BASIC INFORMATION
• Date & Time: Monday, 9 February 2026
• Lecture handout prepared from the teaching session by: Dr. R. K. Mishra
SUMMARY
This comprehensive lecture provides a detailed procedural guide for performing Total Laparoscopic Hysterectomy (TLH), covering fundamental principles, advanced techniques, and the management of complex scenarios and intraoperative complications.
The core of the discussion is a systematic, step-by-step approach to TLH, beginning with uterine manipulation using a “clock face” system to achieve predictive anatomical exposure. The lecture details the safe application of bipolar and monopolar energy, the sequence of ligamentous dissection, and the critical step of posterior broad ligament dissection for ureteric identification.
It addresses challenging cases such as very large uteri or contraindications to standard uterine manipulators, presenting the myoma screw as a viable alternative. Specific techniques for uterine artery ligation using a “no-push” needle pass and extracorporeal knotting are explained.
The lecture culminates with a focus on complication management, offering practical guidance for handling:
• Uterine artery hemorrhage
• Iatrogenic bladder injury
• Ureteric transection
Throughout the session, emphasis is placed on task analysis, disciplined practice, and sound surgical judgment as the cornerstones of safe and effective laparoscopic surgery.
KEY KNOWLEDGE POINTS
- Systematic uterine manipulation: The critical role of the uterine manipulator, guided by a clock face system, to achieve predictable anatomical exposure for dissection.
- Predictive anatomy & task analysis: Mentally mapping the surgical steps and anticipating anatomical structures—fundamental to image-guided laparoscopy.
- Energy device application: Safe use of: • Bipolar energy: coagulate to a yellow endpoint
- Monopolar scissors: activate between elastic and plastic deformation
- Harmonic scalpel: awareness of the “knocking effect”
• Ureteric safety: Opening the posterior leaf of the broad ligament to expose the ureter and skeletonize uterine vessels (key prevention step). ICG methods are discussed for complex cases.
• Uterine artery ligation: No-push technique + secure ligation using an extracorporeal knot.
• Management of large uteri: Modified entry/ports (Palmer’s point, five-port bilateral ipsilateral) + myoma screw traction.
• Vaginal vault closure: Two-layer continuous suturing; caution advised with barbed sutures due to reported fistula risk.
• Complication management: Structured management of: • uterine artery hemorrhage (EndoLoop)
• bladder perforation (immediate single-layer interrupted repair)
• ureteric transection (immediate end-to-end anastomosis over stent)
INTRODUCTION
Total laparoscopic hysterectomy (TLH) is a cornerstone of modern gynecological surgery, offering patients the advantages of minimal access surgery. The transition from open to laparoscopic techniques requires a fundamental shift in surgical philosophy—from tactile feedback to reliance on visual cues and precise pre-planned maneuvers.
The safety and efficacy of TLH depend on systematic task analysis, described here as “predictive anatomy”—mentally rehearsing each step and anticipating the location of critical structures before they are encountered.
This document outlines principles, techniques, and advanced strategies for TLH, emphasizing:
- • coordinated surgical exposure,
- • management of difficult cases, and
- • prompt, structured handling of intraoperative complications to ensure patient safety.
LEARNING OBJECTIVES
• To understand and apply the clock face system for uterine manipulation to expose pelvic ligaments and spaces systematically.
• To master predictive anatomy, task analysis, and the safe application of energy devices.
• To learn standardized techniques for uterine artery ligation, colpotomy, and secure vaginal vault closure.
• To identify indications for alternative techniques (e.g., myoma screw) and adapt port placement for very large uteri.
• To recognize and manage critical intraoperative complications (major hemorrhage, bladder injury, ureteric transection) using a structured approach.
CORE CONTENT
1. Principles of Uterine Manipulation and Predictive Anatomy
Laparoscopic surgery is analogous to a choreographed performance where every step is pre-planned. This is termed predictive anatomy, where the surgeon visualizes the anatomical field before reaching it. The uterine manipulator is the primary tool for creating predictable exposure.
