creation date: 2026-10-29 17:12
tags: Interventions
Total Laparoscopic Hysterectomy, Bilateral Salpingo-Oophorectomy
Background
TLH/BSO refers to a laparoscopic procedure in which the uterus, cervix, both fallopian tubes, and both ovaries are removed.
This procedure is commonly done laparoscopically but can be completed robotically. This is particularly beneficial for more challenging surgeries (eg. elevated BMI, known adhesions within the abdomen) as the robot allows for better range of motion.
Benefits & Risks
The primary benefit depends on the indication for surgery. Generally, gynecologic cancers are well treated with surgery.
The risks to counsel patients on include:
- Risk of blood loss, requiring blood transfusion
- Risk of infection both at surgical sites and at laparoscopic ports
- Risk of surgical complications requiring further surgery to manage
Relating to bilateral oophorectomy, patients who have not undergone menopause will also have symptoms associated with surgically-induced menopause, which is typically managed with estrogen replacement.
Procedure
Preparation
The patient is brought into the OR and given set up on the operating table. Set up includes:
- Anesthesia (roccoronium, fentanyl, propofol) and intubation
- Sequential compression device on lower extremities
- Positioning with stirrups
The patient is also given:
- UFH 5000 U subcut
- Ancef 2g IV
- Flagyl
A foley catheter is inserted. Then a uterine manipulator is inserted vaginally. The patient is typically placed in Trendelenburg so the bowels move away from the pelvis.
Surgery
One incision is made at the umbilicus and a trocar inserted. The abdominal pressure is measured which should be ≤7 on initial measurement. CO2 is then pumped within the peritoneal space gradually, where 15 is typically sufficient. Note that rapid inflation can lead to issues with airflow requiring anesthesia to ventilate the patient.
Further incisions are made (typically 4 more) for laparoscopic instruments.
The surgery then proceeds as followed:
- The round ligament, fallopian tube, and ovarian ligament is cut and coagulated on both sides
- The vesico-uterine space is dissected, separating the uterus from the bladder and exposing the internal space adjacent to the cervix
- The uterine vessels are cut and coagulated
- Colpotomy via cautery around the uterine manipulator’s cervical cup
- Delivery of the specimen vaginally
- Closure of the vagina via suture, typically with VLOC sutures
Hemostasis is confirmed with inspection with any bleeding coagulated. Specimens are labelled and sent for pathology, which typically takes 1 month.
Trocars are extracted and ports closed with a singular deep dermal suture and steri-strips.
Recovery
Patients recover in the PACU. Typically, a one night stay is expected although early surgery may allow for evening discharge.
Discharge instructions include:
- Do not lift anything heavy (>10 lbs) for 6 weeks
- Showing after 24 hours is fine, but no baths or sitting in water for 6 weeks
- Nothing vaginally for 6 weeks
- Do not drive while on narcotic pain medications
- Spotting is expected for 2-4 weeks, use liners/pads