Feasibility of myomatous tissue extraction in laparoscopic surgery by contained in – bag morcellation: A retrospective single arm study

Disseminated peritoneal leiomyoma: a diagnostic dilemma

Disseminated peritoneal leiomyomatosis (DPL) is a rare and benign clinical entity. It is also known as leiomyomatosis peritonealis disseminata (LPD). Here, we report and discuss a case of a primiparous woman in her early 40s who presented with heavy, prolonged, painful menses and heaviness in her lower abdomen. She underwent a laparoscopic myomectomy for a fibroid uterus, 12 months ago for similar complaints. On workup, she was diagnosed with DPL. We performed a total abdominal hysterectomy with bilateral salpingectomy, low anterior resection with stapled colorectal anastomosis and excision of peritoneal tumour deposits in consortium with the gastrosurgery team. Her postoperative period was uneventful, and the patient was discharged on postop day 6. Her histopathology report was consistent with leiomyoma; the follow-up period was uneventful.

Management of Uterine Fibroids and Sarcomas: The Palermo Position Paper

BACKGROUND

Uterine fibroids are benign monoclonal tumors originating from the smooth muscle cells of the myometrium, constituting the most prevalent pathology within the female genital tract. Uterine sarcomas, although rare, still represent a diagnostic challenge and should be managed in centers with adequate expertise in gynecological oncology.

OBJECTIVES

This article is aimed to summarize and discuss cutting-edge elements about the diagnosis and management of uterine fibroids and sarcomas.

METHODS

This paper is a report of the lectures presented in an expert meeting about uterine fibroids and sarcomas held in Palermo in February 2023.

OUTCOME

Overall, the combination of novel molecular pathways may help combine biomarkers and expert ultrasound for the differential diagnosis of uterine fibroids and sarcomas. On the one hand, molecular and cellular maps of uterine fibroids and matched myometrium may enhance our understanding of tumor development compared to histologic analysis and whole tissue transcriptomics, and support the development of minimally invasive treatment strategies; on the other hand, ultrasound imaging allows in most of the cases a proper mapping the fibroids and to differentiate between benign and malignant lesions, which need appropriate management.

CONCLUSIONS AND OUTLOOK

The choice of uterine fibroid management, including pharmacological approaches, surgical treatment, or other strategies, such as high-intensity focused ultrasound (HIFU), should be carefully considered, taking into account the characteristics of the patient and reproductive prognosis.

Contained Power Morcellation in Laparoscopic Uterine Myoma Surgeries: A Brief Review

Uterine fibromas are the most common benign uterine tumors. Although the majority of leiomyomas remain asymptomatic, they can cause serious clinical problems, including abnormal uterine bleeding, pelvic pain, and infertility, which require effective gynecological intervention. Depending on the symptoms as well as patients' preferences, various treatment options are available, such as medical therapy, non-invasive procedures, and surgical methods. Regardless of the extent of the surgery, the preferred option is the laparoscopic approach. To reduce the risk of spreading occult malignancy and myometrial cells associated with fragmentation of the specimen before its removal from the peritoneal cavity, special systems for laparoscopic contained morcellation have been developed. The aim of this review is to present the state-of-the-art contained morcellation. Different types of available retrieval bags are demonstrated. The advantages and difficulties associated with contained morcellation are described. The impact of retrieval bag usage on the course of surgery, as well as the effects of the learning curve, are discussed. The role of contained morcellation in the overall strategy to optimize patient safety is highlighted.

Risk of leakage with a new detachable multi-hard-port containment system for power morcellation during gynecologic laparoscopy: An in vitro study

BACKGROUND

Laparoscopic surgery has been a milestone for minimally invasive surgeries. But safe removal of large uterine tissue is a challenge for minimally invasive procedures, and there still exists concern about the dissemination of benign or occult malignant uterine tissue during the use of the morcellator. Different tissue containment systems have been used in laparoscopic power morcellation. However, a risk of leakage still exists in clinical practice. In this study, we aimed to evaluate leakage and tissue dissemination associated with a new detachable multi-hard-port containment system for tissue removal during laparoscopic myomectomy morcellation.

METHODS

Beef tongue specimens were stained with methylene blue solution and morcellated in a plastic trainer box under laparoscopic guidance. The morcellation test in vitro conditions comprised two different containment systems to simulate laparoscopic power morcellation, specifically a polyurethane bag with two pipes (control group) and a detachable multi-hard-port containment system (experimental group). Insufflation pressure was set at 14 mmHg. Three methods are used to detect the leakage The procedure times were recorded. Thirty trials were performed using a multi-port approach and the two tissue containment systems.

