This video demonstrates TLH with ICG and Mishra's Knot by Three Port performed at World Laparoscopy Hospital by Dr R K Mishra. 48-year old patient with diagnosed 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.

TLH with ICG and Mishra's Knot by Three-Port Technique: A Minimally Invasive Approach
  
Total Laparoscopic Hysterectomy (TLH) is a widely accepted minimally invasive surgical procedure for managing various gynecological conditions. Advancements in laparoscopy have introduced novel techniques to enhance precision, safety, and efficiency. One such refinement is the use of Indocyanine Green (ICG) for better visualization and Mishra’s Knot for secure ligation, performed via a three-port technique. This approach minimizes surgical trauma while maintaining excellent outcomes.
 
Indocyanine Green (ICG) in TLH
 
ICG fluorescence imaging has revolutionized laparoscopic gynecological procedures by improving visualization of vascular structures, lymphatics, and tissue perfusion. In TLH, ICG is injected intravenously and visualized under near-infrared (NIR) fluorescence, allowing the surgeon to:
 
- Clearly delineate the ureters and major blood vessels, reducing the risk of iatrogenic injury.
- Enhance identification of endometriotic lesions and sentinel lymph nodes if required.
- Improve surgical decision-making by assessing real-time tissue perfusion.
 
Mishra’s Knot: A Reliable and Efficient Ligation Technique
 
Mishra’s Knot is a trusted extracorporeal knot-tying technique that provides secure hemostasis with minimal suture material usage. When applied in TLH, it offers:
 
- High tensile strength and slip-proof security, particularly beneficial for uterine artery ligation.
- Reduced dependency on energy devices, leading to decreased thermal spread and collateral damage.
- Enhanced efficiency by shortening operative time and improving cost-effectiveness.
 
Three-Port Technique: Minimizing Invasiveness
 
The three-port approach optimizes TLH by reducing the number of trocar incisions while maintaining surgical precision. The typical port placement includes:
 
1. Umbilical Port (10 mm): Primary camera port for visualization.
2. Lateral Port (5 mm, Right or Left): Working port for instrument manipulation.
3. Contralateral Lateral Port (5 mm): Additional working port for retraction and dissection.
 
This technique offers several advantages, such as:
 
- Reduced postoperative pain and quicker recovery.
- Better cosmetic outcomes due to fewer incisions.
- Lower risk of port-site complications.
 
Conclusion
 
TLH with ICG guidance and Mishra’s Knot, performed via a three-port technique, represents an advanced, patient-friendly surgical approach. The integration of fluorescence imaging enhances safety, while efficient extracorporeal knotting ensures secure hemostasis. By limiting the number of ports, this technique maximizes surgical precision while minimizing invasiveness, leading to improved patient outcomes and faster recovery. As minimally invasive surgery continues to evolve, such refinements are pivotal in optimizing gynecological care.

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