“Large Uterus, Small Ports: How Should Specimens Be Retrieved in Total Laparoscopic Hysterectomy?”

Abstract

Introduction: : Total laparoscopic hysterectomy (TLH) offers significant benefits over laparotomy, but specimen retrieval in cases of large uteri remains challenging. Multiple techniques have been described to preserve minimally invasive advantages while minimizing oncologic risks.

Objectives: To review the literature on specimen retrieval strategies for large uteri during TLH, highlighting efficacy, safety, and limitations of each approach.

Methods: A narrative review was conducted by searching PubMed and Google Scholar for studies published between 2011 and 2025 that reported specimen retrieval techniques in total laparoscopic hysterectomy (TLH). The review focused on case series and clinical reports describing methods used for uteri larger than 280–300 g or exceeding 12 weeks’ gestational size.

Results: Methods included vaginal morcellation, extracorporeal morcellation via mini-laparotomy, contained in-bag morcellation, wedge resection, and innovative approaches such as Colpo-V incision, zigzag umbilical incision, and Bakri balloon–assisted dilation. Vaginal morcellation remains widely practiced (Sinha et al.), while uncontained power morcellation has declined due to oncologic concerns. Contained morcellation and extracorporeal strategies reduce tissue dissemination but prolong operative times.

Conclusion: No single technique is universally superior. Selection should be individualized, balancing uterine size, patient anatomy, and oncologic safety. Further multicenter prospective studies are required to establish evidence-based guidelines.