1.1 The Clock Face System for Uterine Positioning
The assistant managing the uterine manipulator must position the uterus according to a clock face system:
Right-sided structures
• Uterus pushed to 9 o’clock (fundus to left psoas)
Left-sided structures
• Uterus pushed to 3 o’clock (fundus to right psoas)
Anterior dissection (bladder)
• Uterus manipulated between 5, 6, 7 o’clock
• 6 o’clock (retroverted) provides optimal exposure
Posterior dissection
• Uterus moved to 1 o’clock (left), 12 o’clock (uterosacral), 11 o’clock (right)
Colpotomy sequence
• Uterus moved sequentially through 6 → 9 → 12 → 3 o’clock as fornices are incised
2. Operative Technique and Energy Application
2.1 Adnexal Pedicle Dissection
Round ligament, fallopian tube, and ovarian ligament addressed first.
Bipolar coagulation
- • Grasp tissue; activate intermittently (≤ 3 seconds)
- • Stop when color changes white → yellow
- • Brown/black = charring → weaker seal + more thermal spread
Monopolar scissor technique
• Activate between elastic and plastic deformation (bubbling between jaws)
• Too early/late activation → bleeding
Efficiency tip
• Coagulate round ligament + tube + ovarian ligament sequentially, then introduce scissors once to cut all three.
2.2 Vesicouterine Fold and Bladder Dissection
With uterus retroverted (6 o’clock), incise vesicouterine peritoneum.
Bladder mobilization
• Sharp/blunt dissection
• Back of closed scissors = excellent blunt dissector
• Dissect caudally; separate bladder pillars to expose anterior fornix (pearly white with criss-cross vascular pattern)
• Key principle: Fat belongs to the bladder → mobilize superiorly with bladder
Precaution
• Avoid pushing down on bladder with active energy—common cause of injury.
2.3 Posterior Leaf Dissection and Ureteric Identification
Open posterior leaf to skeletonize uterine vessels and identify ureter.
• Uterus positioned at 1 o’clock (left) or 11 o’clock (right)
• Incise peritoneum
Rationale
Opening posterior leaf exposes ureter. Bleeding near an unexposed ureter + frantic hemostasis attempts → common mechanism of ureteric injury. Skeletonization is a key safety step.
Gray area
After mobilizing bladder and posterior leaf, identify an avascular space:
• Medial to anticipated ureter course
• ~2 cm superior to uterosacral ligament
This is the safe zone for uterine artery ligation.
2.4 Uterine Artery Ligation and Transection
No-push needle passage
• Needle held static, perpendicular
• Assistant moves uterus so tissue glides over needle
Extracorporeal knotting
• Sliding knot (e.g., Mishra’s knot) tied extracorporeally
• Tighten until uterine blanching confirms occlusion
• Practice routinely to build proficiency
Transection
• Transect medial to ligature
• Minor uterine-side back bleeding: ignore or gently fulgurate
2.5 Colpotomy and Vaginal Vault Closure
Colpotomy
• Monopolar hook guided by colpotomizer tip
• Stay close to cervix to preserve cuff length
Vault closure (two-layer continuous)
1. First layer: corner → midline → opposite corner; lock by passing needle through loop
2. Return layer: run back and tie to original tail
• Uterosacrals may be incorporated for apical support
Suture choice
• Braided absorbable (e.g., Vicryl) is safe and time-tested
• Caution with barbed sutures due to reported fistula risk
3. Management of Complex Cases
3.1 Hysterectomy with Myoma Screw (No Manipulator)
Indications
• Large cervical polyp
• Severe cervical stenosis
• Significant cervical laceration
Port placement
• Dedicated 5 mm port on linea alba midway between pubic symphysis and umbilicus
Screw insertion
• Into fundus between round ligaments
• One-prick rule to avoid troublesome bleeding
Manipulation
Assistant provides cranial/anteversion/retroversion/contralateral traction via screw.
Challenges
• Bladder dissection: hazardous without vaginal tenting → meticulous blunt dissection
• Colpotomy: incision may be irregular without firm guide
3.2 Hysterectomy for Very Large Uteri
Entry
• Palmer’s point when uterus extends above umbilicus
• Optical port placed epigastrically under vision
Port configuration
• Five-port bilateral ipsilateral (2 right, 2 left) for triangulation
Traction
• Myoma screw essential (manipulator ineffective)
• Place into anterior fibroid for contralateral traction
Ureteric safety
• Consider ICG or illuminated ureteric catheters (distorted anatomy)
Specimen removal
• Laparoscopic power morcellation (time-consuming)
SURGICAL PEARLS
• Coagulate all three upper pedicle ligaments first; then cut with one exchange.