RESULTS

The leakage rate was 0.03% (n = 30) for the experimental group and 26.6% (n = 30) for the control group (p < 0.005). Morcellation time was significantly shorter in the experimental group than in the control group (p < 0.001). Median bag introduction time was shorter in the experimental group than in the control group; however, removal time differences were not significant.

CONCLUSIONS

This study quantified the low leakage rate during morcellation and the improved convenience of operation provided by a new tissue containment system.

The Future of Minimal-Access Myoma Surgery with In-Bag Contained Morcellation

Contained electromechanical morcellation has emerged as a safety approach for laparoscopic myomatous tissue retrieval. This retrospective single-center analysis evaluated the bag deployment practicability and safety of electromechanical in-bag morcellation when used for big surgical benign specimens. The main age of patients was 39.3 years (range 21 to 71); 804 myomectomies, 242 supracervical hysterectomies, 73 total hysterectomies, and 1 retroperitoneal tumor extirpation were performed. A total of 78.7% of specimens weighed more than 250 g (n = 881) and 9% more than 1000 g. The largest specimens, weighing 2933 g, 3183 g, and 4780 g, required two bags for complete morcellation. Neither difficulties nor complications related to bag manipulation were recorded. Small bag puncture was detected in two cases, but peritoneal washing cytology was free of debris. One retroperitoneal angioleiomyomatosis and three malignancies were detected in histology (leiomyosarcoma = 2; sarcoma = 1); therefore, patients underwent radical surgery. All patients were disease-free at 3 years follow-up, but one patient presented multiple abdominal metastases of the leiomyosarcoma in the third year; she refused subsequent surgery and was lost from follow-up. This large series demonstrates that laparoscopic bag morcellation is a safe and comfortable method to remove large and giant uterine tumors. Bag manipulation takes only a few minutes, and perforations rarely occur and are easy to detect intraoperatively. This technique did not result in the spread of debris during myoma surgery, potentially avoiding the additional risk of parasitic fibroma or peritoneal sarcoma.

Mechanical and leakage integrity testing considerations for evaluating the performance of tissue containment systems

Tissue containment systems (TCS) are medical devices that may be used during morcellation procedures during minimally invasive laparoscopic surgery. TCS are not new devices but their use as a potential mitigation for the spread of occult malignancy during laparoscopic power morcellation of fibroids and/or the uterus has been the subject of interest following reports of upstaging of previously undetected sarcoma in women who underwent a laparoscopic hysterectomy. Development of standardized test methods and acceptance criteria to evaluate the safety and performance of these devices will speed development, allowing for more devices to benefit patients. As a part of this study, a series of preclinical experimental bench test methods were developed to evaluate the mechanical and leakage performance of TCS that may be used in power morcellation procedures. Experimental tests were developed to evaluate mechanical integrity, e.g., tensile, burst, puncture, and penetration strengths for the TCS, and leakage integrity, e.g., dye and microbiological leakage (both acting as surrogates for blood and cancer cells) through the TCS. In addition, to evaluate both mechanical integrity and leakage integrity as a combined methodology, partial puncture and dye leakage was conducted on the TCS to evaluate the potential for leakage due to partial damage caused by surgical tools. Samples from 7 different TCSs were subjected to preclinical bench testing to evaluate leakage and mechanical performance. The performance of the TCSs varied significantly between different brands. The leakage pressure of the TCS varied between 26 and > 1293 mmHg for the 7 TCS brands. Similarly, the tensile force to failure, burst pressure, and puncture force varied between 14 and 80 MPa, 2 and 78 psi, and 2.5 N and 47 N, respectively. The mechanical failure and leakage performance of the TCS were different for homogeneous and composite TCSs. The test methods reported in this study may facilitate the development and regulatory review of these devices, may help compare TCS performance between devices, and increase provider and patient accessibility to improved tissue containment technologies.

The incidence of unexpected uterine malignancies in hysterectomies carried out for benign indications

PURPOSE

The aim of the present study was to evaluate the incidence of unexpected uterine malignancies in patients undergoing hysterectomy for benign indications and to evaluate their clinical characteristics.

