This video demonstrates Laparoscopic Hysterectomy By Ligation of Uterine Artery by Mishra's Knot and Vault Closure by Weston Knot. In this procedure, Appendectomy was also performed. Today, lap hysterectomy is a safe and feasible technique to manage benign uterine pathology as it offers minimal postoperative discomfort, shorter hospital stay, rapid convalescence, and early return to the activities of daily living. Considerable technical advances in this procedure have occurred during the last few years. One of the best practice of performing laparoscopic hysterectomy is to ligate the uterine artery. The vascular supply of the uterus is mainly derived from the uterine and ovarian arteries. Because most blood enters the uterus through the uterine arteries, transient uterine ischemia occurs after uterine artery ligation. Bilateral uterine vessel ligation is an efficient method to obliterate the blood flow to the uterus.

Laparoscopic hysterectomy has become one of the most commonly performed minimally invasive procedures in gynecology, offering patients reduced postoperative pain, shorter hospital stays, and quicker recovery compared to traditional open surgery. When combined with other procedures, such as appendectomy, it allows surgeons to address multiple pathologies in a single surgical session, optimizing patient outcomes.

Indications
This combined procedure is indicated in patients with:

• Symptomatic uterine fibroids, adenomyosis, or abnormal uterine bleeding requiring hysterectomy.

• Coexisting appendiceal pathology, such as chronic appendicitis, appendicular cysts, or incidental appendiceal lesions identified during preoperative evaluation.

• Desire for a minimally invasive approach with faster recovery.

Preoperative Preparation

• Thorough history and physical examination.

• Ultrasound or MRI to evaluate uterine and appendiceal pathology.

• Routine blood tests, coagulation profile, and anesthesia assessment.

• Informed consent explaining the risks and benefits of combined laparoscopic procedures.

Surgical Technique

1. Patient Positioning and Port Placement

   • The patient is placed in a lithotomy position with Trendelenburg tilt.

   • Standard laparoscopic ports are inserted: typically a 10 mm umbilical port for the camera and 5 mm accessory ports in the lower abdomen.

2. Ligation of Uterine Artery

   • The uterus is mobilized, and the broad ligament is opened.

   • The uterine artery is identified at its origin from the internal iliac artery.

   • Careful dissection is performed to avoid injury to adjacent structures such as the ureter.

   • The uterine artery is ligated using clips or energy devices to reduce intraoperative bleeding.

3. Hysterectomy Procedure

   • After securing the uterine blood supply, the uterus is detached from its ligaments, including the round ligament, utero-ovarian ligament, and cardinal ligaments.

   • The vaginal cuff is then opened, and the uterus is removed through the vagina or morcellated laparoscopically if necessary.

   • Hemostasis is achieved, and the vaginal cuff is sutured laparoscopically.

4. Simultaneous Appendectomy

   • The appendix is identified and mobilized.

   • The mesoappendix is coagulated and divided, taking care to control the appendiceal artery.

   • The appendix is transected at its base and removed in an endoscopic retrieval bag.

   • The cecal stump is inspected for hemostasis and integrity.

Advantages of the Combined Procedure

• Minimally invasive approach reduces postoperative pain and hospital stay.

• Single anesthesia session reduces overall surgical risk.

• Allows treatment of multiple pathologies without additional surgeries.

• Faster return to normal activities.

Postoperative Care

• Patients are monitored for bleeding, infection, or urinary complications.

• Early ambulation and gradual diet advancement are encouraged.

• Follow-up includes wound inspection, review of pathology reports, and counseling on recovery and lifestyle modifications.

Conclusion
Laparoscopic hysterectomy with ligation of the uterine artery combined with simultaneous appendectomy is a safe and effective approach for patients with coexisting gynecological and appendiceal pathologies. With careful preoperative planning, meticulous surgical technique, and adherence to laparoscopic principles, this combined procedure offers excellent outcomes, reduced morbidity, and enhanced patient satisfaction.