Total laparoscopic hysterectomy has been shown to be a safe method of hysterectomy with minimal complications, yet among all the hysterectomy done only 12% of all hysterectomies are performed by this route of TLH, with 22% by vaginal approach by NDVH and 66% still being performed by laparotomy. 

Suturing the uterine artery can significantly increase the confidence of laparoscopic gynecologist who want to perform total laparoscopic hysterectomy. Practicing surgeons and gynecologist need an effective means for learning suture and knot tying skills and procedures in advanced gynecologic laparoscopy. It is possible that the Mishra's knotting technique of ligating uterine artery facilitated clinical uptake of laparoscopic skills and enhanced the effectiveness of this surgery. The good knotting can only be learnt in any good Hands On comprehensive course.
 

Total laparoscopic hysterectomy with concurrent laparoscopic uterosacral ligament (USL) vaginal vault suspension with the use of extracorporeal Mishra's Knot provides a safe and effective alternative Minimal Access Surgical technique that has efficacy rates similar to abdominal Sacro Colpopexy. The uterosacral ligaments provide a strong supportive tissue for vaginal vault suspension that mimics complete and natural support system of the pelvic floor. For Gynecologist the most challenging aspect of the TLH with laparoscopic USL suspension for the gynecologist is state of the art laparoscopic suturing and intra or extracorporeal knot tying. Recently developed technologies such as da Vinci robotics, automatic suturing devices, and new barbed suture materials are now providing simpler, alternative surgical techniques of Mishra's knot is very promising that will hopefully shorten operative times and increase adoption of this surgical procedure by gynecologists. With continued progress and refinement of this technique of extra corporeal knotting, the TLH with laparoscopic USL suspension may challenge the current standard of care for surgical removal of Uterus.