This video demonstrates TLH with ICG and Mishra's Knot by Three Port performed at World Laparoscopy Hospital by Dr. R K Mishra. A 48-year-old patient with a diagnosis of AUB. Weight 87 kg, height - 162 cm. MR examination- uterus in the forefront of the 75 x 37x50 mm. On the border of the corpus and cervix and in the cervix the area of cystic lesions and slight thickening of the cervical mucous membrane with a total dim. 37 x 19 mm - inflammatory changes. The patient qualified to remove the uterus with the fallopian tube. The procedure was carried out using the ICG illumination. An illuminated manipulator was used due to difficulties in identifying vaginal vaults and small uterine mobility, most likely after inflammation. The left side of the uterine artery was ligated by Mishra's knot.

Total Laparoscopic Hysterectomy (TLH) has become the gold standard for minimally invasive management of benign and some malignant uterine conditions. With advancements in technology and surgical techniques, TLH can now be performed safely and efficiently with fewer ports, improved visualization, and advanced suturing methods. The integration of Indocyanine Green (ICG) imaging and Mishra’s Knot technique has further enhanced the safety and precision of the procedure.

Three-Port Technique
Traditionally, TLH is performed using four or more ports. However, with increased expertise, surgeons have adopted the three-port technique, which reduces trauma, postoperative pain, and scarring while maintaining surgical effectiveness. Typically, the ports include:

Umbilical port – for the laparoscope and main instruments

Left lower abdominal port – for dissection and energy devices

Right lower abdominal port – for suturing and auxiliary instruments

This approach streamlines the procedure and improves patient recovery.

Role of ICG (Indocyanine Green)
ICG is a fluorescent dye used intraoperatively to enhance visualization of vascular structures. During TLH, ICG helps in:

Identifying uterine arteries and key pelvic vessels

Reducing the risk of accidental injury to ureters or surrounding structures

Ensuring optimal hemostasis

By providing real-time perfusion assessment, ICG improves safety and confidence during dissection and vessel sealing.

Mishra’s Knot Technique
Secure closure of the vaginal cuff and hemostasis is critical in TLH. Mishra’s Knot is a specialized laparoscopic suturing technique developed by Dr. R.K. Mishra. It allows:

Rapid and secure knotting in a limited space

Reduced operative time

Minimization of bleeding

Improved post-operative outcomes

Using Mishra’s Knot in conjunction with the three-port approach allows for precise closure of the vaginal cuff with minimal instrumentation.

Procedure Overview

Patient positioning and anesthesia administration.

Creation of pneumoperitoneum and placement of three laparoscopic ports.

Introduction of ICG intravenously to visualize pelvic vasculature.

Stepwise dissection of the uterus, ligation of vessels under ICG guidance.

Removal of the uterus via the vaginal route or morcellation if indicated.

Closure of the vaginal cuff using Mishra’s Knot technique.

Final inspection, hemostasis confirmation, and port closure.

Advantages

Minimally invasive with faster recovery

Reduced post-operative pain and hospital stay

Enhanced vascular visualization with ICG

Secure and efficient suturing with Mishra’s Knot

Minimal scarring with three-port technique

Conclusion
TLH using ICG and Mishra’s Knot through a three-port approach represents a modern evolution in gynecologic surgery. It combines advanced imaging, minimally invasive techniques, and innovative suturing methods to provide safer, faster, and patient-friendly outcomes. Surgeons trained in these techniques can offer patients a superior surgical experience with excellent clinical results.

For more information please contact:
World Laparoscopy Hospital
Cyber City, Gurugram, NCR Delhi
INDIA 122002
Phone & WhatsApp: +919811416838, + 91 9999677788