Total laparoscopic hysterectomy four-handed ergonomic technique: description of an original surgical procedure for the reduction of learning curve

The aim of this study was to propose the four-handed technique for total laparoscopic hysterectomy (TLH), with or without adnexectomy. From our point of view this is a more ergonomic, efficient, and effective technique that can contribute to the training of specialists in obstetrics/gynecology. In fact, teacher and learner have both an active role on the surgical field using two laparoscopic instruments each. They are alternately, mutually, and symmetrically first operator and assistant, reducing number of attempts needed for laparoscopic hysterectomy learning curve. The detailed description of all the surgical steps of TLH, "four-handed technique" (FHT), with or without adnexectomy, make sure that it can be effectively reproduced step by step safely, by transposing "FHT" surgical steps of laparotomic approach. This may allow easy access to anatomical spaces inserting trocars in different ways. By clearly knowing the steps of TLH, "FHT" it is possible to favor minimally invasive routes so that patients benefit from its multiple proven benefits. Operating this way, operative time, blood loss, use of analgesics and hospitalization can be significantly reduced. In conclusion benefits of TLH have already been widely demonstrated in literature. It is a real opportunity that young specialists become confident with this innovative "FHT," a procedure that allows them to be surgeon first assistant, and in which they can learn faster real intraoperative stereotaxis and surgical steps sequence, familiarizing with the anatomy of retroperitoneal space.