Predictors of conversion to open surgery in TLH for enlarged uteri: A retrospective cohort study

Aim: To identify the preoperative and intraoperative independent variables affecting the risk of conversion to laparotomy during total laparoscopic hysterectomy (TLH) in patients with large uteri.

Materials and Methods: Data from 125 patients with a uterine weight of ≥ 300 g who were scheduled for TLH between January 2020 and January 2025 were retrospectively analyzed. In addition to their standard TLH experience, surgeons were categorized based on their volume of large uterus (≥ 300 g) cases as "Highly Experienced" (≥ 100 cases) or "Moderately Experienced" (< 100 cases). Risk factors for conversion were determined using multivariate logistic regression analysis.

Results: The overall conversion rate was 10.4% (n = 13). The diameter of the largest fibroid was significantly higher in the conversion group (100 mm vs. 73 mm, p = 0.009). Multivariate logistic regression analysis revealed that while high surgeon experience significantly reduced the risk of conversion (OR: 0.24; 95% CI: 0.06 – -0.94; p = 0.027), a dominant fibroid diameter of ≥ 10 cm was the primary predictor of conversion risk (OR: 4.70; 95% CI: 1.39 – 15.87; p = 0.046). Uterine weight and BMI showed no independent association with the risk of conversion (p > 0.05). The major complication rate was recorded as 3.2%.

Conclusion: The success of TLH in large uteri is directly related to the size of the dominant fibroid and the surgeon's experience with this specific case group, rather than the total uterine weight. In preoperative assessments, it is recommended that patients with a fibroid diameter of ≥ 10 cm be operated on by high volume surgeons.