This video demonstrates Total Laparoscopic Hysterectomy by Myoma Screw Without Uterine Manipulator. In this technique, the uterus was bound from the uterine corpus and fundus like a bridle with Myoma Screw, to allow abdominal manipulation. The technique was successfully performed at the first attempt in 90% of cases. The mean application time was 30 min. The vaginal manipulator was not required in any of the cases. There were no intraoperative complications. In conclusion, this method has the advantages of not requiring any vaginal manipulator, reducing the number of people required during operation, permitting a near-maximum manipulation of the uterus in all three dimensions, and giving the control of these manipulations directly to the surgeon.

Total Laparoscopic Hysterectomy (TLH) is one of the most advanced minimally invasive procedures for removal of the uterus. Traditionally, a uterine manipulator is used to mobilize the uterus, improve visualization, and facilitate safe dissection. However, in certain clinical situations such as cervical stenosis, vaginal scarring, large fibroid uterus, or when a manipulator is unavailable, TLH can be safely performed using a myoma screw for uterine handling. This technique represents surgical innovation and skill, allowing surgeons to maintain operative efficiency while avoiding the need for vaginal instrumentation.

The procedure begins with proper patient positioning in lithotomy with steep Trendelenburg position. After establishing pneumoperitoneum, laparoscopic ports are inserted, usually one umbilical camera port and two or three accessory ports depending on surgeon preference. Initial diagnostic laparoscopy is performed to assess pelvic anatomy, uterine size, presence of adhesions, and associated pathology. Once the uterus is visualized, a myoma screw is introduced through one of the lateral ports and fixed firmly into the uterine fundus. This provides stable traction and allows the surgeon to mobilize the uterus in multiple directions similar to a uterine manipulator.

The round ligaments are first coagulated and divided bilaterally. The anterior leaf of the broad ligament is opened, and the bladder is carefully dissected downward to expose the cervicovaginal junction. Adequate bladder dissection is crucial to avoid bladder injury, especially without a manipulator to delineate the vaginal fornices. The infundibulopelvic ligaments or utero-ovarian ligaments are then coagulated and divided depending on whether ovaries are preserved or removed. Continuous traction using the myoma screw helps maintain tension and improves visualization of vital structures such as ureters.

The uterine vessels are skeletonized, coagulated, and cut close to the uterus to minimize bleeding. The myoma screw plays a key role during this step by allowing lateral and upward traction, which helps expose the vascular pedicles. Once vascular control is achieved, colpotomy is performed circumferentially using monopolar hook or advanced energy device. The uterus is then detached completely and removed either vaginally or via morcellation if required and safe.

After specimen removal, vaginal cuff closure is performed laparoscopically using intracorporeal suturing. Hemostasis is confirmed, pelvic cavity is irrigated, and ports are removed under vision. The absence of uterine manipulator does not compromise surgical outcome when proper traction is maintained using the myoma screw and when anatomical landmarks are carefully identified.

This technique offers several advantages. It avoids vaginal instrumentation, making it useful in patients with narrow vagina, virginal patients, or severe vaginal scarring. It also reduces cost by eliminating disposable manipulators. Additionally, it provides strong fundal traction which is particularly helpful in large or bulky uterus. However, the technique requires advanced laparoscopic skills, excellent anatomical knowledge, and careful bladder dissection due to lack of vaginal delineation.

In conclusion, Total Laparoscopic Hysterectomy using a myoma screw without uterine manipulator is a safe, feasible, and effective alternative technique. With proper patient selection and surgical expertise, it can achieve outcomes comparable to conventional TLH while expanding the applicability of minimally invasive gynecologic surgery. This approach highlights the evolving nature of laparoscopic surgery and the importance of innovation in overcoming procedural challenges.

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