Prospective cohort study: vascular clamping of uterine artery combined with sacral ligament plication in complex hysterectomy.

There were no statistically significant differences between the two groups in terms of age, BMI, menopausal ratio, parity, preoperative hemoglobin level (Hb g/L), uterine size (maximum diameter), or surgical indications ( P  > 0.05), as shown in Table 1 . Table 1 Comparison of general clinical data parameters between the combined group and the conventional group General clinical indicators Combination group( n  = 50) Conventional group( n  = 50) P value Age(years) 48.3 ± 5.2 47.9 ± 5.6 0.68 BMI(kg/m²) 23.7 ± 2.9 23.5 ± 3.1 0.74 menopausal ratio(%) 18(36.0%) 17(34.0%) 0.82 Parity (times) 2(1–3) 2(1–3) 0.90 preoperative hemoglobin level(g/L) 123.5 ± 10.2 122.7 ± 9.8 0.65 Uterine size(cm) 14.8 ± 1.5 15.6 ± 1.4 0.59 Surgical indications Uterine fibroids (60%) Adenomyosis (20%) Endometriosis stage III-IV (20%)) Uterine fibroids (58%) Adenomyosis (30%) Endometriosis stage III-IV (12%) 0.87 Comparison of general clinical data parameters between the combined group and the conventional group Uterine fibroids (60%) Adenomyosis (20%) Endometriosis stage III-IV (20%)) Uterine fibroids (58%) Adenomyosis (30%) Endometriosis stage III-IV (12%) The combined group showed superior outcomes compared to the conventional group in terms of operative time (85.3 ± 12.4 min vs. 102.6 ± 14.8 min, Cohen’s d= −1.27, 95% CI [−1.70, −0.84]), intraoperative blood loss (68.7 ± 15.2 mL vs. 95.2 ± 18.4 mL, Cohen’s d = −1.57, 95% CI [−2.02, −1.12]), hospital stay (4.5 ± 1.1 vs. 6.2 ± 1.3 days), total hospitalization cost (including (devices, operative time, hospital stay.)(19,200 ± 2,500 vs. 23,500 ± 3,000 CNY), postoperative 24-hour abdominal drainage volume (45.6 ± 10.3 vs. 72.4 ± 12.1 mL), postoperative drainage tube retention time (28.5 ± 4.2 vs. 38.1 ± 5.0 h), and postoperative anal exhaust time (22.8 ± 3.7 vs. 30.4 ± 4.1 h) ( P   0.05), as shown in Table 3 . Table 2 Comparison of intraoperative technical indicators between the combined group and the conventional group Perioperative technical indicators Combined group ( n  = 50) Conventional group( n  = 50) P value Operation time (min) 85.3 ± 12.4 102.6 ± 14.8 < 0.001 Intraoperative blood loss (ml) 68.7 ± 15.2 95.2 ± 18.4 < 0.001 Hospital stay (days) 4.5 ± 1.1 6.2 ± 1.3 0.002 Total hospitalization cost (*10 4 CNY) 1.92 ± 0.25 2.35 ± 0.30 0.008 Postoperative 24-hour abdominal drainage volume (ml) 45.6 ± 10.3 72.4 ± 12.1 < 0.001 Postoperative drainage tube retention time (h) 28.5 ± 4.2 38.1 ± 5.0 < 0.001 Postoperative anal exhaust time (h) 22.8 ± 3.7 30.4 ± 4.1 0.004 Comparison of intraoperative technical indicators between the combined group and the conventional group Table 3 Comparison of intraoperative complications and postoperative complications between the combined group and the conventional group Perioperative technical indicators Combined group ( n  = 50) Conventional group ( n  = 50) P value Ureteral thermal injury (cases) 0 2 0.50 Bladder injury (cases) 0 1 0.31 Vascular injury (cases) 1 2 0.56 Intestinal injury (cases) 0 1 0.31 Urinary retention (cases) 2 3 0.64 Intestinal obstruction (cases) 1 2 0.55 Pelvic hematoma (cases) 2 3 0.64 Vaginal stump bleeding (cases) 1 2 0.55 Vaginal stump polyp (cases) 0 1 0.31 Vaginal stump dehiscence (cases) 1 3 0.62 Vaginal stump infection (cases) 1 2 0.55 Deep vein thrombosis of lower limbs (cases) 0 1 0.31 Pulmonary embolism (cases) 0 0 NA Comparison of intraoperative complications and postoperative complications between the combined group and the conventional group At the 6-month, 1-year, and 3-year follow-ups, the combined group showed superior outcomes in POP-Q staging, vaginal length, PFDI-20 scores, and FSFI scores compared to the conventional group, with statistically significant differences. Proportion of POP-Q stage ≥ II: At all follow-up time points, the combined group had a significantly lower proportion of patients with POP-Q stage ≥ II than the conventional group (6 months: 2% vs. 