Background: Total laparoscopic hysterectomy (TLH) is widely accepted as the preferred minimally invasive technique for the treatment of benign gynecologic conditions. However, significant heterogeneity persists in the literature regarding the operative sequence, particularly for steps such as uterine artery ligation, ureteral identification, and vaginal cuff closure. This lack of standardization may affect complication rates, reproducibility in surgical training, and procedural efficiency. The objective of this study was to develop and evaluate a standardized, anatomically justified surgical protocol for TLH primarily designed for training purposes but applicable to most clinical cases. Methods: This retrospective observational study analyzed 109 patients who underwent TLH between January 2016 and July 2020 at a single tertiary care center. A fixed sequence of surgical steps was applied in all cases, emphasizing early uterine artery ligation at its origin, broad ligament fenestration above the ureter, and laparoscopic figure-of-eight vaginal cuff closure. Patient demographics, operative data, and perioperative outcomes were extracted and analyzed. Results: The mean operative time was 67.2 ± 18.4 min, and the mean uterine weight was 211.9 ± 95.3 g. Intraoperative complications were observed in 3.7% of cases and included bladder injury in 1.8% and small bowel injury in 1.8%, all of which were managed laparoscopically without conversion. Vaginal cuff dehiscence occurred in 1.8%, and postoperative vaginal bleeding in 3.7% of patients. One patient (0.9%) required reoperation due to a vaginal cuff hematoma/abscess. No postoperative infections requiring intervention were reported. The mean hemoglobin drop on the first postoperative day was 1.2 ± 0.9 g/dL. Conclusions: Our findings support the feasibility, reproducibility, and safety of a structured TLH protocol based on anatomical landmarks and early vascular control. Widespread adoption of similar protocols may improve consistency and training, with broad applicability in routine surgical practice and potential adaptation in severely complex cases; however, further validation in multicenter studies is warranted.

Background and Objectives: Hysterectomy is one of the most frequently performed gynecological surgical procedures worldwide. It is well established that the laparoscopic approach offers better outcomes for patients compared to abdominal hysterectomy. However, the technique for vaginal cuff closure during laparoscopic hysterectomy (TLH) remains insufficiently standardized in the international literature. Based on our results, we aim to demonstrate that closure of the vaginal cuff using a figure-of-eight suture is a sufficient, reproducible, time-efficient and safe method during total laparoscopic hysterectomy. Materials and Methods: Our retrospective observational study analyzed 173 patients who underwent a TLH from January 2016 to December 2021 at the University of Debrecen, Department of Obstetrics and Gynecology. Standardized surgical steps were applied in all cases (ligation of the uterine arteries at their origin, fenestration of the broad ligament above the ureter), and the vaginal cuff was closed laparoscopically with an absorbable suture, incorporating vesicovaginal fascia, vaginal mucosa and uterosacral ligaments. Patient demographics, operative data, and perioperative outcomes were extracted and analyzed. Results: TLH was successfully performed in 173 cases, and no conversion to open surgery was necessary. The mean age of the patients was 51.4 (23–86) years, the median body mass index (BMI) was 26.9 (16.9–45) kg/m², and the operative time was 92 (35–240) minutes. The mean uterine weight was 151 (16–440) g. The mean hemoglobin drop was 15.8 (0–44) g/L after the surgery. Regarding complications, ureteral injuries occurred in two cases (1.2%). One patient (0.6%) required relaparotomy due to rectosigmoid perforation. Postoperative complications included vaginal cuff dehiscence in two cases (1.2%), with one patient (0.6%) requiring resuturing, fever in six cases (3.5%), vaginal discharge in four cases (2.3%), and vaginal bleeding in one case (0.6%). Pulmonary embolism occurred in one patient (0.6%). Three patients (1.7%) required blood transfusion based on postoperative blood counts. Conclusions: Our results demonstrate an acceptable operative time and a low rate of postoperative complications, suggesting that closing of the vaginal cuff with a figure-of-eight suture is a sufficient and safe technique. This method can be reliably reproduced and incorporated into the standardized steps of total laparoscopic hysterectomy.