Introduction:
This video showcases how total laparoscopic hysterectomy (TLH) has emerged as the gold standard in gynecological surgeries, offering effective treatment for a wide range of benign and malignant conditions affecting the uterus. Traditionally, TLH involves the use of a uterine manipulator to facilitate exposure and manipulation of the uterus during the procedure. However, a new innovative approach has emerged, utilizing a myoma screw for fixation and traction of the uterus, eliminating the need for a uterine manipulator. This essay explores the innovative approach of myoma screw-assisted TLH without a uterine manipulator, highlighting its advantages and potential implications for patient care.

Procedure:
The myoma screw-assisted TLH without a uterine manipulator involves a modified technique to achieve optimal exposure and precise dissection. The key steps of the procedure are as follows:

1. Patient positioning and anesthesia: The patient is positioned in the dorsal lithotomy position under general anesthesia, ensuring adequate access and visibility during the surgery.

2. Trocar placement: Small incisions are made to introduce trocars into the abdominal cavity to create access points for the laparoscope and other instruments.

3. Myoma screw insertion: A myoma screw is carefully inserted into the uterine fundus, providing a stable grip and fixation of the uterus. The screw's design allows for controlled traction and manipulation without the need for a uterine manipulator.

4. Uterine exposure and dissection: With the assistance of the myoma screw, the surgeon achieves optimal exposure of the uterus, enabling precise dissection and removal of the uterus through the laparoscopic approach. The myoma screw acts as a reliable anchor, facilitating improved visualization and access to the uterine structures.

5. Vaginal cuff closure: After the uterus is removed, the vaginal cuff is closed laparoscopically using sutures or other appropriate techniques to ensure proper healing and closure of the vaginal vault.

Advantages:
The innovative approach of myoma screw-assisted TLH without a uterine manipulator offers several advantages over the traditional technique. These advantages include:

1. Enhanced exposure and visualization: The myoma screw provides secure fixation of the uterus, enabling improved exposure of the surgical field. This allows for better visualization of uterine structures and precise dissection during the procedure.

2. Simplified technique: The elimination of the uterine manipulator simplifies the surgical technique, reducing the need for additional instruments and potential complications associated with the use of a manipulator.

3. Minimized risk of uterine perforation: Uterine perforation is a known complication associated with the use of a uterine manipulator. With the myoma screw technique, the risk of uterine perforation is significantly reduced, promoting patient safety.

4. Reduced procedure time: The simplified technique and improved exposure provided by the myoma screw can lead to shorter procedure times, potentially reducing the overall duration of surgery and anesthesia exposure for patients.

5. Cost-effectiveness: The use of a myoma screw is a cost-effective alternative to uterine manipulators, potentially reducing the financial burden associated with the surgical procedure.

Performing a laparoscopic hysterectomy without a uterine manipulator involves a modified technique to achieve optimal exposure and manipulation of the uterus. The key steps for this procedure are as follows:

1. Patient positioning and anesthesia: The patient is positioned in the dorsal lithotomy position, ensuring appropriate access and visibility during the surgery. General anesthesia is administered to ensure patient comfort and safety.

2. Trocar placement: Small incisions are made in the abdominal wall to insert trocars, creating access points for the laparoscope and other surgical instruments. The number and placement of trocars may vary depending on the surgeon's preference and the patient's specific anatomy.

3. Uterine mobilization and exposure: The surgeon begins by identifying anatomical landmarks, such as the round ligaments, infundibulopelvic ligaments, and broad ligaments. Gentle traction and manipulation of these ligaments are used to mobilize and expose the uterus. This step requires careful dissection to avoid injury to adjacent structures.

4. Uterine fixation: Instead of using a uterine manipulator, various techniques can be employed to achieve uterine fixation and traction. One commonly used method involves using a myoma screw or atraumatic graspers to hold and stabilize the uterus during the procedure. The chosen instrument is inserted into the uterine fundus, allowing for controlled traction and manipulation.

5. Uterine dissection and removal: With the uterus adequately fixed and exposed, the surgeon proceeds with the dissection and removal of the uterus. Specific techniques for dissection may vary depending on the underlying pathology and surgical goals. The uterine arteries are carefully identified and ligated or sealed to minimize bleeding. The uterus is then dissected free from surrounding structures, such as the bladder and rectum, while ensuring the integrity of these adjacent organs.

6. Closure of the vaginal cuff: After the uterus is removed, the vaginal cuff is closed to ensure proper healing and closure of the vaginal vault. Various techniques can be employed, including laparoscopic suturing, stapling, or the use of energy devices. The chosen method should provide secure closure and minimize the risk of complications, such as cuff dehiscence or postoperative bleeding.

7. Closure of trocar sites: The incisions made for trocar placement are closed using absorbable sutures or surgical adhesive, depending on the surgeon's preference.

It is essential to note that the specific steps and techniques employed during a laparoscopic hysterectomy without a uterine manipulator may vary among surgeons. The surgeon's experience, patient characteristics, and underlying pathology will influence the surgical approach. It is crucial for surgeons to adhere to proper aseptic techniques, use appropriate instrumentation, and ensure patient safety throughout the procedure.