10%; 1 year: 4% vs. 16%; 3 years: 6% vs. 24%) ( P  < 0.01, P  < 0.05), as shown in Table 4 and Fig. 2 . Table 4 Comparison of pelvic floor function and sexual quality of life between the combined and conventional groups at different postoperative follow-up time points Follow-up time Group Proportion of POP-Q stage ≥ II Vaginal length (cm) PFDI-20 scores FSFI scores P value 6 months post-operation Combined group ( n  = 50) 2% (1/50) 8.5 ± 0.6 15.2 ± 3.8 26.4 ± 2.1 < 0.05 Conventional group ( n  = 50) 10% (5/50) 7.8 ± 0.9 22.6 ± 5.3 23.1 ± 3.0 1 year post-operation Combined group ( n  = 50) 4% (2/50) 8.3 ± 0.7 16.8 ± 4.1 25.9 ± 2.4 < 0.01 Conventional group ( n  = 50) 16% (8/50) 7.5 ± 1.0 28.4 ± 6.2 21.7 ± 3.5 3 years post-operation Combined group ( n  = 50) 6% (3/50) 8.1 ± 0.8 18.5 ± 4.5 25.2 ± 2.6 < 0.01 Conventional group ( n  = 50) 24% (12/50) 7.0 ± 1.2 35.7 ± 7.8 20.3 ± 4.1 *Note: POP-Q staging: A positive result is defined as the vaginal vault descending to within ≥ 1 cm of the hymenal margin (Ba point ≥ −1) PFDI-20 (Pelvic Floor Distress Inventory): Higher scores indicate more severe pelvic floor symptoms; FSFI (Female Sexual Function Index): A total score ≥ 26.55 indicates normal sexual function Fig. 2 Trend line chart of postoperative POP-Q stage distribution POP-Q staging: A positive result is defined as the vaginal vault descending to within ≥1 cm of the hymenal margin (Ba point ≥ -1);At all follow-up time points, the proportion of patients with POP-Q stage ≥Ⅱ in the combined group was significantly lower than that in the conventional group Vaginal length: The combined group maintained a longer vaginal length than the conventional group at all follow-up time points (6 months: 8.5 ± 0.6 vs. 7.8 ± 0.9 cm; 1 year: 8.3 ± 0.7 vs. 7.5 ± 1.0 cm; 3 years: 8.1 ± 0.8 vs. 7.0 ± 1.2 cm, Cohen’s d = 1.08, 95% CI [0.66, 1.50]) ( P  < 0.01, P  < 0.05), as shown in Table 4 and Fig. 3 . Fig. 3 Scatter plot of the correlation between vaginal length and FSFI scores. FSFI (Female Sexual Function Index): A total score ≥26.55 indicates normal sexual function.Patients in the combined group showed better recovery of sexual quality of life postoperatively, with relatively stable scores during follow-up. In contrast, scores in the conventional group declined year by year, widening the gap over time, and were closely correlated with a vaginal length≥8 cm PFDI-20 scores: PFDI-20 scores: Baseline PFDI-20 scores were 14.5 ± 2.2 in the conventional group and 15.1 ± 3.1 in the combined group. Postoperative PFDI-20 scores were significantly lower in the combined group compared to the conventional group, demonstrating more durable and significant improvement in pelvic floor dysfunction (at 6 months: 15.2 ± 3.8 vs. 22.6 ± 5.3; at 1 year: 16.8 ± 4.1 vs. 28.4 ± 6.2; at 3 years: 18.5 ± 4.5 vs. 35.7 ± 7.8, Cohen’s d = −2.70, 95% CI [−3.24, −2.16]) ( P  < 0.01). FSFI scores: The combined group demonstrated better recovery of sexual quality of life, with relatively stable scores during follow-up, whereas the conventional group showed a gradual decline, widening the gap between groups (6 months: 26.4 ± 2.1 vs. 23.1 ± 3.0; 1 year: 25.9 ± 2.4 vs. 21.7 ± 3.5; 3 years: 25.2 ± 2.6 vs. 20.3 ± 4.1, Cohen’s d = 1.43, 95% CI [0.99, 1.87]) ( P  < 0.01, P  < 0.05), as shown in Table 4 and Fig. 2 . Proportion of POP-Q stage ≥ II: At all follow-up time points, the combined group had a significantly lower proportion of patients with POP-Q stage ≥ II than the conventional group (6 months: 2% vs. 10%; 1 year: 4% vs. 16%; 3 years: 6% vs. 24%) ( P  < 0.01, P  < 0.05), as shown in Table 4 and Fig. 2 . Table 4 Comparison of pelvic floor function and sexual quality of life between the combined and conventional groups at different postoperative follow-up time points Follow-up time Group Proportion of POP-Q stage ≥ II Vaginal length (cm) PFDI-20 scores FSFI scores P value 6 months post-operation Combined group ( n  = 50) 2% (1/50) 8.5 ± 0.6 15.2 ± 3.8 26.4 ± 2.1 < 0.05 Conventional group ( n  = 50) 10% (5/50) 7.8 ± 0.9 22.6 ± 5.3 23.1 ± 3.0 1 