Lateral-posterior First Colpotomy: Optimizing Surgical Comfort and Rectal Safety during Total Laparoscopic Hysterectomy

Abstract

Objective: To evaluate the impact of colpotomy sequencing on operative time, surgical comfort, and perioperative safety during total laparoscopic hysterectomy (TLH), comparing a lateral-posterior first approach to the conventional anterior technique. Methods: A monocentric retrospective study was conducted at the Mohamed V Military Teaching Hospital (Rabat, Morocco) on 80 consecutive patients between 2022 and 2025. Two groups were compared: Group A (n=40, anterior first colpotomy) and Group B (n=40, lateral-posterior first colpotomy). The primary endpoint was colpotomy time. Secondary endpoints included a surgical comfort score (1 to 3) and complication rates (rectal and ureteral injuries). Results: Mean colpotomy time was significantly shorter in Group B, especially for large uteri (10 min vs. 16 min; p < 0.001). In Group B, 90% of procedures were rated "highly satisfactory" for surgical comfort, compared to 30% in Group A. One rectal serosal injury occurred in Group A, while no visceral complications were recorded in Group B. The lateral-posterior technique maintained optimal vaginal tension, preventing posterior uterine tilting. Conclusion: Lateral-posterior first colpotomy is an effective technical variant that optimizes the exposure of the Pouch of Douglas. It reduces operative time and secures the recto-vaginal interface, making it a preferred strategy for large uteri.