Authors: Alfonso Rossetti MD, Ornella Sizzi MD.
Responsables Laparoscopic Gynecological Division, Nuova Villa Claudia Hospital, Rome, Italy.

The major difficulty in case of hysterectomy for a large, apple shaped uterus is due to the lack of lateral but also anterior and posterior spaces.
For this reason, it is quite difficult to reach the structures that must be dissected and divided. In this case we sectioned the round ligaments, the broad ligaments, the infundibulo-pelvic ligaments alternating the two lateral sides depending on where there was an available space in that particular phase.

In this way the anatomical structures are progressively freed increasing the mobilization of the uterus. During the section of the left ovarian vein there was a bleeder. The progressive coagulation of a big vessel increases the electric resistance of the superficial layers of the vessel wall while the inner ones are not yet completely coagulated.

To avoid this problem is advisable to cut the vessel starting from the more superficial layers alternating it with several bipolar coagulations.
Another demanding step was the preparation of the vesico-uterine space. A huge anterior isthmic myoma distended the vesico-uterine ligament and created thick adhesions between the bladder and the pubo-cervical fascia, that were dissected layer by layer.
The valve of the uterine manipulator delineates the vaginal fornices and pushes away the ureters allowing a safe coagulation and cut of the uterine vessels. Then the pericervical ring is dissected with cold scissors and bipolar coagulation.

The vagina is opened with monopolar hook following the movement of the manipulator’s valve.
At this point, the only difficult part of the colpotomy is the mobilization of the big uterus.
The specimen was removed via vaginal morcellation.