AIM: This study aims to evaluate the impact of two-dimensional (2D) versus three-dimensional (3D) imaging systems and barbed versus standard absorbable multifilament sutures on surgical times and complications in total laparoscopic hysterectomy. METHODS: A retrospective cohort study was conducted at a tertiary hospital between May 2020 and September 2024. Patients who underwent total laparoscopic hysterectomy were categorized into four groups based on imaging system (UltraHD-2D vs. FullHD-3D) and suture type (VICRYL™ multifilament suture interrupted figure-of-8 technique vs. V-LOC™ barbed suture running technique). Primary outcomes included vaginal cuff closure time and total operation duration. Secondary outcomes were mean suturing time, perceived difficulty, and postoperative complications. RESULTS: A total of 159 patients were analyzed. Vaginal cuff closure time was significantly shorter with 3D imaging systems compared to 2D systems when VICRYL™ sutures were used (13.85 ± 4.30 vs. 21.17 ± 5.13 min, p <
0.001). No significant difference was observed between imaging systems when V-LOC™ barbed sutures were used. Across both systems, V-LOC™ sutures consistently reduced suturing time compared to VICRYL™ sutures (p <
0.001). Surgeon-perceived difficulty was lower with V-LOC™ sutures, particularly in 2D systems. No significant difference in complication rates was observed between groups (p = 0.188). CONCLUSION: The use of 3D imaging systems in total laparoscopic hysterectomy significantly reduces vaginal cuff closure duration and overall operative time with VICRYL™ sutures, while V-LOC™ sutures consistently enable faster procedures across both imaging modalities. These findings suggest that 3D imaging systems and barbed sutures may enhance surgical efficiency without increasing complication rates.