This video demonstrates Total Laparoscopic Hysterectomy (TLH) performed by Dr. R K Mishra at World Laparoscopy Hospital by Mishra's Knot. There are several different types of hysterectomy, including • total hysterectomy, where both the uterus and cervix (neck of the womb) are removed. • subtotal hysterectomy, where just the uterus is removed and the cervix is not removed • hysterectomy with salpingo-oophorectomy (removal of one or both of your ovaries and fallopian tubes) at the same time. Some laparoscopic hysterectomies are done entirely by keyhole surgery. Others are done partially through your vagina (sometimes called a laparoscopic-assisted vaginal hysterectomy or LAVH).

Total Laparoscopic Hysterectomy (TLH) is a minimally invasive surgical procedure used to remove the uterus completely through laparoscopic techniques. This approach offers patients faster recovery, less post-operative pain, and minimal scarring compared to traditional open surgery. Over the years, various suturing techniques have been developed to enhance safety and efficiency during TLH, with Mishra’s Knot emerging as a significant advancement in laparoscopic suturing.

What is Mishra’s Knot?

Mishra’s Knot is a specialized laparoscopic knot-tying technique pioneered by Dr. R.K. Mishra, designed to facilitate secure and efficient suturing during complex laparoscopic procedures. This knot offers excellent tension control, reduces the risk of slippage, and ensures reliable hemostasis, which is particularly crucial during hysterectomy when vascular structures are involved.

Indications for TLH
TLH is indicated in a variety of gynecological conditions, including:

• Uterine fibroids

• Adenomyosis

• Endometrial hyperplasia

• Abnormal uterine bleeding

• Early-stage uterine cancer (select cases)

Preoperative Preparation
Before performing TLH using Mishra’s Knot, the following preparations are essential:

1. Comprehensive patient evaluation and imaging

2. Preoperative counseling regarding procedure benefits and risks

3. Bowel preparation if required

4. Prophylactic antibiotics and thromboprophylaxis

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 including a 10mm umbilical port and 5mm ancillary ports for instruments.

2. Uterine Mobilization:
   The uterus is mobilized by careful dissection of the broad ligament, round ligament, and uterine vessels.

3. Vascular Control Using Mishra’s Knot:

   • The uterine arteries are ligated laparoscopically.

   • Mishra’s Knot is employed to secure the pedicles efficiently.

   • This knot allows precise tension control, minimizing the risk of bleeding.

4. Cervical and Vaginal Cuff Management:
   After the uterus is detached, the vaginal cuff is closed using Mishra’s Knot for secure approximation and to prevent cuff dehiscence.

5. Specimen Removal:
   The uterus is extracted via the vaginal route or morcellation, depending on the size and pathology.

6. Final Inspection and Hemostasis:
   A thorough inspection of the pelvic cavity ensures hemostasis and confirms that no adjacent structures are injured.

Advantages of Mishra’s Knot in TLH

• Secure and reliable knotting

• Reduced operative time

• Minimizes intraoperative bleeding

• Easier learning curve for laparoscopic surgeons

• Improves post-operative outcomes

Postoperative Care

• Early ambulation and pain management

• Monitoring for signs of infection or bleeding

• Gradual resumption of diet and normal activities

• Follow-up to assess vaginal cuff healing

Conclusion
Total Laparoscopic Hysterectomy using Mishra’s Knot represents a significant advancement in gynecological surgery. By combining minimally invasive techniques with an efficient knot-tying method, surgeons can achieve safer operations, faster recovery, and improved patient satisfaction. This technique continues to gain popularity worldwide as a benchmark for modern laparoscopic hysterectomy.