year post-operation Combined group ( n  = 50) 4% (2/50) 8.3 ± 0.7 16.8 ± 4.1 25.9 ± 2.4 < 0.01 Conventional group ( n  = 50) 16% (8/50) 7.5 ± 1.0 28.4 ± 6.2 21.7 ± 3.5 3 years post-operation Combined group ( n  = 50) 6% (3/50) 8.1 ± 0.8 18.5 ± 4.5 25.2 ± 2.6 < 0.01 Conventional group ( n  = 50) 24% (12/50) 7.0 ± 1.2 35.7 ± 7.8 20.3 ± 4.1 *Note: POP-Q staging: A positive result is defined as the vaginal vault descending to within ≥ 1 cm of the hymenal margin (Ba point ≥ −1) PFDI-20 (Pelvic Floor Distress Inventory): Higher scores indicate more severe pelvic floor symptoms; FSFI (Female Sexual Function Index): A total score ≥ 26.55 indicates normal sexual function Comparison of pelvic floor function and sexual quality of life between the combined and conventional groups at different postoperative follow-up time points *Note: POP-Q staging: A positive result is defined as the vaginal vault descending to within ≥ 1 cm of the hymenal margin (Ba point ≥ −1) PFDI-20 (Pelvic Floor Distress Inventory): Higher scores indicate more severe pelvic floor symptoms; FSFI (Female Sexual Function Index): A total score ≥ 26.55 indicates normal sexual function Fig. 2 Trend line chart of postoperative POP-Q stage distribution POP-Q staging: A positive result is defined as the vaginal vault descending to within ≥1 cm of the hymenal margin (Ba point ≥ -1);At all follow-up time points, the proportion of patients with POP-Q stage ≥Ⅱ in the combined group was significantly lower than that in the conventional group Trend line chart of postoperative POP-Q stage distribution POP-Q staging: A positive result is defined as the vaginal vault descending to within ≥1 cm of the hymenal margin (Ba point ≥ -1);At all follow-up time points, the proportion of patients with POP-Q stage ≥Ⅱ in the combined group was significantly lower than that in the conventional group Vaginal length: The combined group maintained a longer vaginal length than the conventional group at all follow-up time points (6 months: 8.5 ± 0.6 vs. 7.8 ± 0.9 cm; 1 year: 8.3 ± 0.7 vs. 7.5 ± 1.0 cm; 3 years: 8.1 ± 0.8 vs. 7.0 ± 1.2 cm, Cohen’s d = 1.08, 95% CI [0.66, 1.50]) ( P  < 0.01, P  < 0.05), as shown in Table 4 and Fig. 3 . Fig. 3 Scatter plot of the correlation between vaginal length and FSFI scores. FSFI (Female Sexual Function Index): A total score ≥26.55 indicates normal sexual function.Patients in the combined group showed better recovery of sexual quality of life postoperatively, with relatively stable scores during follow-up. In contrast, scores in the conventional group declined year by year, widening the gap over time, and were closely correlated with a vaginal length≥8 cm Scatter plot of the correlation between vaginal length and FSFI scores. FSFI (Female Sexual Function Index): A total score ≥26.55 indicates normal sexual function.Patients in the combined group showed better recovery of sexual quality of life postoperatively, with relatively stable scores during follow-up. In contrast, scores in the conventional group declined year by year, widening the gap over time, and were closely correlated with a vaginal length≥8 cm PFDI-20 scores: PFDI-20 scores: Baseline PFDI-20 scores were 14.5 ± 2.2 in the conventional group and 15.1 ± 3.1 in the combined group. Postoperative PFDI-20 scores were significantly lower in the combined group compared to the conventional group, demonstrating more durable and significant improvement in pelvic floor dysfunction (at 6 months: 15.2 ± 3.8 vs. 22.6 ± 5.3; at 1 year: 16.8 ± 4.1 vs. 28.4 ± 6.2; at 3 years: 18.5 ± 4.5 vs. 35.7 ± 7.8, Cohen’s d = −2.70, 95% CI [−3.24, −2.16]) ( P  < 0.01). FSFI scores: The combined group demonstrated better recovery of sexual quality of life, with relatively stable scores during follow-up, whereas the conventional group showed a gradual decline, widening the gap between groups (6 months: 26.4 ± 2.1 vs. 23.1 ± 3.0; 1 year: 25.9 ± 2.4 vs. 21.7 ± 3.5; 3 years: 25.2 ± 2.6 vs. 20.3 ± 4.1, Cohen’s d = 1.43, 95% CI [0.99, 1.87]) ( P  < 0.01, P  < 0.05), as shown in Table 4 and Fig. 2 .

