Laparoscopic Hysterectomy Tlh By Dr R K Mishra
Total Laparoscopic Hysterectomy (TLH) is a minimally invasive procedure for the removal of the uterus, including the cervix, performed entirely through laparoscopic ports. This technique, pioneered and popularized by experts like Dr. R. K. Mishra, represents a significant advancement in gynecologic surgery. TLH provides smaller incisions, reduced postoperative pain, faster recovery, and superior visualization of pelvic structures compared to traditional abdominal hysterectomy.
Dr. R. K. Mishra, a pioneer in laparoscopic surgery, has refined TLH to emphasize safety, ergonomics, and reproducibility, making it suitable for both benign and selected malignant indications.
Indications
TLH is indicated for a wide range of gynecological conditions, including:
Uterine fibroids causing pain or abnormal bleeding.
Adenomyosis with refractory symptoms.
Endometriosis unresponsive to medical management.
Abnormal uterine bleeding not responsive to conservative therapy.
Pelvic organ prolapse in selected cases.
Early-stage malignancies, such as endometrial carcinoma, in appropriate candidates.
TLH is preferred in patients requiring complete uterine removal with minimal disruption to surrounding tissues and faster recovery.
Preoperative Evaluation
Clinical Assessment:
Detailed history including parity, previous surgeries, menstrual irregularities, and pelvic pain.
Physical examination to assess uterine size, mobility, and adnexal pathology.
Imaging:
Ultrasound to evaluate uterine morphology, fibroids, and endometrial thickness.
MRI for complex fibroids, adenomyosis, or suspected endometriosis.
Laboratory Tests:
Complete blood count, coagulation profile, and metabolic panel.
Preoperative tumor markers if malignancy is suspected.
Patient Counseling:
Explain risks: bleeding, infection, bladder or ureter injury, bowel injury, and vaginal cuff complications.
Discuss benefits: minimally invasive approach, faster recovery, and improved cosmesis.
Anesthesia and Patient Positioning
TLH is performed under general anesthesia with endotracheal intubation.
Dorsal lithotomy position with arms tucked.
Trendelenburg tilt (15–30 degrees) for optimal exposure of the pelvis.
A Foley catheter is inserted to decompress the bladder.
Port Placement
Dr. R. K. Mishra advocates a standard four-port technique for TLH:
Umbilical port (10–12 mm): Camera port.
Two lateral 5 mm working ports: For dissection, coagulation, and suturing.
Suprapubic 5 mm port: Optional, used for uterine manipulation or retraction.
Port placement is adjusted based on uterine size, pelvic anatomy, and adhesions from prior surgeries.
Surgical Steps
Diagnostic Laparoscopy
Initial survey of the abdominal and pelvic cavity.
Identification of adhesions, endometriotic implants, or adnexal pathology.
Adhesiolysis performed if necessary to safely access the uterus.
Uterine Manipulation
A uterine manipulator is inserted vaginally to facilitate exposure of the uterine vessels, broad ligament, and vaginal cuff.
Dissection and Vessel Ligation
Round ligaments are coagulated and transected.
Broad ligaments opened; ureters identified and carefully protected.
Uterine arteries are ligated at their origin using bipolar cautery or advanced energy devices for hemostasis.
Colpotomy
Circumferential incision around the cervix performed laparoscopically.
Uterus detached from the vaginal vault and removed through the vagina or morcellated if large.
Vaginal Cuff Closure
Performed laparoscopically using absorbable sutures.
Techniques such as Weston knot or intracorporeal suturing may be used for secure closure.
Ensures hemostasis and prevents vaginal cuff dehiscence.
Postoperative Care
Early ambulation and resumption of oral intake.
Pain control primarily with NSAIDs; opioids if required.
Foley catheter removed within 24 hours.
Discharge usually within 24–48 hours depending on procedure complexity.
Avoid heavy lifting and sexual activity for 4–6 weeks.
Advantages
Minimally invasive: Reduced pain and small incisions.
Enhanced visualization: Allows precise identification of ureters, bladder, and vessels.
Lower infection rates: Compared to open hysterectomy.
Faster recovery: Patients return to normal activities sooner.
Better cosmetic outcomes: Minimal scarring and improved patient satisfaction.
Complications
Intraoperative: Bleeding, ureteral injury, bladder injury, bowel injury.
Postoperative: Infection, vaginal cuff dehiscence, hematoma, adhesion formation.
Prevention: Careful dissection, meticulous hemostasis, and identification of pelvic structures.
Conclusion
Total Laparoscopic Hysterectomy (TLH) as performed by Dr. R. K. Mishra is a safe, effective, and reproducible minimally invasive technique for the management of a variety of gynecologic conditions.
By combining expert port placement, careful dissection, uterine manipulation, and secure vaginal cuff closure, TLH provides excellent clinical outcomes, minimal complications, and faster recovery, making it a preferred approach in modern gynecologic surgery.
