Laparoscopic Extracorporeal Knot-Tying for Uterine Vessel Occlusion during Hysterectomy with Cervical Cerclage in Large Uteri

This approach effectively overcomes the hemostatic and visualization challenges in laparoscopic hysterectomy for large uteri, thereby eliminating the risk of blood transfusion and lowering healthcare costs. Significant uterine enlargement compromise pelvic workspace, obscure the surrounding anatomical structures which may impair the surgeon's ability to operate effectively and increase the risk of hemorrhage and additional organ injury. A laparoscopic extracorporeal knot-pusher is used to perform cervical cerclage, achieving a complete occlusion of uterine arteries.

Thereafter, the corpus uteri are excised to enhance visibility and facilitate the operative field. To begin, examine the abdominal cavity using laparoscopy to determine the feasibility of the technique. Sew a stitch and tie knots at the uterine lateral wall with a suture for pulling the uterus to expose the pelvic anatomical structures.

Conduct coagulation and transection of the utero-ovarian ligament if salpingectomy is indicated. Electrocoagulate and sever the round ligament. Then, separate the anterior and posterior layers of the broad ligament subsequently.

Utilize the knot-pusher to form a Roeder's knot with an absorbable synthetic polyglactin braided suture around the cervical isthmus. Inject diluted vasopressin into the space between the uterine fibroid and myometrium. Pull the Roeder's knot farther forward to occlude the uterine vessels completely as the uterine body turns blanched and firmed, with its color turning to pale or dark purple.

Now, transect the uterine corpus 1 to 1.5 centimeters above the cerclage line using scissors. Execute loop ligation around the residual cervical stump to reinforce hemostasis with the extracorporeal Roeder's knot. Incise the vesico-uterine peritoneum with a unipolar hook to expose the uterine arteries.

Coagulate and divide the uterine vessels. Next, perform a circumferential colpotomy at the vaginal fornix with a monopolar hook. Morcellate the uterus completely with scissors.

Lastly, perform peritoneal and vaginal stump closure with an absorbable synthetic polygalactin braided suture. Laparoscopic extracorporeal knot tying for uterine vessel occlusion during hysterectomy with cervical cerclage was successfully performed in 31 patients over the past two years. The median age of the 31 patients were 48 years, and body mass index of 21.25 kilograms per square meter.

Most patients had a total parity of one or more with 35.48%having one and 45.16%having two or more. Vaginal parity was absent in 38.71%of patients and cesarean parity was absent in 70.97%The median uterine size was equivalent to 20 weeks of gestation. A history of previous abdominal surgery was reported in 32.26%of patients and preoperative anemia was observed in 38.71%Menometrorrhagia was the most common surgical indication, reported in 58.06%of patients.

All 31 patients completed the surgery without conversion to laparotomy, resulting in a 100%objective success rate and a subjective success score of 96.77%After the first 15 cases, median operative time decreased significantly from 214 to 116 minutes. Median intraoperative blood loss was also significantly reduced after the first 15 cases from 150 to 60 milliliters.