This video demonstrates TLH with ICG and Mishra's Knot by Three Port performed at World Laparoscopy Hospital by Dr R K Mishra. 48-year old patient with diagnosed AUB. Weight 87 kg, height - 162 cm. MR examination- uterus in the forefront of the 75 x 37x50 mm. On the border of the corpus and cervix and in the cervix the area of cystic lesions and slight thickening of the cervical mucous membrane with a total dim. 37 x 19 mm - inflammatory changes. The patient qualified to remove the uterus with the fallopian tube. The procedure was carried out using the ICG illumination. An illuminated manipulator was used due to difficulties in identifying vaginal vaults and small uterine mobility, most likely after inflammation. The left side of the uterine artery was ligated by Mishra's knot.

Total Laparoscopic Hysterectomy (TLH) is one of the most advanced minimally invasive gynecological procedures performed for various uterine pathologies such as fibroids, adenomyosis, abnormal uterine bleeding, and early-stage malignancies. The integration of Indocyanine Green (ICG) fluorescence imaging and Mishra’s Knot technique using a three-port approach represents a significant evolution in surgical precision, safety, and cosmetic outcome.

At World Laparoscopy Hospital, this technique is widely practiced and taught under the guidance of Dr R K Mishra, who developed the Mishra’s Knot for safe and secure intracorporeal ligation.

Three-Port Technique in TLH

The three-port method is designed to reduce surgical trauma while maintaining optimal ergonomics and visualization.
Typical port placement includes:

• One 10 mm umbilical camera port

• Two 5 mm working ports in the lower abdomen

Advantages:

• Less postoperative pain

• Better cosmetic results

• Faster recovery

• Reduced port-related complications

Role of ICG in TLH

Indocyanine Green (ICG) fluorescence imaging enhances intraoperative visualization of vascular anatomy and tissue perfusion.

Clinical Benefits:

• Better identification of uterine vessels

• Improved ureteric safety

• Real-time perfusion assessment

• Reduced intraoperative bleeding

This is particularly useful in difficult hysterectomy cases such as previous surgeries, endometriosis, or distorted anatomy.

Mishra’s Knot in TLH

Mishra’s Knot is an advanced laparoscopic knot-tying technique used for secure pedicle ligation.

Key Features:

• Strong knot security

• Easy intracorporeal application

• Minimal suture slippage

• Useful in vascular pedicle control

It is especially valuable during:

• Uterine artery ligation

• Cardinal ligament control

• Vault closure support

Surgical Steps Overview

1. Patient positioning and anesthesia

2. Creation of pneumoperitoneum

3. Three-port placement

4. ICG dye administration and fluorescence assessment

5. Dissection of uterine pedicles

6. Uterine artery ligation using Mishra’s Knot

7. Colpotomy and specimen removal

8. Vaginal vault closure

Outcomes and Clinical Significance

Combining ICG imaging with Mishra’s Knot via a three-port TLH approach results in:

• Enhanced surgical safety

• Reduced blood loss

• Shorter operative time in expert hands

• Early patient discharge

• High patient satisfaction

Training and Global Adoption

World Laparoscopy Hospital has played a major role in training surgeons globally in advanced laparoscopic hysterectomy techniques. The structured training modules help surgeons master fluorescence-guided surgery and advanced intracorporeal suturing skills.