Inclusion criteria: A total of 100 patients who underwent laparoscopic difficult hysterectomy at our institution from January 2021 to June 2022 were included after screening according to exclusion criteria. The conventional group had an age range of 42–56 years, with a mean age of (45.3 ± 4.2) years; parity ranged from 0 to 5, with a mean of (2.1 ± 0.5), and the menopause rate was 30% (15/50). The combined group had an age range of 41–58 years, with a mean age of (44.7 ± 1.2) years; parity ranged from 0 to 6, with a mean of (3.0 ± 9.5), and the menopause rate was 36% (18/50), showing no statistically significant difference (see Table 1 ). Surgical indications: meeting one of the following criteria: (1) severe uterine adhesions to the bladder or rectum (e.g., DIE); (2) uterine size exceeding that of a 3-month pregnancy; (3) special cases such as broad ligament or cervical fibroids undergoing laparoscopic surgery. All surgeries were performed by the same surgeon and team. Exclusion criteria: (1) preoperative diagnosis of malignant disease; (2) severe medical or surgical comorbidities rendering the patient unfit for surgery or anesthesia; (3) preoperative stress urinary incontinence or pelvic organ prolapse; (4) failure to sign informed consent documents. ① Preoperative examination and preparation: Preoperative blood routine, biochemical tests, coagulation mechanism, electrocardiogram, chest X-ray, color Doppler ultrasound of the liver, gallbladder, pancreas, spleen, and kidneys, vaginal discharge routine, cervical liquid-based cytology, and colposcopy were all within normal limits. If there is a history of abnormal uterine bleeding, intraoperative fractional curettage is performed for rapid pathology to exclude malignant lesions. Fasting for 12 h and no water intake for 4 h before surgery, along with bowel preparation. A single dose of cefazolin was administered intravenously 30 min preoperatively, with an additional dose given if the surgical duration exceeded 3 h or there was significant blood loss. Based on the Caprini score, high-risk patients received subcutaneous low molecular weight heparin 24 h postoperatively. A multimodal analgesia regimen was implemented, including preoperative acetaminophen and celecoxib, intraoperative local anesthetic infiltration of the incision, and postoperative opioids as needed. Vasopressin was not utilized during the surgery. Energy device settings must adhere to the following specifications: Ultrasonic scalpel should be set to LEVEL 3 (medium) for dissecting tissues such as the broad ligament, vesicouterine peritoneal reflection, and uterosacral ligaments, with the blade maintaining a safe distance of > 10 mm from critical structures like the ureter and intestines. Bipolar electrocautery should be set to 40 watts for managing the uterine artery or paracervical tissues, ensuring clear identification of the ureter’s course and maintaining a safe distance. Monopolar electrocautery/cutting (cutting at 50 watts/coagulation at 40 watts) is used for incising the vaginal vault and performing spot coagulation of residual bleeding points; prolonged continuous activation should be avoided to minimize smoke production and thermal spread risks. This study is a primary prospective cohort study. The primary outcome was preset as intraoperative estimated blood loss. Secondary outcomes include operative time, incidence of intraoperative complications (such as ureteral injury), and pelvic floor dysfunction assessed by the PFDI-20 questionnaire at 3 years postoperatively, etc. ② Surgical anesthesia and positioning: General anesthesia with endotracheal intubation is used. The patient is placed in the lithotomy position, with legs padded and the head lowered 15–30 degrees. The surgeon stands on the left side of the patient, and the assistant stands on the right. Routine disinfection of the perineum and abdomen is performed, followed by pneumoperitoneum establishment and puncture. The uterus, adnexa, bladder, rectum, and pelvic adhesions are examined to clarify anatomical relationships. ③ Surgical steps: Electrocoagulate the isthmus of the fallopian tube (near the uterine cornu) and dissect laterally to the fimbriated end for complete removal of the fallopian tube. If preserving the ovary, care must be taken to avoid damaging the ovarian blood supply. If the ovary is to be removed simultaneously, the suspensory ligament of the ovary is transected, followed by dissection toward the uterus. The next step involves managing the uterine arteries and veins in groups: Observation Group: (1) Transect the round ligament: The round ligament, extending between the uterus and the labia majora, is superficial and easily identifiable. After incision, access to the retroperitoneal space is achieved.(2) Expose the origin (main trunk) of the uterine artery: Open the posterior leaf of the broad ligament and locate the terminal branch of the internal iliac artery (lateral umbilical ligament) medial to the external iliac vessels. If the lateral umbilical ligament is indistinct, traction on the superficial lateral umbilical ligament of the anterior abdominal wall can aid exposure. Trace it distally to the first branch (origin of the uterine artery), bluntly dissect the surrounding loose tissue, and confirm it as the uterine artery based on its relation to the ureter. Expose a 2–3 cm vascular segment.