• Back of a closed monopolar scissors blade is excellent for blunt bladder dissection.
• Stop bipolar at yellow to avoid charring and ensure a strong seal.
• One-prick rule for myoma screw placement.
• Keep needle static; let uterine manipulation pass tissue over it during uterine artery ligation.
• In major complications: pause hysterectomy and repair first—uterus provides traction/exposure for repair.
• During vaginal bisection/conization: primary surgeon controls traction to prevent cuff avulsion.
COMPLICATIONS AND THEIR MANAGEMENT
Intraoperative
Uterine artery hemorrhage
• Often due to “overcooking” (charring) → weak seal
• Do not chase spurter with ultrasonic device (“fountaining”)
Management
• Grasp pedicle with atraumatic grasper
• Apply EndoLoop (Roeder’s knot) at base
Bladder injury (cystotomy)
• Higher risk: adhesions, large cervical fibroids, myoma screw use
Identification
• Fill bladder retrograde with diluted methylene blue or ICG
Management
• Stop hysterectomy
• Repair single-layer, full-thickness, interrupted absorbable sutures
• Avoid continuous suture (loosening compromises whole line)
• Foley catheter drainage 7–14 days
Ureteric injury / transection
• Prevention: exposure + meticulous dissection
• If transected: stop hysterectomy; do not remove uterus (maintains traction)
Repair
• Immediate laparoscopic end-to-end anastomosis over DJ stent
• 4-0 monofilament absorbable
• First stitch: 6 o’clock (posterior), then 10 and 2 o’clock
Late postoperative
• Vaginal vault fistula: rare; reported with barbed sutures
• Vault prolapse: lower after TLH vs LAVH/NDVH (non-prolapsed uterus) due to better uterosacral preservation/incorporation
MEDICOLEGAL AND PATIENT SELECTION CONSIDERATIONS
• Identifying ureter before energy use is standard of care; failure may be considered breach.
• Surgeon must ensure team coordination (including manipulator assistant).
• Conversion to supracervical hysterectomy in hazardous dissection is sound judgment, not failure.
• Alternative techniques (myoma screw, ICG) should be clinically justified and documented.
• Skill comes from disciplined repetitive practice—not only supervised courses.
SUMMARY AND TAKE-HOME MESSAGES
• Successful TLH relies on clock-face uterine manipulation + predictive anatomy.
• Energy mastery is essential: bipolar stop at yellow; monopolar cut in elastic→plastic phase.
• Posterior leaf opening for ureter exposure is non-negotiable.
• Advanced skills (extracorporeal knots, myoma screw) expand capability in complex cases.
• Major complications are manageable with prompt recognition and structured repair—priority shifts to repair over completion.
ASSIGNMENTS
1. Train nurses on clock-face uterine manipulation positions.
2. Practice uterine artery ligation with extracorporeal knots routinely.
3. Practice port placement landmarks using the “baseball diamond” method.
4. Practice suturing/knot-tying on endo-trainer (loose wraps, proper sliding).
5. With harmonic scalpel: infero-medial traction; keep active tip away from vital structures (avoid “knocking effect”).
6. Ensure extracorporeal EndoLoop is always available in OT.
7. Study bilateral ipsilateral five-port strategy and Palmer’s point entry.
8. Review bladder and ureter repair techniques.
9. Research ICG and infrared ureteric catheters to prevent ureteric injury in TLH.
10. Issue sponsoring letters for AAGL membership to attendees.
11. Suggest attendees review TLH lecture on AAGL website using provided credentials.
MULTIPLE CHOICE QUESTIONS (MCQs)
