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) has revolutionized gynecologic surgery by offering a minimally invasive approach for removing the uterus. Traditionally, TLH involves the use of a uterine manipulator to mobilize the uterus, providing better visualization and access during surgery. However, in certain cases, the use of a uterine manipulator may be contraindicated or unavailable. In such situations, the myoma screw technique provides an effective alternative.

What is a Myoma Screw?
A myoma screw is a surgical instrument commonly used to manipulate the uterus during laparoscopic procedures. It has a threaded tip that can be inserted into the uterine wall or fibroid, allowing the surgeon to elevate, rotate, or stabilize the uterus without the need for a uterine manipulator.

Indications
TLH using a myoma screw without a uterine manipulator is particularly useful in:

• Large or distorted uteri due to fibroids (myomas)

• Patients with vaginal stenosis or previous cervical surgeries

• Cases where insertion of a manipulator is technically difficult or risky

Step-by-Step Surgical Technique

1. Patient Preparation

   • Place the patient in a lithotomy position under general anesthesia.

   • Insert a Foley catheter to decompress the bladder.

2. Port Placement

   • Create pneumoperitoneum and insert standard laparoscopic ports:

     • Umbilical port for the camera

     • Two lateral ports for working instruments

     • Optional suprapubic port for assistance

3. Uterine Manipulation Using Myoma Screw

   • Insert the myoma screw into the fundus or a large fibroid.

   • Use it to elevate, antevert, retrovert, or rotate the uterus to improve visualization of ligaments, vessels, and surrounding structures.

4. Dissection and Mobilization

   • Incise the broad ligaments and round ligaments.

   • Identify and dissect the uterine vessels at their origin from the internal iliac artery.

   • Mobilize the bladder by careful dissection to avoid injury.

5. Uterine Removal

   • Once the uterus is fully mobilized, it is detached from the vagina.

   • Specimen retrieval can be performed via the vagina (vaginal extraction) or through a minimally extended port using morcellation if required.

6. Hemostasis and Closure

   • Ensure hemostasis of all vessels.

   • Close the vaginal cuff laparoscopically.

   • Remove ports and close the abdominal incisions.

Advantages of Using Myoma Screw Without Uterine Manipulator

• Avoids potential complications of uterine manipulators such as cervical injury or uterine perforation.

• Effective in large or distorted uteri where standard manipulators cannot be inserted.

• Maintains laparoscopic precision and visualization.

Postoperative Care

• Early mobilization and pain management are key.

• Patients usually resume normal activities within 1–2 weeks.

• Monitor for vaginal bleeding, infection, or urinary complications.

Conclusion
Total Laparoscopic Hysterectomy using a myoma screw without a uterine manipulator is a safe and effective technique for minimally invasive hysterectomy, particularly in challenging uterine anatomy. This approach combines the benefits of laparoscopic surgery with an alternative method for uterine manipulation, ensuring patient safety and optimal surgical outcomes.