Hysterectomy in case of big uterus requires the insertion of an additional trocar 8-10 cm above the umbilical level for the optic.
The umbilical trocar will be used for the central instrument like midline suprapubic trocar. The two lateral suprapubic ports will be inserted at a higher level according with the dimension of the uterus.
Bilateral cutting of the round ligaments, cutting the anterior leaf and opening a window in the posterior leaf of the broad ligament are performed using the grasping forceps, the bipolar forceps and the scissors in a specular way between operator and assistant. The patient had a previous C-section: the adhesions at the level of the vesico- uterine space can make the dissection of the bladder more difficult.
The tip to use in this case is to start laterally dissecting the bladder at the level of the avascular space above the uterine artery were is easier to find the right plane. The uterine vessels are coagulated and cut. The pericervical ring connective fibers are cut and dissected down along the vaginal fornices delineated by the colpotomizer of the uterine manipulator.
The vagina is the opened using monopolar cutting current.