As with any surgical intervention, laparoscopic hysterectomy without a uterine manipulator carries potential risks and complications. These may include bleeding, infection, injury to adjacent structures, conversion to open surgery, or anesthesia-related complications. Surgeons should have thorough knowledge and experience in laparoscopic techniques to minimize these risks and provide optimal patient care.

Laparoscopic hysterectomy without a uterine manipulator offers several advantages over traditional techniques that involve the use of a manipulator. These advantages include:

1. Reduced risk of uterine perforation: Uterine perforation is a known complication associated with the use of uterine manipulators. By eliminating the need for a manipulator, the risk of accidental uterine perforation is significantly reduced. This enhances patient safety during the procedure.

2. Minimized risk of cervical trauma: Uterine manipulators can exert pressure on the cervix, potentially causing trauma or injury. Performing a laparoscopic hysterectomy without a manipulator reduces the risk of cervical damage, ensuring better preservation of cervical integrity.

3. Improved visualization and exposure: Without a uterine manipulator obstructing the surgical field, the surgeon gains improved visualization and exposure of the uterus and surrounding structures. This enhanced view allows for more precise dissection, reducing the risk of inadvertent injuries.

4. Simplified technique: The absence of a uterine manipulator simplifies the surgical technique, potentially reducing the learning curve associated with its proper placement and usage. This can benefit surgeons, particularly those who are less experienced or those who encounter challenges in utilizing a manipulator effectively.

5. Reduced cost: Uterine manipulators can be costly and may add to the overall expenses of the surgical procedure. By eliminating the need for a manipulator, laparoscopic hysterectomy without a manipulator can potentially reduce costs, making the procedure more economically feasible for patients.

6. Shorter procedure time: The simplified technique and improved visualization offered by avoiding a manipulator can contribute to shorter procedure times. This benefits both the patient and the surgical team, reducing the overall duration of surgery and anesthesia exposure.

7. Enhanced patient comfort: Uterine manipulators can cause discomfort for some patients, particularly during their placement and removal. By eliminating the need for a manipulator, laparoscopic hysterectomy without a manipulator may offer increased patient comfort and satisfaction.

8. Faster postoperative recovery: Minimally invasive techniques, such as laparoscopic hysterectomy, are associated with shorter hospital stays, decreased postoperative pain, and faster recovery compared to open surgery. Avoiding a uterine manipulator in laparoscopic hysterectomy may further contribute to these benefits, allowing for an expedited recovery process.

It is important to note that laparoscopic hysterectomy without a uterine manipulator may not be suitable for all cases, and the decision to forego a manipulator should be made on an individual basis, considering patient factors, surgeon experience, and the specific surgical objectives. Surgeons who opt for this approach should possess the necessary skills and expertise in laparoscopic techniques to ensure optimal outcomes and patient safety.

Although laparoscopic hysterectomy without a uterine manipulator offers several advantages, like any surgical procedure, it is not without potential complications. Some complications associated with this technique may include:

1. Difficult uterine manipulation: Without a uterine manipulator, achieving optimal exposure and manipulation of the uterus may be challenging in certain cases. The absence of a manipulator can make it more difficult to grasp and mobilize the uterus, especially in situations where the uterus is large or distorted due to pathology.

2. Limited exposure and visualization: While improved visualization is listed as an advantage of this technique, in some cases, the absence of a uterine manipulator may limit the surgeon's ability to adequately visualize and access certain areas of the uterus and surrounding structures. This can potentially increase the risk of incomplete dissection or inadvertent injury to adjacent organs.

3. Increased risk of injury to adjacent structures: Without the aid of a manipulator, there is a slightly higher risk of unintentional injury to nearby structures, such as the bladder, ureters, or bowel. Careful dissection and precise surgical technique are essential to minimize this risk, but the absence of a manipulator may make it slightly more challenging to avoid such injuries.

4. Longer operative time: In some cases, the absence of a uterine manipulator may lead to longer operative times. Without the manipulation and stabilization provided by a manipulator, surgeons may require additional time and effort to achieve the necessary exposure and dissection. Prolonged operative times can increase the risk of complications and the overall duration of anesthesia.

5. Potential for conversion to open surgery: In situations where the laparoscopic approach becomes technically challenging or unsafe without a uterine manipulator, there may be a higher likelihood of conversion to open surgery. This conversion is done to ensure patient safety and adequate surgical access. However, it should be noted that the decision to convert to open surgery is made in the best interest of the patient.

It is important to remember that the occurrence of complications can vary depending on the individual patient, surgeon expertise, and specific surgical circumstances. Surgeons who choose to perform laparoscopic hysterectomy without a uterine manipulator should have appropriate training, skills, and experience in laparoscopic techniques to minimize the risk of complications and provide optimal patient care. Preoperative evaluation, meticulous surgical planning, and adherence to best practices in laparoscopic surgery are crucial for mitigating potential complications and achieving successful outcomes.

Conclusion:
The innovative approach of myoma screw-assisted TLH without a uterine manipulator offers several advantages in terms of enhanced exposure, simplified technique, minimized risk of uterine perforation, reduced procedure time, and cost-effectiveness. However, it is important to note that this technique requires experienced surgeons trained in the proper placement and utilization of the myoma screw. Further studies and long-term outcomes are necessary to validate the efficacy, safety, and reproducibility of this innovative approach. Nonetheless, it holds promising potential in advancing the field of laparoscopic hysterectomy and improving patient care.