METHODS

We conducted a retrospective review of patients who underwent benign hysterectomy in the Department of Gynecology, the First Hospital of Shanxi Medical University from January 2015 to December 2020. The clinical data of these patients were retrieved and collected.

RESULTS

Their median age was 49.8 years (31-82 years). The mean parity was 1.86 ± 2.54. Their mean BMI was 27.5 ± 7.6 kg/m2. 42.90% were (2438/5683) postmenopausal. The benign indications of procedure were as follows: symptomatic uterine leiomyomas 2218/5683 (39.02%), pelvic organ prolapse 1406/5683 (24.74%), symptomatic endometriosis or adenomyosis 1132/5683 (19.91%), and 927/5683 (16.31%) to treat other benign conditions such as abnormal uterine bleeding, infection, polyps, and endometrial hyperplasia without atypia. In minimally invasive surgery subgroups, 1560/2621 (59.52%) specimens were removed by in-bag manual morcellation through vaginal cuff. The mean operative time of minimally invasive surgery with in-bag morcellation was shorter than abdominal hysterectomy (96.75 ± 35.7 vs. 140 ± 32.6, P < .001), and the estimated blood loss was also less than abdominal hysterectomy (47.35 ± 42.3 vs. 170 ± 60.4, P < .001). A total of 19/5683 (0.33%) unexpected uterine malignancies were recorded, of which 14/5683 (0.26%) were unexpected endometrial carcinomas and 5/5683 (0.08%) were unexpected uterine sarcomas.

CONCLUSION

Preoperative examination in the context of benign hysterectomy must be undertaken with care, and patients should be educated about the very slight possibility of a malignant diagnosis.

To Laparoscopically Preserve Fertility in Intraabdominal Giant Myoma with Application of Contained In-Bag Morcellation: Mission Impossible?

A technical video was produced to demonstrate in step-by-step fashion a multiple contained myomectomy of a 20 × 30 cm giant myoma and seven additional fibroids found in the same patient, which required two different types of specimen retrieval bags for the electronic power morcellation. This complete surgical procedure included leiomyomata enucleation, contained in-bag electronic power morcellation, uterine reconstruction and the application of an adhesion prophylactic medical product.

Total surgical time in laparoscopic supracervical hysterectomy with laparoscopic in-bag-morcellation compared to laparoscopic supracervical hysterectomy with uncontained morcellation

Background

A possible solution to the problem of cell dissemination through laparoscopic uncontained morcellation during laparoscopic supracervical hysterectomy (LASH) is the use of laparoscopic in-bag morcellation. One criticism regarding the use of in-bag morcellation is the additional surgical time associated with this procedure.

Objectives

In this retrospective study we compared the total surgical time in LASH with laparoscopic in-bag morcellation (107 cases from 2016-2018) and LASH with uncontained morcellation (47 cases from 2015-2017).

Materials and Methods

All surgeries were performed in the same department of minimally invasive gynaecological surgery by a total of three experienced surgeons for the indication of bleeding disorder and / or dysmenorrhea.

Main outcome measures

We measured and compared total surgical time, surgical outcome, blood loss and complications in LASH with in-bag morcellation and with uncontained morcellation.

Results

Total surgical time in both procedures do not show a significant difference. Considering the learning curve in laparoscopic bag use, the total surgical time in LASH with laparoscopic in-bag morcellation is shorter than total surgical time in LASH with uncontained morcellation. Laparoscopic in-bag morcellation consumes time for bag use and handling, but saves time as it eliminates the need for meticulous sampling of lost tissue fragments and the complex lavage of the peritoneal cavity after morcellation. There is no difference between both groups in terms of blood loss, complications and surgical results.

Conclusion/What is new?

We conclude that LASH with in-bag morcellation is not related to additional surgical time when compared to LASH with uncontained morcellation.

Endobag use in laparoscopic gynecological surgeries: a systematic review

PURPOSE

The purpose of this systematic review was to assess the characteristics of endobags present in the market, the weight of specimen removed, complications of the operations and time required for in-bag morcellation in women undergoing laparoscopic gynecologic surgeries.

MATERIAL AND METHODS

We performed a systematic review, including prospective and retrospective studies, with or without randomized allocation of the patients, using endobags in laparoscopic gynecologic surgeries. We extracted data about study design, type and price of bag used, type of surgical procedure, specimen weight, mean time for morcellation and for total surgical procedure, complications.