(3) Ureter avoidance: The uterine artery typically courses inferomedially from the internal iliac artery and crosses superior to the ureter. Loose connective tissue between the artery and ureter was dissected to achieve clear separation. The artery was mobilized over a 1–1.5 cm length to allow secure placement of two clips. A “ureteral safety window” was created using a right-angle clamp.(4) Vascular occlusion (Bilateral uterine artery handling): Place a Hem-o-lok clip on both the proximal and distal ends of the uterine artery origin. After transection, the uterus immediately enters a ‘shock state’ (pale color, reduced size) (see Fig 1 A, B and C).(5) Following uterine artery occlusion, proceed with standard hysterectomy steps: Open the vesicouterine peritoneal reflection, push the bladder down to the level of the external cervical os, and coagulate the ascending branch of the left uterine artery at the level of the internal cervical os (upper edge of the uterine manipulator cup). Repeat the same for the right side. Use an electrosurgical hook to circumferentially incise the vaginal fornix along the uterine manipulator cup, remove the entire uterus vaginally (or reduce uterine volume via morcellation), and pack the vagina with gauze. Irrigate the pelvic cavity with warm saline under visualization, confirm hemostasis, and then: (6) Vaginal cuff closure: Use delayed-absorbable suture (Polydioxanone, PDS II 2 − 0) for a continuous locked suture of the vaginal mucosa. Fold and suture the uterosacral ligament in a figure-of-8 suture fashion 2–2.5 cm from its severed end to fix it to the lateral angles of the vaginal cuff, shortening it by ~ 1/3. Re-irrigate the pelvis and confirm no bleeding at the suture site (see Fig. 1 D). Then, a single #2 non-absorbable suture (Ethibond) was employed using a single-pass, bilateral fixation technique, sequentially traversing both sacral ligaments and the vaginal vault, and ultimately tied at the midline—the sacral ligament end was sutured at the thickest portion of the ligament, approximately 3–4 cm medial to the ischial spine, ensuring full-thickness fibrous tissue inclusion while avoiding penetration of the posterior peritoneum, and the vault end was sutured 1–2 cm lateral to the midline after cuff closure, incorporating the full-thickness vaginal mucosa and endopelvic fascia; during suture tightening, the vaginal vault was manually and gently elevated to the level of the ischial spine or slightly higher, with tension adjusted to prevent slippage or tissue tearing, and finally, five single knots were secured using a laparoscopic knot pusher, preceded by a ureteral palpation check using the blunt tip of an instrument to verify the absence of ureteral entanglement, tension, or injury. Fig. 1 A Schematic diagram of vascular clamping technique: Three-dimensional relationship of internal iliac artery - uterine artery - ureter (right pelvis). B Schematic diagram of vascular clamping technique: Placement of one Hem-o-lok clip each at the proximal and distal ends of the uterine artery origin. C Schematic diagram of vascular clamping technique: "Shock response" after Hem-o-lok clamping of uterine vessels in a 4-month gestational-sized uterus.*Uterine Atony in Hemorrhagic Shock: In the combined group, bleeding decreased to <10 mL/min within 5 minutes after uterine artery clamping (conventional group remained at 30-50 mL/min, P<0.001). Surgical field score: A 5-point scale was used to assess clarity (1=very poor, 5=excellent), with the combined group scoring 4.8±0.3 vs. the conventional group scoring 3.1±0.7 (P<0.01). Uterine volume reduction rate = (preoperative volume - volume 10 min after clamping) / preoperative volume × 100%. D Plication of the sacral ligament 2 cm from the severed end, fixed to both lateral angles of the vaginal stump A Schematic diagram of vascular clamping technique: Three-dimensional relationship of internal iliac artery - uterine artery - ureter (right pelvis). B Schematic diagram of vascular clamping technique: Placement of one Hem-o-lok clip each at the proximal and distal ends of the uterine artery origin. C Schematic diagram of vascular clamping technique: "Shock response" after Hem-o-lok clamping of uterine vessels in a 4-month gestational-sized uterus.