To our knowledge, this is the first TLH of a uterus of this size. Normally, we, as well as a growing number of surgeons, attempt to manage all cases of uterine fibroids via a laparoscopic approach, and we decide to convert to an open abdominal approach only if specific abdominal conditions, such as tenacious adhesions syndrome, exist that may influence the result of a minimally invasive technique. This aims to give the patient the best possible care associated with the best achievable quality of life regardless of the size of the uterus, while simultaneously respecting the protection of her body image. As already indicated in our previous work [
4], the elements that must be considered in assessing the feasibility of a laparoscopic approach for removal of large uteri are both the characteristics of the patient and the uterus anatomical relationships, without considering hypothetical limits related to the uterine weight. In this regard, in the present paper, we report the case of a patient that underwent laparoscopic hysterectomy for the removal of a 5320 g uterus without side effects and with very good compliance. A previous study by Guan X et al. in 2014 [
6] described a case of hand-assisted laparoscopic hysterectomy with the removal of a 5200 g uterus. The surgery lasted 5 h, and the patient was discharged to home the second day after surgery with an unremarkable recovery. It must be highlighted that Guan X et al. [
6] used a GelPort to allow the repetitive entry of an assistant’s hand to help in retraction and manipulation of the uterus. In any case, we believe that the procedure used by Guan X, et al. [
6] should also be considered as a mini-invasive procedure in consideration of uterus size, as the author himself pointed out very well in his paper. In 2011, Kondo et al. [
1] reported on the laparoscopic removal of a 4660 g uterus in a retrospective series that compared the laparoscopic to the laparotomic hysterectomy for large uteri over 1000 g. He showed that in selected patients, with a careful pre-operative evaluation of anatomical limits, the laparoscopic hysterectomy was successfully completed and resulted in a superior postoperative course compared with that of the laparotomic approach [
1]. Subsequently, in a series of large uteri with the largest one weighing 4500 g, Alperin et al. [
3], showed that the laparoscopic approach was feasible and that increased uterine weight was not associated with increased operative morbidity.
The procedure in our patient lasted approximately 220 min, as reported by the computer records of the operating room, where about 90 min were devoted to the total hysterectomy and the remaining time to perform the manual morcellation with the extraction of the uterus. In considering studies on laparoscopic hysterectomy for large uteri reporting that increased uterine size is associated with an increase of procedure time [
4,
7,
8], our case had an acceptable operative time. Noteworthy, in the present case the timing spent for the hysterectomy was limited, whilst the greatest time was dedicated to the extraction of the huge uterus that required also a lot of attention in performing morcellation, avoiding spillage; then, it was the extraction that influenced significantly the time of the entire operation.
Notably, as well explained by Wu KY et al. [
9] and Yazucan et al. [
10], and also the case in our patient, the trocars positioning on the basis of the uterine size was the first and valued as the most important step affecting the laparoscopic surgery outcome, in addition to the choice of instruments and the experience and the harmony of the operating team [
1,
11]. Furthermore, the techniques that we found helpful in completing the procedure through a minimally invasive approach were changing the trocars sites of the laparoscope throughout the procedure for better visualization (in fact, in the present case we started with the trocar positioned near the xiphoid process and then continued with umbilical access), and as specified by Yazucan et al. [
10] the ability to suspend from the pelvic floor the uterus through a skillful use of the uterine manipulator thus obtaining also both the best inspection of the ureter projections and a clear visualization of the vesico-uterine fold that aids to avoid potential bladder injury. Additionally, in our experience the importance of the use of the BiClamp for coagulation of the uterine vessels is relevant: such an instrument provides excellent hemostatic control allowing for good dissection based on the surgical plans. In conclusion, TLH for large uteri by experienced laparoscopists is safe and feasible if some technical strategies are strictly followed [
10]. Therefore, as demonstrated by the present case, uterine size is no longer a determinant as a final surgical decision to use laparoscopic hysterectomy. Then, if not contraindicated by the patient’s comorbidities or peculiar anatomical conditions, we believe that laparoscopic hysterectomy could be performed in the presence of large uteri without hypothetical weight limits.