RESULTS

We included 11 studies, including a total of 1160 patients, in which the investigators used MorSafe, Endocatch II autosuture, More-Cell-Safe, Endocatch, EcoSac and LapBag. A wide range of specimens were morcellated with the largest successfully morcellated specimen weighing 2314 gr. Only half of the studies comparing uncontained and contained morcellation found a significant increase of total operative time. Finally, the number of complications was not increased when endobag was used.

CONCLUSION

According to our systematic review, in-bag (contained) morcellation can be considered as a safe and unexpensive option, associated with a very low number of complications, even with large specimens.

Leiomyomatosis peritonealis dissemianata five years after laparoscopic uterine myomectomy: A case report

Introduction

Leiomyomatosis peritonealis disseminata (LPD) is a rare disease that can be challenging to diagnose. In this report, we present a case of LPD arising 5 years after laparoscopic uterine myomectomy using a power morcellator.

Presentation of case

A 32-year-old woman was admitted to our hospital with complaints of vaginal bleeding and abdominal discomfort. Five years previously, she had undergone laparoscopic uterine myomectomy using a power morcellator. Pelvic ultrasonography and magnetic resonance imaging demonstrated multiple pelvic tumors closely attached to peritoneum with no indication of malignancy. An exploratory laparotomy revealed multiple sites of leiomyomatosis in the peritoneum, especially on the parietal peritoneum at the port site of the previous laparoscopic surgery. We surgically removed all visible tumors and performed a total hysterectomy. Histologic examination confirmed the diagnosis of LPD.

Discussion

The use of a power morcellator without in-bag containment system might have played a role in the pathogenesis of LPD in our case. Ultrasonography, computed tomography, and MRI are among the most effective to distinguish between leiomyomas and other solid tumors in the pelvis, but they are not of great help in the differential diagnosis of malignancies.

Conclusion

The physicians need to combine medical history, clinical findings, imaging techniques and histopathological examination to establish a correct diagnosis of LPD. The application of containment bags in the setting of power morcellation should be considered to reduce the risk of developing LPD. The optimal intervention strategy should be chosen according to the particular features of each patient.

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Leiomyomatosis peritonealis disseminata (LPD) is a rare disease that can be challenging to diagnose.

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The physician should suspect LPD when the woman has a history of hysterectomy or myomectomy, particularly if a power morcellator was used.

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Ultrasonography, computed tomography, and MRI are among the most effective to distinguish between leiomyomas and other solid tumors in the pelvis, but they are not of great help in the differential diagnosis of malignancies.

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Tumor markers such as CEA, CA19-9 and CA-125 seem not to be useful for the differential diagnosis, since LPD are sometimes associated with elevated levels of these markers.

Complete Laparoscopic Removal and Staging of a Large Ovarian Malignancy: A Case Report

BACKGROUND Advances in minimally invasive surgery are essential for the improvement of patient care, overall health care efficiency, and total cost reductions. Morcellation, the technique used in the present case, is often used to aid minimally invasive laparoscopic procedures, whereby larger tissue specimens are broken down and divided to be removed via smaller incisions. Morcellation has become controversial in the medical community owing to the risk of the procedure spreading an occult malignancy. CASE REPORT A 47-year-old woman with obesity presented with right-sided pelvic pain and suspicion of ovarian torsion. The patient experienced severe acute pain and was taken to the operating room for laparoscopy to remove the left-sided adnexal mass seen on imaging. During surgery, there was no evidence of torsion, and the mass was perfused. During removal of the entire tumor, blunt instruments were utilized for in-bag manual morcellation to avoid spillage of the contents of the bag, which were then sent for frozen section analysis, and a diagnosis of adenocarcinoma of the ovary was made. Once the tumor was removed, a board-certified gynecologic oncologist was consulted to assist with the remainder of the procedure. Following this, the ovarian cancer staging procedure was able to be completed laparoscopically. CONCLUSIONS This technique of in-bag manual morcellation using blunt instruments allows laparoscopic procedures to be performed on large tissue specimens with potential malignancies without spreading cancerous tissue, overcoming the associated risks of dissemination of malignancy. This technique is therefore more beneficial to patients.

Leiomyomatosis peritonealis disseminata mimicking peritoneal carcinomatosis 13 years after laparoscopic uterine myomectomy: A case report

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Leiomyomatosis peritonealis disseminata (LPD) is a rare clinical condition.

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It is challenging to diagnose because its clinical features mimic other conditions.