*Uterine Atony in Hemorrhagic Shock: In the combined group, bleeding decreased to <10 mL/min within 5 minutes after uterine artery clamping (conventional group remained at 30-50 mL/min, P<0.001). Surgical field score: A 5-point scale was used to assess clarity (1=very poor, 5=excellent), with the combined group scoring 4.8±0.3 vs. the conventional group scoring 3.1±0.7 (P<0.01). Uterine volume reduction rate = (preoperative volume - volume 10 min after clamping) / preoperative volume × 100%. D Plication of the sacral ligament 2 cm from the severed end, fixed to both lateral angles of the vaginal stump Remove the vaginal gauze, confirm hemostasis, turn off the insufflator, evacuate intra-abdominal CO 2 , and close the skin incision with a single No. 1 silk suture. Surgery concluded. Conventional Group: Expose the ascending branch of the uterine artery at the level of the internal cervical os, coagulate it with bipolar forceps, and follow the same surgical sequence as the combined group, including conventional locked suture closure of the vaginal cuff. General data: age, body mass index (BMI), preoperative hemoglobin (Hb), obstetric history, uterine size, and comorbidities. Perioperative indicators: operation time, intraoperative blood loss, postoperative hospital stay, total hospitalization cost, 24-hour postoperative drainage volume, duration of postoperative drainage tube placement, and time to first postoperative anal exhaust. Surgical complications: Intraoperative complications mainly involve adjacent organ injuries, such as ureter, bladder, blood vessel, or intestinal damage.Ureteral thermal injury is an iatrogenic injury caused by the thermal energy from energy devices (such as electrocautery, ultrasonic scalpel) during surgical procedures, directly or indirectly leading to coagulation necrosis of ureteral tissue, often manifesting as delayed and insidious; postoperatively, if unexplained fever, low back pain, abdominal distension, ascites, or renal dysfunction occur, CT urography should be prioritized and comprehensively evaluated in combination with surgical history, symptoms, and other examinations.Postoperative complications include urinary retention, intestinal obstruction, pelvic hematoma, vaginal stump bleeding, postoperative infection, and deep vein thrombosis or pulmonary embolism. Postoperative sexual satisfaction scale and pelvic floor function assessment scale (patients with no sexual activity or less than three years of sexual activity postoperatively were excluded). General data: age, body mass index (BMI), preoperative hemoglobin (Hb), obstetric history, uterine size, and comorbidities. Perioperative indicators: operation time, intraoperative blood loss, postoperative hospital stay, total hospitalization cost, 24-hour postoperative drainage volume, duration of postoperative drainage tube placement, and time to first postoperative anal exhaust. Surgical complications: Intraoperative complications mainly involve adjacent organ injuries, such as ureter, bladder, blood vessel, or intestinal damage.Ureteral thermal injury is an iatrogenic injury caused by the thermal energy from energy devices (such as electrocautery, ultrasonic scalpel) during surgical procedures, directly or indirectly leading to coagulation necrosis of ureteral tissue, often manifesting as delayed and insidious; postoperatively, if unexplained fever, low back pain, abdominal distension, ascites, or renal dysfunction occur, CT urography should be prioritized and comprehensively evaluated in combination with surgical history, symptoms, and other examinations.Postoperative complications include urinary retention, intestinal obstruction, pelvic hematoma, vaginal stump bleeding, postoperative infection, and deep vein thrombosis or pulmonary embolism. Postoperative sexual satisfaction scale and pelvic floor function assessment scale (patients with no sexual activity or less than three years of sexual activity postoperatively were excluded). All data were analyzed using SPSS 26.0 statistical software. Normally distributed measurement data were expressed as mean ± standard deviation (x̄ ± s) and compared using the independent samples t-test. Non-normally distributed measurement data were expressed as median (M) and interquartile range (P25, P75) and compared using the rank-sum test. Count data were presented as frequency (n) and percentage (%) and analyzed using the chi-square test or Fisher’s exact probability test. A P-value < 0.05 was considered statistically significant. The sample size calculation for this study was based on the primary outcome—intraoperative estimated blood loss. According to previous literature data, under the conditions of α = 0.05 (two-sided) and statistical power (1-β) of 80%, sample size estimation was conducted using PASS 26.0 software for comparing means between two independent samples. To further ensure the study’s power and account for loss to follow-up or missing data, it is finally planned to include 50 patients in each group, with a total sample size of 100 cases.

Precision vascular clipping at the first branch of the internal iliac artery revolutionizes hemorrhage control in Complex hysterectomies via the " Uterine Atony in Hemorrhagic Shock " effect, while its anatomy-guided approach sets a “gold standard” for ureteral protection. Combined with uterosacral plication, it optimizes perioperative outcomes and offers an anatomical reconstruction solution to prevent pelvic floor dysfunction—ideal for young, sexually active, or high-prolapse-risk patients. Standardized protocols and long-term efficacy warrant further research.

