Adhesive Versus Spatial Anatomical Distortion Determines Energy Device Performance in Complex Total Laparoscopic Hysterectomy

STUDY OBJECTIVE: To evaluate whether the type of anatomical distortion-spatial or adhesive-determines the relative performance of the energy device in complex total laparoscopic hysterectomy (TLH). DESIGN: Retrospective cohort study. SETTING: Single tertiary referral center. PATIENTS: A total of 167 women who underwent complex TLH between 2018 and 2025 were included. Cases were classified according to intraoperatively confirmed distortion type as spatial (uterine enlargement), adhesive (previous cesarean delivery or endometriosis), or combined. INTERVENTIONS: TLH performed with conventional bipolar electrosurgery (CBP, n = 94) or LigaSure (LG, n = 73). Device selection was based on real-time availability. MEASUREMENTS AND MAIN RESULTS: Primary outcome was operative time. Overall operative time (136 ± 18 vs. 140 ± 17 min, p = 0.761), hemoglobin change, and length of hospital stay were comparable between groups. Subgroup analysis revealed a significant interaction between device type and distortion subgroup (F (1,90) = 18.0, p < 0.001). In the spatial distortion subgroup, LG was associated with shorter operative time (90 ± 23 vs. 110 ± 17 min, p = 0.004). In the adhesive distortion subgroup, CBP outperformed LG (140 ± 23 vs. 155 ± 19 min, p = 0.003). Multivariable regression confirmed that the device-distortion interaction remained significant after adjustment for potential confounders (B = 18.9, p < 0.001). Bladder injury was more frequent in the LG group (8.2% vs. 1.1%, p = 0.031), exclusively in patients with prior cesarean delivery. All conversions to laparotomy occurred in the spatial distortion subgroup, with no significant difference between devices (4.3% vs. 4.1%, p = 0.961). CONCLUSION: Device efficiency in complex TLH is determined by the type of anatomical distortion. LG offers operative advantages when complexity is defined by uterine enlargement, whereas CBP electrosurgery is superior in the presence of adhesive disease. These findings support anatomy-driven device selection in complex TLH.