This video demonstrates Total Laparoscopic Hysterectomy with Appendectomy by Suturing. The term 'total laparoscopic hysterectomy (TLH) with classical suture method' refers to a surgical procedure performed using only sutures and ligations with intracorporeal or extracorporeal ties, without using any laser or electronic cauterization devices during laparoscopic surgery as in total abdominal hysterectomy. It can be perform combining energy as well as suturing.

Watch this detailed video on Total Laparoscopic Hysterectomy with Appendectomy by Suturing, demonstrating advanced minimally invasive surgical techniques. This educational surgical video highlights precise laparoscopic dissection, safe appendectomy steps, and intracorporeal suturing methods performed by expert surgeons.

This step-by-step surgical video is ideal for surgeons, gynecologists, and medical professionals who want to enhance their understanding of combined laparoscopic procedures and improve suturing skills in minimally invasive surgery.

Total Laparoscopic Hysterectomy (TLH) is a minimally invasive surgical procedure in which the uterus (and often cervix) is removed entirely using laparoscopic techniques. When combined with appendectomy—removal of the appendix—this dual procedure can address gynecological disease while preventing or treating appendiceal pathology in the same surgical session. The addition of advanced suturing techniques further enhances surgical precision, hemostasis, and tissue healing.

TLH is now widely accepted as an alternative to open abdominal hysterectomy because it allows complete removal of the uterus laparoscopically, including vessel transection and vaginal vault closure.

Rationale for Combining TLH with Appendectomy

1. Preventive and Diagnostic Benefits

• Incidental appendectomy during gynecologic laparoscopy can detect hidden pathology such as chronic appendicitis or tumors.

• Studies have shown appendiceal pathology in approximately 9% of cases even when the appendix appears normal.

• Historically, incidental appendectomy has been considered safe during abdominal and pelvic surgery.

2. Single-Anesthesia Advantage

Performing both surgeries together reduces:

• Repeated anesthesia exposure

• Multiple hospital admissions

• Overall recovery time

3. Safety Profile

Some studies suggest no significant increase in complications when appendectomy is performed during TLH.
However, newer large-scale analyses show slightly higher overall complication rates and longer operative times, highlighting the importance of patient selection.

Indications

Indications for TLH

Common conditions include:

• Uterine fibroids

• Adenomyosis

• Early gynecologic malignancy

• Chronic pelvic pain

• Abnormal uterine bleeding
  These represent common reasons for TLH in large clinical series.

Indications for Concomitant Appendectomy

• Suspected appendiceal pathology

• Chronic pelvic pain evaluation

• Endometriosis near appendix

• Prophylactic removal during pelvic surgery

Role of Suturing in TLH with Appendectomy

Advanced laparoscopic suturing is essential for:

• Vaginal cuff closure

• Pedicle ligation

• Mesenteric stump closure after appendectomy

• Reconstruction and suspension techniques

Both intracorporeal and extracorporeal knotting methods are commonly used, including square knots and sliding knots.

Suture-based hysterectomy techniques have demonstrated low complication rates and early discharge in large patient series.

Surgical Technique (Step-by-Step Conceptual Approach)

1. Patient Preparation

• General anesthesia

• Lithotomy with Trendelenburg position

• Foley catheter and uterine manipulator placement

2. Port Placement

Typically includes:

• Umbilical camera port

• Two or three working ports

• Optional assistant port

Single-incision combined TLH and appendectomy is also technically possible but requires advanced expertise.

3. Total Laparoscopic Hysterectomy Steps

1. Diagnostic laparoscopy

2. Uterine ligament coagulation and transection

3. Uterine vessel ligation

4. Colpotomy creation

5. Specimen removal

6. Vaginal cuff closure using laparoscopic suturing

4. Laparoscopic Appendectomy by Suturing

Key steps include:

• Identification and mobilization of appendix

• Mesenteric vessel control (energy device or suture ligation)

• Base ligation using endoloop or intracorporeal suturing

• Division of appendix

• Stump invagination or reinforcement suturing (optional)

Advantages of Suturing-Based Approach

• Better stump security

• Reduced risk of bleeding

• Avoids excessive energy use

• Strong vaginal cuff closure

• Useful in infection or malignancy suspicion

Outcomes and Evidence

Positive Findings

• Similar blood loss and complication rates in some studies

• Short hospital stay (about 1–1.5 days in some series)

Caution Findings

• Slightly higher overall complication rate in some modern studies

• Longer operative time in combined procedures

Potential Complications

TLH Related

• Ureteric injury

• Bladder injury

• Vaginal cuff dehiscence

Appendectomy Related

• Stump leak

• Intra-abdominal abscess

• Wound infection

Despite risks, major complication rates remain relatively low overall.

Postoperative Recovery

Typical recovery includes:

• Early ambulation within 24 hours

• Discharge within 1–2 days

• Return to normal activity in 2–4 weeks

Future Perspectives

With robotic platforms and advanced suturing materials:

• Combined procedures are becoming safer

• Single-incision and scarless surgery are emerging

• Enhanced recovery protocols improving outcomes

Conclusion

Total Laparoscopic Hysterectomy with appendectomy by suturing represents an advanced minimally invasive surgical strategy. When performed in properly selected patients by experienced surgeons, it offers the benefit of treating gynecologic pathology while simultaneously addressing appendiceal disease or preventing future appendicitis. Suturing techniques play a critical role in ensuring secure closure, reducing complications, and improving long-term outcomes.