1. To expose the left-sided adnexal structures during TLH, the uterine fundus should be positioned towards the:
a) Left psoas muscle
b) Right psoas muscle
c) Sacral promontory
d) Anterior abdominal wall
2. When using a simple bipolar device, the optimal endpoint for coagulation is when the tissue color becomes:
a) White
b) Yellow
c) Brown
d) Black
3. What is the main reason for opening the posterior leaf of the broad ligament during TLH?
a) To actively retract the ureter laterally
b) To expose the ureter and uterine vessels for safe dissection
c) To facilitate posterior colpotomy
d) To ligate the ovarian artery at its origin
4. According to the “no-push” technique for uterine artery ligation, the surgeon should:
a) Push the needle rapidly through the pedicle
b) Hold the needle static while the assistant moves the uterus onto it
c) Use a curved needle to bypass the artery
d) Apply bipolar energy before passing the needle
5. Which step becomes significantly more challenging when using a myoma screw instead of a uterine manipulator?
a) Round ligament dissection
b) Ovarian ligament coagulation
c) Separation of the bladder from the cervix
d) Identification of the fallopian tube
6. In a very large uterus extending to the epigastrium, the safest primary entry point is:
a) Supraumbilical
b) Subxiphoid
c) Palmer’s point
d) Umbilicus
7. Recommended immediate management for a briskly bleeding, retracted uterine artery pedicle:
a) Increase pneumoperitoneum to 20 mmHg
b) Apply ultrasonic device to the spurter
c) Grasp pedicle and apply an EndoLoop
d) Immediate conversion to open
8. If a ureter is completely transected intraoperatively, the correct immediate action is:
a) Complete hysterectomy then call urologist
b) Place drain and manage postoperatively
c) Stop hysterectomy and perform immediate end-to-end anastomosis
d) Remove uterus to improve exposure
9. First stitch in laparoscopic end-to-end ureteric anastomosis should be:
a) 12 o’clock stitch
b) Any anterior stitch
c) 6 o’clock stitch
d) 3 o’clock stitch
10. Preferred suture technique for iatrogenic bladder injury repair:
a) Continuous double-layer non-absorbable
b) Interrupted single-layer full-thickness absorbable
c) Continuous running locked both ends
d) Figure-of-eight serosa only
11. “Knocking effect” of Harmonic scalpel refers to:
a) Loud sound during activation
b) Sealing vessels up to 7 mm
c) Adjacent tissue damage via vibration without direct grasping
d) Knocking instruments out of surgeon’s hand
12. “One-prick rule” for myoma screw placement is critical to:
a) Ensure strong fundal grip
b) Avoid troublesome myometrial bleeding
c) Prevent uterine perforation
d) Place screw quickly
13. For optimal exposure during bladder dissection, uterus should be placed at:
a) 12 o’clock
b) 3 o’clock
c) 6 o’clock
d) 9 o’clock
14. Key advantage of TLH over NDVH in non-prolapsed uterus:
a) Shorter operating time
b) Less postoperative pain
c) Lower vault prolapse risk due to uterosacral preservation
d) Lower instrumentation cost
15. When using monopolar scissors for hemostatic cutting, energy should be activated:
a) Immediately after engaging tissue
b) After tissue is fully transected
c) Between elastic and plastic deformation
d) Only after pre-coagulation with bipolar
16. “Gray area” for safe uterine artery ligation is located:
a) Lateral to ureter, inferior to uterosacral
b) Medial to ureter course, superior to uterosacral
c) Directly over pulsating ureter
d) Within bladder pillar fibers
17. Prudent alternative to TLH in extremely dense bladder adhesions:
a) LAVH
b) Open conversion
c) Supracervical hysterectomy followed by bladder repair
d) Abandon procedure
18. Reported late complication associated with barbed sutures in vault closure:
a) Improved healing
b) Fistulization
c) Decreased postoperative pain
d) Increased vault support
19. “Fat belongs to the bladder” implies:
a) Excise all fat
b) Push fat down toward cervix
c) Mobilize fat superiorly with the bladder
d) Ignore fat as landmark
20. Recommended port configuration for very large uterus:
a) Standard four-port diamond
b) Three ports midline row
c) Five-port bilateral ipsilateral
d) Single-port umbilical
Answer Key:
1(b), 2(b), 3(b), 4(b), 5(c), 6(c), 7(c), 8(c), 9(c), 10(b), 11(c), 12(b), 13(c), 14(c), 15(c), 16(b), 17(c), 18(b), 19(c), 20(c)
MOTIVATIONAL MESSAGE FROM DR. R. K. MISHRA
Surgical mastery is not a destination but a continuous journey of refinement. It is forged in the discipline of practice, tempered by the humility to learn from every case, and perfected by the unwavering commitment to patient safety above all else. My best wishes to all of you as you pursue excellence on this noble path. May your dedication to learning be as sharp as your…
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