" A Systematic Approach to Laparoscopic Hysterectomy for Enlarged Uteri: The Ship Theory"

Stefano Restaino^1*Giulia Pellecchia²Angelo Finelli³Alessandro Gioè⁴Martina Arcieri¹Stefano Cianci⁵Federico Paparcura²Alice Poli²Stefano Uccella⁶Giovanni Scambia⁷Lorenza Driul²Giuseppe Vizzielli²Salvatore Gueli Alletti⁴

• ¹Azienda sanitaria universitaria Friuli Centrale, Udine, Italy
• ²Universita degli Studi di Udine, Udine, Italy
• ³Mater Olbia Hospital, Olbia, Italy
• ⁴Ospedale Buccheri La Ferla Fatebenefratelli, Palermo, Italy
• ⁵Universita degli Studi di Messina, Messina, Italy
• ⁶Universita degli Studi di Verona, Verona, Italy
• ⁷Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy

Total laparoscopic hysterectomy (TLH) for enlarged uteri presents a significant challenge for surgeons due to limited surgical field exposure, increasing the risk of injury to the bowel, bladder, ureters, and blood vessels. To minimize these intraoperative complications, a surgical approach known as "The Ship Theory" has been developed at our center. According to this concept, the uterus is likened to a large vessel moored within the pelvis. As its supporting ligaments ("anchors") are progressively released, the uterus gains mobility, allowing it to migrate into the abdominal cavity. This enhanced mobility improves visualization and facilitates surgical access, enabling a safer and more effective TLH for large uteri. Using this approach, we successfully performed this procedure on a 51-year-old female patient with uterine leiomyomas and metrorrhagia. Preoperative imaging revealed a uterus measuring 189 × 158 × 148 mm. Institutional review board and ethics committee approval was obtained. The total operative time was approximately 90 minutes, with an estimated blood loss of less than 50 mL. The patient was discharged 48 hours postoperatively without complications. This technical report demonstrates that the application of a minimally invasive surgical technique for uteri with significant spatial constraints—as outlined in "The Ship Theory"— is not only feasible but can be successfully executed when performed in a systematic and structured manner.