Laparoscopic hysterectomy has become one of the standard surgical approaches for benign gynecological conditions due to its minimally invasive nature and rapid recovery [ 15 ]. With the increasing maturity of fertility preservation techniques such as ovarian tissue cryopreservation (OTC), the adoption of this surgical procedure has further expanded [ 16 – 18 ].However, in complex cases such as pelvic adhesions (e.g. deep infiltrating endometriosis, multiple prior surgeries), an enlarged uterus (e.g., fibroids exceeding 12 weeks’ gestation), or anatomical variations (e.g. broad ligament or cervical fibroids), surgical complexity significantly increases, raising the risks of conversion to laparotomy and intraoperative complications (e.g. bleeding, organ injury).Although transvaginal natural orifice transluminal endoscopic surgery (vNOTES) can significantly shorten operative time and reduce blood loss, with lower postoperative pain scores on days 1, 3, and 7, patients tend to ambulate earlier and return to daily activities more quickly. However, no significant differences were found in terms of hospital stay, intraoperative complications, or re-intervention/readmission rates. Additionally, its learning curve may limit widespread adoption. Currently, optimizing the key steps of laparoscopic hysterectomy to reduce intraoperative complications remains a practical clinical issue [ 19 ].Studies indicate that clamping the main uterine artery can block over 90% of uterine blood supply, aligning better with the “bloodless surgery” concept compared to conventional parauterine electrocoagulation [ 20 ]. For uteri larger than 16 weeks’ gestation or cases with extensive adhesions, early vascular occlusion can reduce uterine volume by over 30%, markedly lowering procedural complexity [ 21 ]. In challenging hysterectomies, applying vascular clips (e.g. Hem-o-lok) to the main uterine artery within a safe zone effectively achieves hemostasis, creating a “Uterine Atony in Hemorrhagic Shock” that rapidly minimizes intraoperative bleeding and improves visibility—particularly beneficial for cases with large vessels or a narrow pelvis. Our observations revealed that post-clipping, uterine volume decreased swiftly, with average blood loss dropping below 10 mL/min, significantly outperforming conventional methods (30–50 mL/min). This confirms the reliability of this technique for vascular control. Additionally, the combined approach demonstrated markedly lower mean intraoperative blood loss (68.7 ± 15.2 mL) than conventional methods (95.2 ± 18.4 mL, p < 0.001), consistent with literature reports [ 22 ].Moreover, intraoperative clip application avoids suture slippage risks, ensures precise vessel occlusion, and reduces ureteral angulation caused by tissue traction. Another major concern in Complex laparoscopic hysterectomies is ureteral injury. Our team’s “retrograde dissection” technique along the internal iliac artery reduced ureteral injury risk from the reported 2%–11% to 0%, mitigating thermal damage or accidental clipping from blind dissection (no ureteral complications occurred in this study versus 4% in conventional groups) [ 23 – 25 ]. Disruption of pelvic floor support structures following hysterectomy is a significant contributing factor to postoperative vaginal vault prolapse. This study involved immediate uterosacral ligament plication after hysterectomy, effectively reducing the risk of vaginal axis alteration by shortening the ligaments, reconstructing the vaginal apex structure, and enhancing support to prevent postoperative vaginal vault relaxation and associated pelvic organ prolapse. Based on POP-Q and PFDI-20 scores, the combined approach group demonstrated significantly better outcomes than the conventional group from six months to three years postoperatively. The combined group maintained superior vaginal length preservation, with a significantly lower incidence of POP-Q stage ≥ II ( P  < 0.01), indicating the technique’s effectiveness in preserving or improving pelvic floor structural integrity and enhancing anatomical stability post-hysterectomy, while serving both therapeutic and preventive roles in complex hysterectomies. Additionally, sexual quality of life (FSFI scores) remained consistently higher in the combined group over time, likely due to better vaginal length retention, cavity stability, and pelvic floor function improvement—particularly meaningful for younger patients or those with high sexual function demands. Uterosacral ligament plication avoids mesh-related erosion or infection risks, aligning better with physiological repair principles. Key intraoperative considerations include preserving adequate ligament length (>3 cm) to prevent ureteral kinking [ 26 , 27 ]. Delayed-absorbable sutures (PDS) were chosen because post-degradation scar tissue in the ligament-vaginal complex can functionally replace conventional “high uterosacral ligament suspension.” PDS retains over 50% tensile strength for three months, covering the critical vaginal cuff healing period [ 28 ]. Compared to non-absorbable sutures, delayed-absorbable sutures significantly reduce suture-related granuloma formation (vaginal cuff polyps: 0 cases in combined group vs. 1 in conventional group). However, delayed absorption may prolong complete vaginal cuff epithelialization; one patient (postmenopausal for 5 years) experienced complete dehiscence after intercourse at 70 days post-op, attributed to reduced healing capacity, yet outcomes remained favorable versus three dehiscence cases in the conventional group. The innovation of this study lies in the combination of vascular clip closure technique with uterosacral ligament plication, with synergistic effects manifested in: (1) Surgical process optimization: Hem-o-lok is first applied to control the main uterine artery, reducing intraoperative bleeding interference that prolongs surgery duration and increases complications, while also enhancing clarity during subsequent ligament exposure and plication; (2) Pelvic floor function preservation: Precise closure of the main uterine artery while retaining microvascular networks within the ligaments may promote postoperative ligament healing, thereby reducing long-term complications like vaginal vault prolapse—particularly beneficial for young, multiparous women or those with connective tissue disorders. Traditional difficult hysterectomies require reoperation in approximately 8% of cases due to bleeding or prolapse, whereas no such cases occurred in the combined technique group [ 29 ]. Furthermore, the combined approach demonstrated superior outcomes in postoperative hospitalization duration, time to first flatus, and total hospitalization costs compared to traditional methods, further indicating its potential to enhance recovery and conserve medical resources. Despite the encouraging results, this study has several limitations. First, as a prospective cohort study with a moderate sample size ( n  = 100), all procedures were performed by a single surgical team to minimize bias. However, the single-center design may limit the generalizability of the findings. The patient population may be influenced by specific regional, socioeconomic, and institutional factors, potentially introducing selection bias. Moreover, this design does not allow evaluation of the potential impact of center effect on outcomes. Second, the 3-year follow-up period may be insufficient to capture the long-term progression of pelvic floor dysfunction, such as risks of surgical recurrence, late-term complications (e.g., mesh erosion or new-onset prolapse), and the continuing effects of aging and natural disease history on therapeutic outcomes. This could lead to overestimation of mid-term success rates and underestimation of long-term risks. Pelvic floor dysfunction is inherently an age-related progressive disorder. The effect of aging within the 3-year timeframe may not yet be apparent. However, over a longer follow-up period of 5 or 10 years, as the patient cohort enters older age groups, the benefit of the surgery may be diminished by age-related tissue weakening. Short-term follow-up cannot distinguish between “loss of surgical efficacy” and “advancement of the natural disease process.” These limitations should be acknowledged when interpreting the results. Third, this study was conducted by a senior surgical team with a significantly compressed learning curve. Experienced laparoscopic surgeons may master this technique relatively quickly, with fewer postoperative complications. Additionally, the hospital is equipped with comprehensive laparoscopic equipment and instruments, supported by strong multidisciplinary collaboration capabilities. However, primary-level hospitals with relatively limited resources may lack high-definition laparoscopic systems or specialized vascular clips, and the proficiency of their anesthesia and nursing teams may vary. Therefore, while this technique may demonstrate good replicability in hospitals of comparable levels, its promotion in primary-level hospitals requires careful evaluation.