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LPD often mimics peritoneal carcinomatosis or metastatic lesions.

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LPD should be considered in women with disseminated intraabdominal or pelvic tumors.

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A history of gynecologic surgery, if present, may offer a pointer to the diagnosis.

Introduction

Leiomyomatosis peritonealis disseminata (LPD) is a rare clinical condition that can be challenging to diagnose because its clinical features mimic other conditions. We present a case of LPD mimicking peritoneal carcinomatosis 13 years after laparoscopic uterine myomectomy using a power morcellator. The aim of this paper is to report a rare case which surgeons can learn from and to provide more clinical information for further studies to investigate LPD.

Presentation of Case

A 49-year-old woman was referred to us because sonography revealed abnormal abdominal and pelvic nodules. Thirteen years previously, she had undergone laparoscopic uterine myomectomy using a power morcellator. An exploratory laparotomy revealed nodules on the peritoneum, greater omentum, intestinal mesentery, and terminal ileum. We surgically removed all visible nodules and performed bilateral salpingo-oophorectomy. LPD was confirmed based on the morphology and immunohistochemistry results.

Discussion

Diagnosing LPD preoperatively may be difficult because its clinical manifestations resemble peritoneal carcinomatosis or metastatic lesions. Abdominal pain due to diffuse tumor growth is a common manifestation. LPD degenerating into malignancy is rare, but possible. The probable etiological factors, clinical manifestations, and treatment options which may aid when dealing with LPD have been described in this report.

Conclusion

LPD should be considered in women, particularly those with a history of gynecologic surgery presenting with disseminated intraabdominal or pelvic tumors.

Comparison of the Number of Spindle Cells in Peritoneal Washings between Laparoscopic Myomectomy with Morcellation and Open Myomectomy without Morcellation

STUDY OBJECTIVE

This study evaluated peritoneal washings for the detection of spindle cells (SCs) in laparoscopic and open myomectomies.

DESIGN

Prospective, nonrandomized clinical trial.

SETTING

An academic tertiary referral center.

PATIENTS

Women suspected of having benign uterine myoma undergoing laparoscopic or open myomectomy from October 2016 to April 2018.

INTERVENTIONS

Washing of the peritoneal cavity to detect SCs was performed twice during the laparoscopic myomectomy. The first washing was after the closure of the myometrial incision and before morcellation. The second one was performed after morcellation. The procedure was also performed once during the open myomectomy, after the completion of the myomectomy and the closure of the incision. After a peritoneal washing with 200 mL normal saline, 30 mL liquid was collected and sent to the laboratory for SC detection. Surgical parameters such as operating time, mean change in serum hemoglobin level, complications, length of hospital stay, and readmission were compared between the 2 groups.

MEASUREMENTS AND MAIN RESULTS

A total of 150 participants were included in the analysis: 78 in the laparoscopic group and 72 in the open myomectomy group. After morcellation, the incidence of SCs was 2.6% (n = 2) and 6.9% (n = 5) in the laparoscopic and open myomectomy groups, respectively (p = .204).

CONCLUSION

SCs were observed in both the laparoscopic and open myomectomy groups. Thus, morcellation alone could not be the cause for SC dissemination, which might also be triggered by the manipulation of myoma(s).

Safety of Minimally Invasive Tissue Extraction in Myoma Management: A Systematic Review

OBJECTIVE

This review seeks to establish the incidence of adverse outcomes associated with minimally invasive tissue extraction at the time of surgical procedures for myomas.

DATA SOURCES

Articles published in the following databases without date restrictions: PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews and Trials. Search was conducted on March 25, 2020.

METHODS OF STUDY SELECTION

Included studies evaluated minimally invasive surgical procedures for uterine myomas involving morcellation. This review did not consider studies of nonuterine tissue morcellation, studies involving uterine procedures other than hysterectomy or myomectomy, studies involving morcellation of known malignancies, nor studies concerning hysteroscopic myomectomy. A total of 695 studies were reviewed, with 185 studies included for analysis.

TABULATION, INTEGRATION, AND RESULTS

The following variables were extracted: patient demographics, study type, morcellation technique, and adverse outcome category. Adverse outcomes included prolonged operative time, morcellation time, blood loss, direct injury from a morcellator, dissemination of tissue (benign or malignant), and disruption of the pathologic specimen.

