterus (201 X 83 X 74 mm) with multiple fibroids, the largest being located in the lower part of the uterus and measuring 102 mm. Her creatinine level was normal, as well as her LDH (200). An embolization of the uterine arteries was suggested to the patient but declined, and the option of a TLH was chosen. The necessity of a morcellation was explained to the patient, including the potential complications. To further assess the anatomy and decrease the risk of incidental finding of a sarcoma, a pelvic MRI was organized. The largest fibroid in the cervix measured 13.2 x 10.9 cm and demonstrated signs of myxoid degeneration without any locally aggressive features to raise the possibility of uterine sarcoma.

Preparation of the patient included oral iron therapy, autologous blood banking of 2 units and GnRH analogs for 2 months.

On examination under anaesthesia, a large posterior cervical fibroid expanding the posterior vaginal wall pushed the cervix anteriorly and superiorly, cephalad to the pubic symphysis. The markedly displaced cervix rendered the uterine cannulation difficult, and the manipulation limited. Laparoscopic examination showed that the cervical fibroid occupied the whole pelvic cavity, expanding retroperitoneally over the pelvic side walls, and into the rectovaginal space.

The lack of mobility of this difficult fibroid caused a major challenge.

After dividing the upper pedicles of the uterus, bladder dissection was carried out cautiously in the context of very distorted anatomy. Bilateral uterine arteries were carefully searched, thoroughly dissected and ligated at their origin with LigaClips. During the dissection, there was a superficial damage to the left ureter involving the adventitia and the external muscularis. No stent was inserted. The uterus was morcellated with a harmonic hook, to allow the extraction through the vagina and the final weight was close to 1 kg. The patient made an uneventful postoperative recovery and the post-operative urinary tract ultrasound was normal without signs of dilation.