Total Laparoscopic Hysterectomy (TLH) has revolutionized the field of gynecologic surgery, offering a minimally invasive alternative to traditional abdominal hysterectomy. It allows surgeons to remove the uterus through small incisions, providing patients with faster recovery, reduced postoperative pain, and minimal scarring. Dr. R. K. Mishra, the world-renowned laparoscopic surgeon and Director of World Laparoscopy Hospital, has developed a systematic, step-by-step approach to performing a simple TLH safely and efficiently — especially tailored for beginners and trainees entering the world of advanced laparoscopic surgery.

Understanding the Fundamentals of TLH

Before proceeding to the surgical steps, it is vital for beginners to understand the key principles of laparoscopic hysterectomy. A TLH involves complete detachment of the uterus and cervix from the surrounding structures (uterine arteries, ligaments, and vaginal cuff) using laparoscopic instruments, followed by vaginal or morcellated removal of the specimen.
Dr. Mishra emphasizes the importance of anatomy visualization, ergonomic port placement, and precise energy application to minimize complications.

Step 1: Patient Preparation and Positioning

The patient is placed under general anesthesia in the lithotomy position with both arms tucked and legs supported in adjustable stirrups. A Foley catheter is inserted to keep the bladder empty throughout the procedure.
Dr. Mishra recommends a 15–20° Trendelenburg tilt to allow gravitational displacement of the intestines away from the pelvis, creating a clear operative field.

Key Tips:

Secure the patient properly to prevent sliding.

Use an anti-skid mattress or shoulder supports.

Confirm all equipment, light source, and insufflator are functional before incision.

Step 2: Creating Pneumoperitoneum and Port Placement

A closed or open (Hasson) technique can be used to create pneumoperitoneum using a Veress needle at the umbilicus. CO₂ insufflation is initiated, maintaining intra-abdominal pressure around 12–15 mmHg.

Port Placement (Dr. Mishra’s Technique):

10 mm umbilical port: for the laparoscope (camera).

5 mm left and right lower quadrant ports: for operative instruments such as scissors, graspers, or bipolar energy devices.

5 mm suprapubic port: for the uterine manipulator or auxiliary retraction.

Proper triangulation and ergonomically aligned ports are essential for smooth instrument handling and surgical precision.

Step 3: Pelvic Inspection and Uterine Manipulation

Once the laparoscope is inserted, a thorough inspection of the pelvis and upper abdomen is performed. The uterine manipulator helps in moving and positioning the uterus, providing exposure of the surgical planes.
Dr. Mishra stresses the importance of maintaining orientation throughout the procedure by frequently identifying key landmarks — uterus, bladder fold, round ligaments, and infundibulopelvic (IP) ligaments.

Step 4: Dissection of the Round Ligaments and Broad Ligament

Using bipolar energy or ultrasonic shears, the round ligaments on both sides are coagulated and divided. This opens up the anterior and posterior leafs of the broad ligament.
Dr. Mishra advises beginners to stay lateral during this step to avoid injury to the ureter and uterine vessels.

Pro Tip: Always visualize the ureter’s course while working in the pelvic sidewall.

Step 5: Creation of the Bladder Flap

The vesicouterine peritoneum is incised horizontally, and the bladder is gently dissected downward from the lower uterine segment and cervix.
This step is crucial for preventing bladder injury during later dissection of the uterine arteries.
Dr. Mishra recommends using gentle sweeping movements with a blunt dissector or suction tip to develop this plane.

Step 6: Uterine Artery Coagulation and Division

The uterine arteries are carefully identified at the level of the internal cervical os. Using bipolar forceps, the arteries are coagulated and then divided with laparoscopic scissors.
Dr. Mishra emphasizes the principle:

“Always coagulate before you cut.”

Adequate coagulation prevents postoperative bleeding and ensures a dry field.

Safety Check: Ensure the ureter is well away from the surgical area before sealing the vessel.

Step 7: Dissection of the Uterosacral and Cardinal Ligaments

After the uterine arteries are divided, attention is turned to the uterosacral and cardinal ligaments. These are coagulated and cut sequentially.
At this stage, the uterus becomes completely mobile, supported only by the vaginal cuff.

Step 8: Colpotomy (Opening of the Vaginal Cuff)

Using monopolar hook or harmonic scalpel, the vaginal vault is incised circumferentially at the cervicovaginal junction.
The uterus is then removed either vaginally (if small) or by in-bag morcellation if large.
Dr. Mishra highlights maintaining continuous visualization and ensuring a smoke-free field during this step to avoid inadvertent thermal injury.

Step 9: Vaginal Cuff Closure

The vaginal cuff is sutured laparoscopically using either Vicryl 1-0 or barbed suture in a continuous or interrupted fashion.
Dr. Mishra’s preferred method involves extracorporeal or intracorporeal knotting techniques that he extensively demonstrates during hands-on training sessions at World Laparoscopy Hospital.
Proper closure restores pelvic support and prevents postoperative cuff dehiscence.

Step 10: Hemostasis, Irrigation, and Port Closure

A final inspection is done to confirm hemostasis and ensure no active bleeding points remain. The pelvic cavity is irrigated with warm saline, and the fluid is aspirated.
All instruments are withdrawn under vision, pneumoperitoneum is released, and ports are closed securely.

Postoperative Care and Recovery

Patients undergoing TLH typically experience minimal pain and can ambulate within a few hours after surgery. Oral intake is resumed early, and most can be discharged within 24–48 hours.
Dr. Mishra encourages early mobilization, hydration, and deep-breathing exercises to prevent complications like DVT or atelectasis.

Learning TLH with Confidence at World Laparoscopy Hospital

For beginners, mastering TLH requires structured training, supervised practice, and repeated exposure to live surgeries. Under the mentorship of Dr. R. K. Mishra, trainees at World Laparoscopy Hospital gain both theoretical knowledge and practical confidence through hands-on training with endotrainers, virtual simulators, and real operating room sessions.
His teaching emphasizes precision, patience, and safety, ensuring every surgeon leaves with the skill and confidence to perform laparoscopic hysterectomy independently.

Conclusion

The Step-by-Step Guide to Simple TLH by Dr. R. K. Mishra stands as an essential learning tool for budding laparoscopic surgeons. By following his structured approach — from patient positioning to port closure — beginners can minimize errors, enhance efficiency, and achieve consistently safe outcomes.
Through his dedication to surgical education, Dr. Mishra continues to inspire a new generation of minimally invasive surgeons worldwide, transforming the way hysterectomies are performed and taught.