CONCLUSION

Complications related to morcellation are rare; however, there is a great need for higher quality studies to evaluate associated adverse outcomes.

Italian consensus conference on management of uterine sarcomas on behalf of S.I.G.O. (Societa' italiana di Ginecologia E Ostetricia)

BACKGROUND

Uterine sarcomas are very rare tumours with different histotypes, molecular features and clinical outcomes; therefore, it is difficult to carry out prospective clinical trials, and this often results in heterogeneous management of patients in the clinical practice.

AIM

We planned to set up an Italian consensus conference on these diseases in order to provide recommendations on treatments and quality of care in our country.

RESULTS

Early-stage uterine sarcomas are managed by hysterectomy + bilateral salpingo-oophorectomy according to menopausal status and histology; lymphadenectomy is not indicated in patients without bulky nodes, and morcellation must be avoided. The postoperative management is represented by observation, even though chemotherapy can be considered in some high-risk patients. In early-stage low-grade endometrial stromal sarcoma and adenosarcomas without sarcomatous overgrowth, hormonal adjuvant treatment can be offered based on hormone receptor expression. In selected cases, external beam radiotherapy ± brachytherapy can be considered to increase local control only. Patients with advanced disease involving the abdomen can be offered primary chemotherapy (or hormonal therapy in the case of low-grade endometrial stromal sarcoma and adenosarcoma without sarcomatous overgrowth), even if potentially resectable in the absence of residual disease in order to test the chemosensitivity (or hormonosensitivity); debulking surgery can be considered in patients with clinical and radiological response. Chemotherapy is based on anthracyclines ± ifosfamide or dacarbazine. Palliative radiotherapy can be offered for symptom control, and stereotactic radiotherapy can be used for up to five isolated metastatic lesions.

CONCLUSIONS

Treatment of uterine sarcoma should be centralised at referral centres and managed in a multidisciplinary setting.

Unexpected tumor-to-tumor metastasis of synovial sarcoma within leiomyoma: A case report and literature review

A tumor metastasis within another tumor is known as tumor-to-tumor metastasis (TTM). We report a 43-year-old woman who presented with hypermenorrhea and an abdominal mass. She had history of a soft tissue tumor on her left ankle at 38 years of age. Laboratory data showed slight elevation of CA125 and no other abnormal findings and magnetic resonance imaging revealed a circumscribed margin mass in the uterine fundus. We diagnosed the mass as benign leiomyoma and performed total laparoscopic hysterectomy. Postoperative pathological examination revealed TTM of synovial sarcoma within the uterine leiomyoma. A database search identified 29 cases of TTM within uterine leiomyoma. The donor tumor was mostly breast cancer (in 23 cases). To the best of our knowledge, this is the first report of a sarcoma TTM to a uterine leiomyoma. Despite the difficulty of preoperative diagnosis, TTM should be considered during the treatment approach for a patient with leiomyoma and a history of malignant tumors.

Laparoscopic total hysterectomy still not routinely chosen Operative description and available instruments

Hysterectomy is the most common gynecological surgical intervention; therefore, there are many technical variations in different healthcare systems around the world. We aimed to review, step by step, the technique of laparoscopic hysterectomy as well as to present the available variety of surgical instruments impartially so that the operative team can decide in an informed manner the model and characteristics of the equipment used. The surgical technique is presented based on the experience of the authors, focusing mainly on intraoperative recommendation and suggestions. Advantages and disadvantages of the available instruments are also extensively detailed. Surgical positioning, as well as inserting the uterine manipulator are essential steps. The open technique is used to create pneumoperitoneum. The utero-ovarian ligament or the infundibulopelvic ligament is identified, coagulated and cut. The round ligament is incised, entering the space between the two layers of the broad ligament and advancing caudally in this space, which, if correctly identified, should be avascular. The uterine vessels located on the posterior sheet of the broad ligament are dissected and coagulated. The vaginal wall is sectioned with the help of the manipulator's cap, making it easier to expose the insertion line of the vagina on the cervix. The uterus is removed through the vagina or through a trans-parietal incision. Thereafter, the vagina is sutured using separate Vicryl sutures. Between 2011 and 2016, laparoscopic hysterectomy had an increasing trend all over Europe. With a reported percentage of 3%, Romania ranks last in hysterectomies performed laparoscopically. The laparoscopic approach offers the advantages of minimal invasiveness: less pain, faster recovery and early social reintegration; therefore, this trend of improvement should become more accepted.