1. Before surgery, perioperative intravenous antibiotics and antiembolic prophylaxis are routinely administered.

2. Appropriate positioning of a patient for vaginal hysterectomy includes the patient being in dorsal lithotomy position with her feet in candy cane or Allen stirrups. The patient’s buttocks extend slightly over the table so that the posterior retractor can be easily placed. The thighs are somewhat abducted and the hips are flexed. Excessive flexion and abduction of the thigh are avoided, which can lead to position-induced injuries. Candy cane stirrups are preferred for deep vaginal surgery and when two vaginal surgical assistants are needed.

3. Examination under anesthesia is performed to confirm the uterine size, the degree of uterine mobility, the width of the vaginal canal, and the presence or absence of pelvic pathologic abnormalities. The freedom of the cul de sac is noted, and a rectovaginal bimanual examination is performed.

4. The vaginal, perineal, and lower abdominal areas are prepared in normal fashion, and the patient is sterilely draped. The urinary bladder is then emptied by a catheter, or an indwelling Foley catheter is placed for continual drainage.

5. The cervix is grasped with two single-tooth uterine tenacula, and downward traction is placed. The author prefers to use a vasoconstrictor agent such as vasopressin or a prepared solution of 0.5 % lidocaine; 1 : 200,000 epinephrine can be used if no contraindications exist. The solution is injected into the cervix or paracervical tissue just before the incision is made, which has been shown to decrease operative blood loss without an increase in morbidity in randomized trials. The maximum amount of lidocaine administered with epinephrine should not exceed 7 mg/kg body weight or 500 mg total in a healthy adult. Should a medical contraindication be present to the use of vasopressors or epinephrine, injectable saline provides the benefits of hydrodistention without the benefit of vasoconstriction or any increase in cardiovascular risk.

6. A knife or electrosurgical instrument is used to make the initial incision through the vaginal mucosa at the cervicovaginal junction (Figure 4-1). The position and depth of this incision is extremely important, and, if performed correctly, significantly facilitates the simplicity of the hysterectomy. The appropriate location of this incision is at the site of the bladder reflection, which is identified by a crease formed in the vaginal mucosa when the cervix is pushed slightly inward. If the location cannot be identified, the incision is made lower rather than higher to avoid any potential bladder injury. The circumferential incision is cut down until the cervical stroma is encountered. A clear plane exists between the full thickness of the vaginal wall and the cervical stroma. When this plane is reached, the vaginal tissue falls away from the underlying cervical tissue; this direct plane leads the surgeon to both the anterior and posterior cul-de-sacs.

7. Posterior mobilization of the vagina allows access to the posterior cul-de-sac, which is sharply entered with Mayo scissors and then explored digitally for any adhesive diseases, masses, or bowel, as well as to confirm the size of the uterus (Figures 4-2 and 4-3).

8. Downward traction on the uterus and pulling it to one side facilitates the placement of the first clamp. A Heaney or Ballentine clamp is used to ligate the uterosacral ligament (Figure 4-4). This pedicle is cut with Mayo scissors and ligated with an absorbable suture. The authors prefer an O-vicryl suture on a CT1 needle. The cut pedicle is suture ligated with a type of transfixing suture in which the needle enters the upper part of the ligament pedicle just behind the tip of the Heaney clamp; it is withdrawn and then reintroduced into the pedicle at its midpoint. This suture has been termed a Heaney-type stitch. Each uterosacral ligament is usually tagged for later identification.

9. Sharp dissection is then used to further mobilize the vaginal wall off the cervix, and the cardinal ligaments are bilaterally clamped and ligated in a similar fashion. Careful and concise incisions are used to enter the anterior cul-de-sac to prevent any inadvertent cystotomy (Figure 4-5). In addition, forceful blunt dissection of the bladder off the cervix with a finger or a sponge stick is discouraged because lacerations can occur. Many women who have had previous cesarean sections may exhibit significant scarring between the anterior vaginal wall and the base of the bladder. No attempt to enter the anterior cul-de-sac is made until the vesicouterine space has been developed and the preperitoneal tissue has been visualized (Figure 4-6). Once the vesicouterine space has been entered, a retractor is used to elevate the bladder off the uterus, and the anterior cul-de-sac peritoneum can be entered. A Heaney retractor is then placed anteriorly using a finger to protect the bladder (Figure 4-7).

