Hysterectomy is one of the most commonly performed major gynaecological procedures. Since the introduction of total laparoscopic hysterectomy in 1993 [10], many surgeons have adopted various modifications and tools that could help in making the surgery safer and more accessible. One of the tools is the uterine manipulator which is widely used in various gynaecological procedures. It is regarded as a key instrument in total laparoscopic hysterectomy as it is thought to provide better visualization of surgical field, delineation of colpotomy and reducing risk of ureteric injury [4].

Despite technological advances and the contemporary implementation of laparoscopic hysterectomy as the standard of care, only few studies reported TLH without the use of uterine manipulator or vaginal tubes in the setting of benign conditions. One case study reported the efficacy and the safety in performing TLH without the use of manipulator or tube in two large uteruses, weighting 5700 g and 3670 g. This study highlighted the limitation of the manipulator in case of vaginal stenosis and restricted anatomy [6]. Mebes et al. reported the outcomes of TLH without manipulator between two groups according to uterus size and stated that laparoscopic hysterectomy without uterine manipulator can be more appropriate in cases of vaginal stenosis [11]. A retrospective study by Tinelli et al. compared TLH with and without the use if uterine manipulator in early-stage endometrial cancer and showed no difference in early recurrence between two groups. However, detailed operative technique was not reported [7].

A study on 67 laparoscopic hysterectomies by Kavallaris et al. reported that TLH can be safely done without uterine manipulation. This study supported the hypothesis that total laparoscopic hysterectomy without manipulator (TLHwM) was appropriate and feasible in patients with vaginal stenosis and small cervix, where the application of instruments is inaccessible. Furthermore, this technique avoids the potential of short vagina syndrome by incising it close to cervix, under direct visualization [5]. However, a limitation of the technique reported by both Kavallaris et al. [5] and Mebes et al. [11] was the requirement of digital vaginal manipulation and guidance at the stage of colpotomy. In contrast to this, our approach (KTLH) did not apply any vaginal instrumentation or manipulation during colpotomy which is guided by the demarcation between the cervix and vagina.

It is reported in the literature that uterine manipulator helps to reduce lower urinary tract injury by lateralization of uterus allowing perpendicular dissection of uterine arteries [12, 13]. According to a literature review on laparoscopic hysterectomy, the overall incidence of urinary tract injury was 0.73%, while ureteral injuries ranged from 0.02 to 0.4% and bladder injuries were 0.05–0.66% [14]. However, our present data demonstrated neither ureteric nor bladder injuries in all 86 women. Similarly, both Kavallaris et al. [5] and Mebes et al. [11] reported no lower urinary injury in their reports which shared the same technique of TLH without uterine manipulator. However, Tinelli et al. reported lower urinary tract injury in 5 (9%) patients undergoing TLH without manipulator for early endometrial cancer [7].

In the present study, the mean operative (64.7 min) time was shorter then reported in standard TLH (99.3 [15] and 126 min [16]). This is also less than reports by Kavallaris et al. (80–90 min) and Mebes et al. (90–111 min) [5, 7]. Additionally, we observed less intraoperative blood loss comparing with TLH with uterine manipulator; Jugent et al. [17] and Candiani et al. [15] reported bloods loss of 98 ml and 83 ml, respectively, which were almost twice as much as our bloods loss (46.2 ± 54.6 ml). Kavallaris et al. (TLHwM) reported a similar estimated blood loss of 50 ml [5].

On analysing postoperative recovery, our reported pain and the requirement for analgesia were comparable to previous studies on TLH with the use of uterine manipulator [15, 18, 19]. Additionally, our length of stay (3.3 ± 0.97 days) was comparable to that reported in literature [2, 20, 21]. Under normal conditions, our patients could be discharged on postoperative day 1 or 2. This is keeping with a publication by Candiani et al. advocating the 33% of patient undergoing TLH could be discharged on day 2 after surgery. Moreover, hospitalization time does not entirely represent postoperative recovery, as it is often driven by economic aspects, hospital setting, patient’s tolerance and local policies [2].

In the present study, similarly to Kavallaris et al. and Mebes et al. [5, 7], there were no intraoperative complications; intraoperative complications in TLH include bladder injury (1.2–2%), ureteral injury (0.6–0.9%), bowel injury (0.2–0.8%) and other laparoscopic-related injuries [22]. In many studies on total laparoscopic hysterectomy, intraoperative complications were not grouped and these are reported as overall postoperative complications [2]. Moreover, none of the 86 TLH in our current study required conversion to open surgery. In previous reports, the rate of conversion was up to 5.8% [23,24,25]. This is mostly related to technical difficulties, extensive adhesion, uncontrolled bleeding and the experience of the surgeon.

In our series, postoperative complications were categorized according to the Clavien-Dindo score. There was only 1 (1.2%) grade IIIB complication; a patient with a vaginal wall dehiscence as a consequence of premature sexual intercourse. It required a vaginal-approached repair under general anaesthesia. This was the only complication requiring reintervention or admission. A review on 47 laparoscopic hysterectomy studies concluded that the incidence of vaginal dehiscence was up to 0.64% [26]. Grade IIIA complications occurred in 2 (2.3%) patients in the form of a vaginal granuloma which was excised in the outpatient clinic.

The rest of the complications were grade II (13/86 15.1%): 6 patients required extra antibiotics coverage, 3 patients developed vaginal vault infection, one pelvic collection which was spontaneously resorbed, one patient required bloods transfusion postoperatively for preoperative anaemia and 2 urinary tract infections. Overall, the total number of all grades of complications was 16/86 (18.6%). Our reported complication rate is favourable when compared to Mereu et al. who retrospectively reviewed 361 TLH with similar overall complications rate (53/361–14.6%) [2].

Although uterine manipulator has several reported benefits, total laparoscopic hysterectomy without uterine manipulator (KTLH) is a systematic approach to perform TLH without uterine or vaginal manipulation. Our technique illustrated reduced operative time, reduced cost of procedural costs, obviates the need for an assistant for the manipulation and less intraoperative complications. KTLH is also beneficial in situations when application of uterine manipulator is inaccessible such as those with vaginal stenosis or huge uterus.