https://www.laparoscopyhospital.com
This video demonstrates a Hysterectomy for Multiple Fibroid by Dr. R K Mishra at World Laparoscopy Hospital. TLH is performed for this patient. Hysterectomy is a major surgical procedure in which the uterus and possibly the ovaries, fallopian tubes, and cervix are removed.
In Total Laparoscopic Hysterectomy, the surgeon performs most of the procedure through 3 small abdominal incisions aided by long, thin surgical instruments inserted through the incisions. Your surgeon then removes the uterus through an incision made in your vagina or in the case of large fibroid morcellators are used.
Laparoscopic hysterectomy has become one of the most advanced and patient-friendly surgical approaches for the management of multiple uterine fibroids. With continuous innovation in minimal access surgery, the 3-port laparoscopic hysterectomy technique offers excellent surgical outcomes with minimal trauma. At World Laparoscopy Hospital, surgeons are trained in advanced laparoscopic techniques that focus on safety, precision, and faster patient recovery.
Multiple uterine fibroids often cause symptoms such as heavy menstrual bleeding, pelvic pain, pressure symptoms, infertility, and anemia. When conservative treatment or myomectomy is not suitable, hysterectomy becomes the definitive treatment option. The laparoscopic 3-port technique is particularly beneficial as it reduces surgical invasiveness while maintaining optimal visualization and operative control.
In laparoscopic 3-port hysterectomy, three small incisions are used—one primary port for the camera (usually at the umbilicus) and two accessory working ports. After creating pneumoperitoneum, the pelvis is carefully inspected. The uterine vessels are identified, coagulated, and divided safely using advanced energy devices. The ligaments supporting the uterus are sequentially dissected while preserving surrounding vital structures such as the ureters and bladder. The uterus containing multiple fibroids is then detached and removed, often through vaginal extraction or morcellation when appropriate.
Laparoscopic Total Hysterectomy (TLH) for a uterus enlarged by multiple fibroids is a signature procedure at World Laparoscopy Hospital (WLH). While many centers revert to open surgery when the uterus reaches a "middle size" (comparable to a 12–16 week pregnancy), the techniques developed by Dr. R.K. Mishra allow for these cases to be managed safely using only three ports.
1. The 3-Port Strategic Advantage
Traditionally, surgeons use four or even five ports for large uteri to help with bowel retraction. At WLH, the 3-port technique is prioritized to reduce post-operative pain and improve the cosmetic outcome.
-
Port 1 (10 mm): Umbilical or supra-umbilical (depending on the height of the fundus) for the 30-degree telescope.
-
Port 2 (5 mm): Left iliac fossa (lower left abdomen) for the primary surgeon’s working instrument.
-
Port 3 (5 mm): Right iliac fossa (lower right abdomen) for the secondary instrument or bipolar grasper.
By mastering ambidextrous surgery, the surgeon eliminates the need for a fourth port, using the assistant’s uterine manipulator to provide the necessary internal exposure.
2. Surgical Challenges of the "Middle-Sized" Fibroid Uterus
A uterus with multiple fibroids presents specific hurdles:
-
Limited Space: The bulk of the fibroids reduces the "airspace" (pneumoperitoneum) available to move instruments.
-
Distorted Anatomy: Fibroids can displace the ureters or the uterine arteries, making dissection risky.
-
Vascularity: Fibroid-heavy uteri often have enlarged, engorged vessels that require meticulous sealing.
3. The Step-by-Step "Mishra Technique"
A. Uterine Manipulation
The key to a 3-port success is the Cisneros or Mangeshikar Uterine Manipulator. This allows the assistant to push the uterus upward and laterally, "presenting" the ligaments to the surgeon and keeping the ureters at a safe distance.
B. The "Top-Down" Dissection
-
Ligation of Round Ligaments: Using bipolar energy or ultrasonic shears (like Harmonic), the round ligaments are divided.
-
The "Bladder Flap": The vesicouterine peritoneum is incised, and the bladder is gently pushed down. In a fibroid uterus, fibroids in the lower segment can make this step difficult; Dr. Mishra teaches "traction-countertraction" to find the correct plane.
-
Uterine Artery Control: The uterine arteries are desiccated at the level of the internal os. For a middle-sized uterus, secure ligation here is vital to prevent blood loss during the subsequent steps.
C. Vault Incision and Specimen Removal
Once the uterus is detached from the vaginal vault, a "middle-sized" uterus (too large to fit through the vagina intact) requires Morcellation.
-
In-Sieve Morcellation: At WLH, the uterus is placed in a protective bag and "sliced" into smaller strips using a mechanical morcellator or a scalpel (Vaginal Morcellation) to allow for safe removal through the vaginal canal.
4. Safety and Innovation at WLH
-
Ureteric Mapping: Before any major vessel is cut, the surgeon identifies the course of the ureter.
-
The "Rule of Halves": If a fibroid is obstructing the view, the surgeon may perform a "myomectomy-in-situ" (removing the obstructing fibroid first) to gain better access to the uterine vessels.
-
Suturing the Vault: The vaginal vault is closed using intracorporeal suturing, ensuring a strong, high-quality seal that prevents future vault prolapse.
5. Recovery Outcomes
| Metric | Traditional Open Surgery | 3-Port TLH (WLH) |
| Blood Loss | 200–500 ml | < 50 ml |
| Hospital Stay | 4–6 Days | 24–48 Hours |
| Recovery Time | 6–8 Weeks | 1–2 Weeks |
| Incision Size | 10–15 cm | 3 tiny punctures |
Conclusion
A 3-port laparoscopic hysterectomy for a middle-sized fibroid uterus is a testament to surgical skill over mechanical reliance. By utilizing advanced manipulation and the precise energy techniques taught at World Laparoscopy Hospital, patients with multiple fibroids can avoid the trauma of a large abdominal incision and enjoy a rapid return to health.