10. The next clamp usually includes the uterine vessels and incorporates anterior and posterior peritoneal reflections of both cul-de-sacs. The placement of these clamps is perpendicular to the longitudinal axis of the cervix, and the tips of the clamps slide off the tip of the cervix and uterus to ensure that all of the parametrical and vascular tissues have been included (Figure 4-8). This placement of the clamps helps avoid excessive bleeding and clearly ensures that the surgeon is staying close to the cervix, which should avoid any potential for ureteral injury. The uterine vessels are then suture ligated with a fixation stitch in which each pedicle is sutured into the previous pedicle. This technique completely obliterates the dead space between pedicles, thus decreasing the potential for the tearing of tissue and bleeding (Figure 4-9). Depending on the size of the uterus, several more clamps may be needed. If the uterus is enlarged, then morcellation techniques are used and usually started at this point. (See Video 4-2, “Morcellation Techniques in Patients with an Unsuspected Enlarged Uterus.” ) Once the adnexal pedicles have been identified, the uterus can usually be posteriorly delivered through the vagina by grasping the fundus with a tenaculum and pulling downward to expose the uterovaginal ligament. A Heaney clamp is placed close to the uterus, clamping the pedicles. Usually, one clamp is sufficient; however, at times, two clamps may be needed if the pedicle is large (Figure 4-10). If two clamps are used, then they should overlap each other in the midline. Before cutting the specimen away from the clamps, the finger is placed behind the clamps to ensure that no small bowel comes in proximity to the back of the uterus. Some surgeons prefer double ligating this pedicle first with a free suture and then followed by a suture ligature. Once both clamps have incised the specimen (i.e., the uterus and cervix), it is handed off and sent for a pathologic evaluation. The clamps are then retracted and the adnexal structures (i.e., ovaries and tubes) are palpated to ensure that they are normal and that no unsuspecting pathologic abnormalities exist. If the adnexa are to be removed following the preference of the patient or if an abnormality or a lesion is found in the ovaries and patient consent has been previously obtained, then the ovaries and tubes can be removed. (See Video 4-3, “Technique for Vaginal Oophorectomy.” ) The ovarian ligature sutures are held without tension, as are the uterosacral pedicles. (For a detailed discussion on the indications and techniques for vaginal oophorectomy at the time of vaginal hysterectomy, the reader is referred to Walters M, Barber M; editors: Hysterectomy for benign disease. In Karram M, editor: Female pelvic surgery video atlas series, Philadelphia, 2010, Elsevier.)

11. Some surgeons prefer an electrosurgical bypass or vessel-sealing device to seal or fuse the blood vessels instead of using the traditional methods of clamping, cutting, and suture-ligating these pedicles. The tissue effusion instrument consists of a disposable device with a pistol grip, Heaney-type clamp, and retractable scalpel to cut tissue after fusion. Pedicles are clamped, sealed, and fused; they are then cut before the clamp is released. This device is then advanced to the next pedicle, and the process is repeated. Although no randomized trials have compared this procedure with the traditional clamping techniques to verify clinical benefit, this technology is popular and has been shown in several small studies to decrease operating and anesthesia time, as well as patient blood loss. (See Video 4-4, “Electrosurgical Device–Assisted Vaginal Hysterectomy.” )

12. At this time, the support of the vaginal cuff is assessed and the surgeon must determine whether a simple culdoplasty is sufficient to facilitate apical vaginal length or whether a formal apical suspension is needed. The author of this text believes that if the vaginal cuff descends to less than a −2 station after the uterus has been removed, then a McCall culdoplasty is an excellent mechanism to obliterate the enterocele, support the cuff to the uterosacral ligaments, and add sufficient posterior vaginal wall length. A McCall culdoplasty should almost routinely be considered in all vaginal hysterectomies whether performed for prolapse conditions or other gynecologic indications. In a randomized surgical trial, adding this maneuver, compared with simple vaginal closure, was shown to lower the risk of future prolapse. (Cruikshank, Kovac, 1999) The McCall culdoplasty is performed by passing nonabsorbable sutures from the vaginal lumen just lateral to the midline of the posterior vaginal wall into the peritoneal cavity. This same suture is then taken through the left uterosacral ligament across the intervening peritoneum and through the right uterosacral ligament; it then exits the vaginal cuff just to the left of the midline. Numerous external sutures can be placed as needed. Internal McCall sutures, which are sutures that simply plicate the two uterosacral ligaments and intervening peritoneum, can then be placed as needed. External McCall sutures are always delayed absorbable sutures; as the knots are tied in the lumen of the vagina, while internal McCall sutures are permanent sutures because the knot is tied intraperitoneally (Figure 4-11). (Video 4-5, “Modified McCall Culdoplasty,” demonstrates the use of the McCall procedure). A modification of the McCall culdoplasty, which is commonly used in patients with prolapse, involves the technique of removing a redundant wedge of the posterior vaginal wall and peritoneum (Figure 4-12).