Complex hysterectomies (such as those involving large fibroids, pelvic adhesions, broad ligament or cervical fibroids, or endometriosis) often present challenges such as excessive intraoperative bleeding and anatomical variations. Conventional electrocautery or suture ligation methods for hemostasis are often unreliable and may significantly increase the risk of ureteral injury. In recent years, disposable vascular clips (e.g., Hem-o-lok) have been widely used in surgical procedures for vascular closure due to their simplicity of operation and reduced thermal injury. During conventional laparoscopic hysterectomies, surgeons typically coagulate and transect the uterine artery at the level of the internal cervical os. However, in challenging cases—such as those with an enlarged uterus exceeding the size of a 3-month pregnancy or patients with broad ligament or cervical fibroids—the uterine body or fibroids occupy most of the pelvic space, making it complex to expose the ascending branch of the uterine artery at the internal os. Additionally, the uterine vessels in these cases are often significantly engorged, increasing the likelihood of incomplete vascular occlusion after coagulation, leading to massive bleeding post-transection. This may necessitate conversion to laparotomy or result in inadvertent thermal injury to the ureter due to blind coagulation attempts. Similarly, in cases of deep infiltrating endometriosis with severe adhesions involving the bladder or rectum, exposure and occlusion of the uterine vessels become challenging. Dissection of adhesions may directly injure the ureter, or uncontrolled bleeding from the uterine vessels may prompt blind coagulation, further risking thermal ureteral injury [ 1 – 5 ]. To address these issues, clinicians have explored various surgical modifications aimed at reducing intraoperative bleeding and avoiding collateral damage. Techniques such as intramyometrial injection of vasopressin, suturing the ascending branch of the uterine artery, or ligating the uterine artery with No. 7 silk sutures have been attempted. However, these methods carry drawbacks, including significant drug side effects (e.g., vasopressin-induced hypertension) or the need for extensive dissection around the uterine artery [ 6 – 8 ]. In response, we adopted the use of vascular clips (Hem-o-lok) to permanently occlude the main trunk of the uterine artery before coagulating its ascending branch during complex laparoscopic hysterectomies. This approach minimizes intraoperative bleeding, shortens operative time, and reduces both intraoperative risks and postoperative complications. Meta-analyses indicate that patients undergoing total hysterectomy often experience pelvic floor dysfunction, such as vaginal vault prolapse, anterior/posterior vaginal wall bulging, shortened vaginal length, and diminished sexual quality of life. These concerns are a major deterrent for patients with benign conditions considering hysterectomy [ 9 , 10 ]. In cases of severe prolapse, certain patients require repeat sacrocolpopexy, where mesh is utilized to affix the anterior and posterior vaginal walls to the anterior longitudinal ligament overlying the sacrum, significantly compromising postoperative quality of life [ 11 ]. In recent years, uterosacral ligament plication techniques, based on the concept of “structural reconstruction,” have gradually replaced simple vaginal cuff closure. However, their feasibility in complex hysterectomies has not been systematically evaluated [ 12 – 14 ]. To address this, we employed delayed-absorbable No. 0 Ethibond sutures, placing them 2–3 cm anterior to the sacral attachment of the uterosacral ligament and plicating both ligaments to fix the vaginal cuff. This technique elongates the vaginal canal, elevates the vaginal vault, and prevents postoperative pelvic organ prolapse, offering a practical clinical solution. Therefore, we systematically evaluated the short- and long-term clinical outcomes of using vascular clips for uterine artery occlusion and uterosacral ligament plication in complex laparoscopic hysterectomies. Follow-up to date has demonstrated favorable results, as detailed below. This study was approved by the Ethics Committee of Wuxi Maternal and Child Health Hospital (Ethics No.: XJSLLY2024010,2024-05-15).