Design: Retrospective comparative study

Setting: Academic, tertiary care centre

Patients or Participants: Indications for TLH with history of previous caesarean sections

Interventions: TLH was performed by the lateral approach and by the 3-step technique which involves:

1. Posterior approach to uterine artery dissection and ligation, prior to bladder dissection
2. Creating a bladder canopy and navigating the roadblock of bladder adhesions by working in the cotton candy uterovesical space beneath it
3. Anterior approach of contralateral uterine artery ligation

Measurements and Main Results: Over a 4 year period, 878 TLH were conducted. 396 patients had history of previous cesarean section, of which 81 had 3 or more CS. Among these, 194 TLH were performed using the lateral approach (Group A), and 202 TLH using the 3-step approach (Group B). Patient demographics, i.e. age, BMI, and uterine weight showed no significant differences. However, there were notable variations in operative parameters. Group B exhibited lower average estimated blood loss (80 ml vs.150 ml) due to an avascular plane. Even in a densely ventrifixed uterus where bladder and uterus appeared as one; ease of navigation in cotton candy uterovesical space and quicker bladder dissection time (11 min vs. 20 min) was noted. Complication rates, particularly bladder and ureteric injuries, were also lower in Group B (2 cases and 0 case, respectively) compared to Group A (5 cases and 2 cases, respectively).

Conclusion: These findings underscore the advantages of the 3-step approach in managing densely adherent bladders with reduced operative time, blood loss and complication rates in TLH.