Approach to the Total Laparoscopic Hysterectomy for a Didelphys Uterus

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Procedure Summary:

  • A didelphys uterus results from incomplete fusion of Mullerian ducts, creating two uterine cavities and cervices; it represents 8.3% of all Mullerian anomalies.
  • Pre-operative imaging is crucial to identify renal anomalies, as 30% of Mullerian anomalies have renal a-genesis; accurate surgical planning is required.
  • Key surgical techniques include identifying uterus and renal anomalies, ligating uterine arteries at their origin, dissecting an adherent bladder, and performing a wider colpotomy due to double cervices.
  • Uterine artery ligation at the origin helps ensure hemostasis, while careful dissection of the adherent bladder is necessary due to previous caesarean sections.
  • To complete a total laparoscopic hysterectomy for a didelphys uterus, the vaginal cuff is closed laparoscopically using extra caporal rotor knots and interrupted sutures.

Presented By

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Dr. Brenna Swift
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Dr. Arthur Zaltz
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Dr. Carmen McCaffrey


University of Toronto

See Also

What is Total Laparoscopic Hysterectomy?

  • Total laparoscopic hysterectomy (TLH) is a minimally invasive surgical procedure to remove the uterus and cervix entirely through small incisions in the abdomen.
  • The procedure uses a laparoscope, a thin tube with a camera and light, which allows the surgeon to visualize the pelvic organs and perform the surgery with precision.
  • TLH results in less pain, faster recovery time, and reduced scarring compared to traditional open hysterectomy surgery.
  • The surgery may be performed to treat various gynecologic conditions, such as fibroids, endometriosis, abnormal uterine bleeding, and gynecologic cancers.
  • The ovaries and fallopian tubes may also be removed during the procedure if deemed necessary, which is called a total laparoscopic hysterectomy with bilateral salpingo-oophorectomy.
  • Although considered safe and effective, potential risks include bleeding, infection, and damage to surrounding organs or blood vessels.

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Video Transcript

Approach to the total laparoscopic hysterectomy for a didelphys uterus. A didelphys uterus is formed from the incomplete fusion of the Mullerian ducts leading to two uterine cavities and two cervices with a longitudinal vaginal septum. The incidence of Mullerian anomalies is 0.5 to 5% in the population with didelphys uterus representing 8.3% of all Mullerian anomalies.

Our surgical case is a 41-year-old G2P2 female with Lynch syndrome. Upon completion of childbearing, she elected to undergo a risk-reducing hysterectomy and bilateral salpingo-oophorectomy. She had a known didelphys uterus and two previous caesarean sections.

This video highlights surgical techniques to overcome unique challenges associated with a didelphys uterus. Specifically identifying the uterus and renal anomalies, ligation of uterine arteries at their origin, dissecting an adherent bladder and finally, performing a wider colpotomy due to the double cervices.

First Steps

Firstly, as renal a-genesis is present in 30% of Mullerian anomalies, pre-operative imaging to identify renal anomalies is important. In our case, the patient had an absent right kidney and right ureter which was important for accurate surgical planning.

The ureter is identified by peristalses. Lysis should be performed to follow the course of the ureter to the point where it travels under the uterine artery. This step is important to minimise the risk of ureteric injury at the time of uterine artery ligation at the cervix and colpotomy. 

Secondly, the uterine arteries are ligated at their origin for haemostasis. To begin, the most important landmark to identify is the obliterated umbilical artery as the first medial branch is the uterine artery. An equally important structure to identify is the ureter which courses below the uterine artery near the origin as the “water under the bridge”.

Tugging on the medial umbilical ligament that courses along the anterior abdominal wall helps identify the obliterated umbilical artery. Carefully dissect cranially on the medial side of the umbilical artery, the uterine artery is the first medial branch. The paravesical and pararectal spaces are then developed which share the uterine artery and cardinal ligament as a common border. 

Laparoscopic clips can be applied to ligate the uterine artery at its origin for haemostasis. These should be placed medial to the bifurcation after the course of the ureter has been identified.

Creating the Bladder Flap

Next, we’ll review the tips for creating the bladder flap as with the didelphys uterus, the lower uterine segment is wider and there’s a higher rate of previous caesarean sections. This makes the bladder more adherent to the lower uterine segment. As mentioned in this case, a patient had two previous caesarean sections.

Traction upwards on the bladder and downwards on the uterus facilitate using the laser to dissect the plane. Initially, the bladder can be approached laterally along the paravesical space. If finding the correct plane is difficult, the bladder can be retro-filled with CO2 to help delineate the plane and dissection with the laser.

The uterine artery is then skeletonised using the ligature to open the anterior and posterior leaf of the broad ligament. The ureter is seen peristalsing below. The uterine artery is coagulated medial to the ureter.

Performing the Colpotomy

Finally, we are prepared to perform the colpotomy. The ureterolysis, the ligation of the uterine artery at the origin, the bladder flap, and a large colpo probe will surround both cervices to facilitate a wider colpotomy.

Beginning with the anterior edge, the monopolar outlook is used. The incision is opened laterally and countertraction is applied to the cervix. The posterior colpotomy transects the cervix from the upper vagina. The specimen is then delivered through the vagina.

The vaginal cuff is then closed laparoscopically using extra caporal rotor knots. First, the left angle is secured taking care to avoid the bladder, reapproximate the vaginal mucosa and incorporate the uterosacral for support of the vault. The right angle is secured in the same manner.

Then, interrupted sutures are placed between to reapproximate the edges of the vaginal    cuff,taking care to include the vaginal mucosa. This completes our approach to the total laparoscopic hysterectomy for a didelphys uterus.

In summary, the didelphys uterus presents unique surgical challenges for a total laparoscopic hysterectomy. Pre-operative imaging is essential to detect renal anomalies for accurate surgical planning. Intra-operative strategies to facilitate a wider colpotomy include complete ureterolysis, ligation of uterine arteries at their origin to minimise bleeding and dissection of an adherent bladder.