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

Large benign uterine pathologies affect millions of women globally and impose substantial socioeconomic costs. Although hysterectomy remains the definitive treatment, minimally invasive surgery (MIS) methodologies, including vaginal procedures and laparoscopy, have largely supplanted open laparotomy. However, significant uterine enlargement compromises pelvic workspace, obscures surrounding anatomical structures, which may impair the surgeon's ability to operate effectively, and increase the risks of hemorrhage and adjacent-organ injury. Consequently, many gynecological surgeons regard uteri ≥ 17-week equivalent as a contraindication to total laparoscopic hysterectomy (TLH). We devised a novel approach known as Laparoscopic Extracorporeal Knot-Tying for Uterine Vessel Occlusion during Hysterectomy with Cervical Cerclage (LEKTUVOHCC) in Large Uteri, comprising a cervical cerclage using an extracorporeal laparoscopic knot-pusher for en bloc occlusion of uterine arteries and corpus uteri excised to debulk the uterus and optimize the operative field. We successfully performed this procedure in 31 cases at our hospital. We recorded operative time (OT), intraoperative blood loss (IBL), and intra- and postoperative complications, and patient satisfaction over a median follow-up of 12 months. The median operative time was 127 (100, 213) min; the mean IBL was 80 (50, 200) mL. Complete LEKTUVOHCC was achieved in all cases (31/31, 100%), with patient-reported satisfaction in 30/31 (96.77%). No significant complications were observed during or after surgery. This approach effectively overcomes the hemostatic and visualization challenges in laparoscopic hysterectomy for large uteri, such as the dissection of uterine blood arteries and the reduction of IBL, thereby eliminating the risk of blood transfusion and lowering healthcare costs. This technique is reproducible, facilitates rapid adoption, and represents a significant advance in MIS.