Dr. R. K. Mishra’s technique emphasizes precision, safety, and efficiency, setting a benchmark for surgeons performing advanced laparoscopic hysterectomy.
Dr. R. K. Mishra, a pioneer in laparoscopic surgery, has refined TLH to emphasize safety, ergonomics, and reproducibility, making it suitable for both benign and selected malignant indications.
Indications
TLH is indicated for a wide range of gynecological conditions, including:
Uterine fibroids causing pain or abnormal bleeding.
Adenomyosis with refractory symptoms.
Endometriosis unresponsive to medical management.
Abnormal uterine bleeding not responsive to conservative therapy.
Pelvic organ prolapse in selected cases.
Early-stage malignancies, such as endometrial carcinoma, in appropriate candidates.
TLH is preferred in patients requiring complete uterine removal with minimal disruption to surrounding tissues and faster recovery.
Preoperative Evaluation
Clinical Assessment:
Detailed history including parity, previous surgeries, menstrual irregularities, and pelvic pain.
Physical examination to assess uterine size, mobility, and adnexal pathology.
Imaging:
Ultrasound to evaluate uterine morphology, fibroids, and endometrial thickness.
MRI for complex fibroids, adenomyosis, or suspected endometriosis.
Laboratory Tests:
Complete blood count, coagulation profile, and metabolic panel.
Preoperative tumor markers if malignancy is suspected.
Patient Counseling:
Explain risks: bleeding, infection, bladder or ureter injury, bowel injury, and vaginal cuff complications.
Discuss benefits: minimally invasive approach, faster recovery, and improved cosmesis.
Anesthesia and Patient Positioning
TLH is performed under general anesthesia with endotracheal intubation.
Dorsal lithotomy position with arms tucked.
Trendelenburg tilt (15–30 degrees) for optimal exposure of the pelvis.
A Foley catheter is inserted to decompress the bladder.
Port Placement
Dr. R. K. Mishra advocates a standard four-port technique for TLH:
Umbilical port (10–12 mm): Camera port.
Two lateral 5 mm working ports: For dissection, coagulation, and suturing.
Suprapubic 5 mm port: Optional, used for uterine manipulation or retraction.
Port placement is adjusted based on uterine size, pelvic anatomy, and adhesions from prior surgeries.
Surgical Steps
Diagnostic Laparoscopy
Initial survey of the abdominal and pelvic cavity.
Identification of adhesions, endometriotic implants, or adnexal pathology.
Adhesiolysis performed if necessary to safely access the uterus.
Uterine Manipulation
A uterine manipulator is inserted vaginally to facilitate exposure of the uterine vessels, broad ligament, and vaginal cuff.
Dissection and Vessel Ligation
Round ligaments are coagulated and transected.
Broad ligaments opened; ureters identified and carefully protected.
Uterine arteries are ligated at their origin using bipolar cautery or advanced energy devices for hemostasis.
Colpotomy
Circumferential incision around the cervix performed laparoscopically.
Uterus detached from the vaginal vault and removed through the vagina or morcellated if large.
Vaginal Cuff Closure
Performed laparoscopically using absorbable sutures.
Techniques such as Weston knot or intracorporeal suturing may be used for secure closure.
Ensures hemostasis and prevents vaginal cuff dehiscence.
Postoperative Care
Early ambulation and resumption of oral intake.
Pain control primarily with NSAIDs; opioids if required.
Foley catheter removed within 24 hours.
Discharge usually within 24–48 hours depending on procedure complexity.
Avoid heavy lifting and sexual activity for 4–6 weeks.
Advantages
Minimally invasive: Reduced pain and small incisions.
Enhanced visualization: Allows precise identification of ureters, bladder, and vessels.
Lower infection rates: Compared to open hysterectomy.
Faster recovery: Patients return to normal activities sooner.
Better cosmetic outcomes: Minimal scarring and improved patient satisfaction.
Complications
Intraoperative: Bleeding, ureteral injury, bladder injury, bowel injury.
Postoperative: Infection, vaginal cuff dehiscence, hematoma, adhesion formation.
Prevention: Careful dissection, meticulous hemostasis, and identification of pelvic structures.
Conclusion
Total Laparoscopic Hysterectomy (TLH) as performed by Dr. R. K. Mishra is a safe, effective, and reproducible minimally invasive technique for the management of a variety of gynecologic conditions.
By combining expert port placement, careful dissection, uterine manipulation, and secure vaginal cuff closure, TLH provides excellent clinical outcomes, minimal complications, and faster recovery, making it a preferred approach in modern gynecologic surgery.
Dr. R. K. Mishra’s technique emphasizes precision, safety, and efficiency, setting a benchmark for surgeons performing advanced laparoscopic hysterectomy.
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