Description

Total Laparoscopic Hysterectomy (TLH) is a minimally invasive surgical technique in which the uterus is removed using laparoscopic instruments. Over the years, advancements in suturing methods and energy devices have refined the procedure, making it safer and more efficient. Among the suturing techniques, the Meltzer’s Knot has gained prominence for its reliability and simplicity in securing the vaginal cuff closure during TLH. What is Meltzer’s Knot? Meltzer’s Knot is a type of extracorporeal knot commonly used in laparoscopic surgery. It provides a strong, secure, and slip-resistant ligature, making it particularly useful in gynecological surgeries like TLH. The knot is tied outside the abdominal cavity and then pushed inside using a knot pusher, which reduces intra-abdominal manipulation and ensures effective tissue approximation. Steps of Total Laparoscopic Hysterectomy Using Meltzer’s Knot Patient Preparation The patient is placed in lithotomy position under general anesthesia. A uterine manipulator is used to aid mobilization of the uterus. Port Placement Typically, a four-port technique is used: one umbilical port for the camera and three accessory ports for operating instruments. Dissection and Uterine Vessel Control Round ligament, ovarian or infundibulopelvic ligament, and broad ligament are dissected. Uterine arteries are skeletonized and coagulated using advanced energy devices. Colpotomy Circumferential incision is made at the vaginal fornix using monopolar hook or harmonic scalpel. The uterus is removed vaginally or morcellated if required. Vaginal Cuff Closure with Meltzer’s Knot Meltzer’s Knot is prepared extracorporeally with delayed absorbable suture material (usually 1-0 or 2-0 polyglactin). The knot is pushed inside with a knot pusher and placed securely at one end of the cuff incision. Multiple bites are taken along the cuff edges, and each secured with Meltzer’s Knot to achieve hemostasis and proper closure. Final Check and Hemostasis The pelvic cavity is irrigated and inspected for bleeding. Ports are removed and incisions closed. Advantages of Meltzer’s Knot in TLH Provides a firm, reliable closure of the vaginal cuff. Minimizes slippage, reducing the risk of postoperative complications like vault dehiscence. Saves time, as it is easier and quicker to tie extracorporeally. Useful in cases where intracorporeal suturing may be technically challenging. Enhances surgeon’s confidence during complex hysterectomy procedures. Clinical Significance The use of Meltzer’s Knot in Total Laparoscopic Hysterectomy has significantly improved the efficiency of cuff closure. Studies and surgical experiences have shown reduced operative time, lower risk of cuff complications, and better postoperative recovery. It is particularly valuable for young surgeons mastering laparoscopic suturing, as it offers both simplicity and safety. Conclusion Total Laparoscopic Hysterectomy by Meltzer’s Knot represents a refined blend of modern minimally invasive surgery and reliable suturing techniques. By incorporating this knot, gynecologic surgeons can achieve secure closure, reduced complications, and enhanced patient outcomes, thereby making TLH a more accessible and safer procedure worldwide.