Total Laparoscopic Hysterectomy (TLH) has become one of the most advanced and preferred minimally invasive procedures for the management of various benign and malignant gynecological conditions. Traditionally, uterine manipulators are widely used during TLH to improve uterine mobility, delineate vaginal fornices, and facilitate safer dissection. However, in selected cases, a uterine manipulator may not be feasible due to cervical stenosis, distorted anatomy, vaginal narrowing, large fibroid uterus, or malignancy concerns. In such situations, the use of a myoma screw offers an effective alternative for uterine manipulation and traction.

Performing TLH using a myoma screw without a uterine manipulator is a safe, cost-effective, and technically efficient technique that provides excellent uterine control while avoiding the potential complications associated with manipulator insertion. This approach is especially valuable in difficult pelvic surgeries where optimal exposure and precise tissue handling are required.

Indications

Total Laparoscopic Hysterectomy using a myoma screw without a uterine manipulator can be performed in patients with:

• Symptomatic uterine fibroids
• Adenomyosis
• Abnormal uterine bleeding
• Chronic pelvic pain
• Endometriosis
• Large bulky uterus
• Cervical stenosis
• Previous pelvic surgeries
• Obesity
• Narrow vagina
• Early-stage gynecological malignancies in selected cases

Advantages of Myoma Screw Technique

The use of a myoma screw instead of a uterine manipulator provides several advantages:

Better Uterine Traction

The myoma screw offers firm and controlled traction of the uterus in multiple directions, facilitating precise dissection during surgery.

Reduced Instrumentation Cost

Avoiding disposable uterine manipulators significantly reduces the overall procedural cost, making the surgery more economical.

Useful in Difficult Anatomy

In cases where insertion of a uterine manipulator is difficult or impossible, the myoma screw becomes an excellent alternative.

Minimal Vaginal Manipulation

The technique avoids excessive vaginal instrumentation and may reduce vaginal trauma.

Improved Surgical Ergonomics

Direct traction through the abdominal port allows better visualization of pelvic structures and easier identification of tissue planes.

Surgical Technique

Patient Position and Port Placement

The patient is placed in a lithotomy position under general anesthesia. After creating pneumoperitoneum, laparoscopic ports are inserted according to standard TLH protocol. Usually, a 10 mm umbilical camera port and three accessory ports are used.

Introduction of Myoma Screw

A myoma screw is inserted through one of the lateral ports and fixed firmly into the uterine fundus. The screw acts as a dynamic handle to manipulate the uterus in different directions throughout the procedure.

Dissection of Round Ligaments

The round ligaments are coagulated and divided bilaterally using bipolar energy or advanced vessel sealing devices. This opens the broad ligament and facilitates access to pelvic spaces.

Bladder Dissection

The vesicouterine peritoneum is incised, and the bladder is carefully dissected downward from the cervix and upper vagina to avoid bladder injury.

Skeletonization of Uterine Vessels

The uterine vessels are identified, coagulated, and divided close to the uterus. Continuous traction using the myoma screw helps expose the vascular pedicles clearly.

Colpotomy

Circumferential colpotomy is performed laparoscopically using monopolar energy. In the absence of a uterine manipulator cup, careful anatomical identification of the cervicovaginal junction is essential.

Specimen Removal

The uterus is removed vaginally or through morcellation when necessary, depending on uterine size and pathology.

Vaginal Vault Closure

The vaginal cuff is sutured laparoscopically using delayed absorbable sutures. Hemostasis is confirmed before completion of the procedure.

Challenges of Surgery Without Uterine Manipulator

Although the technique is highly effective, certain challenges require advanced laparoscopic expertise:

• Identification of vaginal fornices may be more difficult
• Colpotomy requires careful anatomical orientation
• Exposure in deep pelvis can be technically demanding
• Surgeon experience plays a major role in procedural safety

Despite these challenges, skilled laparoscopic surgeons can perform TLH safely and efficiently using a myoma screw alone.

Safety Considerations

Several important precautions should be followed:

• Secure fixation of the myoma screw is essential to prevent slippage
• Excessive traction should be avoided to prevent uterine tissue tearing
• Continuous visualization of ureters is necessary during vessel dissection
• Proper bladder mobilization reduces urinary tract injury risk

Clinical Significance

The technique of Total Laparoscopic Hysterectomy by myoma screw without uterine manipulator demonstrates the evolution of minimally invasive gynecologic surgery toward simplified and resource-efficient approaches. It is particularly beneficial in low-resource settings and in complex anatomical situations where conventional manipulators cannot be utilized.

This method highlights the importance of advanced laparoscopic skills, anatomical knowledge, and innovative surgical strategies to ensure patient safety and excellent surgical outcomes.

Conclusion

Total Laparoscopic Hysterectomy using a myoma screw without a uterine manipulator is a feasible, safe, and effective minimally invasive technique. It provides excellent uterine control, reduces procedural cost, and offers a practical solution in challenging surgical scenarios. With proper surgical expertise and careful anatomical dissection, this approach can achieve outstanding operative outcomes while maintaining all the benefits of laparoscopic surgery, including minimal pain, faster recovery, shorter hospital stay, and improved patient satisfaction.