A total laparoscopic hysterectomy (TLH) is a minimally invasive surgery that removes the entire uterus, including the cervix, through several small incisions in the abdomen rather than one large cut. A tiny camera and specialized instruments are inserted through these incisions, allowing the surgeon to operate while viewing magnified images on a screen. The uterus is detached from its supporting ligaments and blood supply, then removed through the vagina.
What “Total” Means in This Context
The word “total” refers to what gets removed, not the surgical technique. A total hysterectomy takes out both the body of the uterus and the cervix. A subtotal (also called supracervical) hysterectomy removes the uterus but leaves the cervix in place. Three randomized controlled trials comparing the two approaches found no significant differences in sexual function, urinary symptoms, or bowel symptoms afterward.
Keeping the cervix does slightly shorten operating time and reduce surgical complexity. But it comes with trade-offs: some patients continue to have cyclical bleeding until menopause, and there’s a small ongoing risk of cervical cancer. One retrospective study found that 2.2% of all cervical cancer cases originated from a retained cervical stump. Removing the cervix is particularly recommended for anyone with a history of abnormal Pap test results, pelvic pain, or endometriosis.
Separately, the ovaries and fallopian tubes may or may not be removed during a TLH. That decision depends on your age, cancer risk, and the reason for surgery. Removing the ovaries is a different procedure layered onto the hysterectomy, not part of the “total” designation.
Why Surgeons Prefer This Approach
The American College of Obstetricians and Gynecologists recommends minimally invasive hysterectomy whenever feasible, based on well-documented advantages over open abdominal surgery. Among minimally invasive options, vaginal hysterectomy is preferred when it’s possible. Laparoscopic hysterectomy is the recommended alternative when a vaginal approach isn’t indicated or feasible, such as when the surgeon needs better visibility of the pelvic anatomy or when there’s significant scarring from prior surgeries.
Compared to traditional open abdominal hysterectomy, TLH results in roughly 150 mL less blood loss on average (about 328 mL versus 471 mL in one comparative study). Hospital stays are shorter too: typically 1 to 2 days for TLH versus 2 to 3 days for the open approach. TLH patients also had no reported cases of wound infection in that study, likely because the incisions are so much smaller. The trade-off is a somewhat longer time in the operating room.
Common Reasons for the Surgery
The most frequent indications are symptomatic fibroids and abnormal uterine bleeding that hasn’t responded to other treatments. TLH is also performed for endometriosis, chronic pelvic pain, uterine prolapse, and gynecologic cancers. Your surgeon will weigh your specific condition, uterine size, surgical history, and anatomy when recommending an approach.
Large uteri were historically considered a contraindication for laparoscopic surgery, with most studies setting the cutoff at roughly the size of a 15- to 16-week pregnancy or a uterine weight over 500 grams. However, more recent evidence has shifted that thinking. Reviews of TLH performed on very large uteri found the procedure feasible and safe, leading many surgeons to conclude that uterine size alone should no longer rule out a laparoscopic approach.
What Happens During the Surgery
You’ll be under general anesthesia for the entire procedure. The surgeon makes three or four small incisions in the abdomen, each roughly 5 to 12 millimeters long, and inflates the abdominal cavity with carbon dioxide gas to create a working space. A camera is inserted through one incision, and instruments through the others.
A uterine manipulator is placed through the vagina to position the uterus during surgery. The surgeon then works through a sequence of steps: sealing and cutting the ligaments that anchor the uterus in place, separating the bladder from the lower uterine segment, and sealing the uterine blood vessels. Once the uterus is fully detached, the surgeon cuts around the top of the vagina (the vaginal fornix) to free the uterus completely.
If the uterus is small enough, it’s pulled out through the vagina intact. Larger uteri may need to be divided into smaller pieces before removal. The surgeon then closes the top of the vagina (called the vaginal cuff) with stitches placed laparoscopically, incorporating the surrounding supportive tissue layers for strength.
Complication Risks
TLH is generally safe, but the proximity of the uterus to the bladder and ureters (the tubes connecting your kidneys to your bladder) makes urinary tract injury the most closely watched complication. In a study of 126 consecutive TLH procedures, the overall rate of lower urinary tract injury was 4.0%. This included bladder injuries in 3.2% of cases and ureteral obstruction in 0.8%.
An important finding from that study: only 40% of injuries were recognized during surgery without a specific screening step (injecting dye through the bladder to check for leaks). None of the patients required additional intervention within the six-week recovery period, meaning the injuries were caught and repaired during the original surgery. Patients who needed more extensive dissection near the ureters had a significantly higher risk of injury.
Other potential complications include bleeding that requires transfusion, infection, and injury to surrounding organs. These are uncommon but worth understanding before you consent to the procedure.
Preparing for Surgery
Your surgical team will review all the medications and supplements you take. Certain changes are typical in the days before surgery: aspirin may need to be adjusted or stopped about 7 days beforehand, vitamin E and herbal supplements should be stopped 7 days prior, and anti-inflammatory pain relievers like ibuprofen or naproxen are usually stopped 2 days before. All of these can increase bleeding risk.
You’ll be told to stop eating at midnight the night before surgery. After midnight, you can typically drink clear liquids (water, black coffee, plain tea, clear juice, or sports drinks) up until 2 hours before your scheduled arrival time. No milk, creamers, or honey in your drinks. Your care team will tell you which of your regular morning medications to take with a small sip of water. If you receive different instructions from your surgeon, those take priority over general guidelines.
Recovery Timeline
Most people go home within 1 to 4 days after a laparoscopic hysterectomy. You’ll be encouraged to take a short walk the day after surgery, which helps prevent blood clots and gets your digestive system moving again. Any stitches that need removing are typically taken out 5 to 7 days after the operation.
For the first couple of weeks, expect fatigue and some abdominal discomfort, particularly around the incision sites. Shoulder pain from the carbon dioxide gas used during surgery is common in the first day or two and resolves on its own. You should avoid heavy lifting during recovery.
Returning to work depends on the physical demands of your job. If your work doesn’t involve manual labor or heavy lifting, 6 to 8 weeks is a common timeframe, though many TLH patients feel ready sooner than those who’ve had open surgery. You can start driving again once you’re comfortable wearing a seatbelt and confident you could perform an emergency stop. Full recovery, including the internal healing of the vaginal cuff, generally takes about 6 to 8 weeks.