This video will demonstrate utilization of a low-cost vaginal hysterectomy simulation trainer. The creation of this model is described in a separate video on the ACOG toolkit website. The goals for this model are to incorporate surgical techniques of clamping, suturing, and tying alongside the procedural steps for vaginal hysterectomy. The steps shown are those of the Mayo technique for vaginal hysterectomy. However, the model can be used to simulate any technique. We chose to overlay still images from an operative case for each procedural step. The anterior and posterior lip of the cervix are grasped with a toothed tenacula. Lateral incisions are made using a knife handle to later identify vaginal cuff angles. A circumferential ghost incision is made in the vaginal epithelium. With downward traction on the cervix, the epithelium is grasped and scissors are used to enter the anterior cul-de-sac. A DEVA retractor is placed in the anterior cul-de-sac. Now with upward traction on the cervix, the epithelium is grasped and pulled downward and scissors are used to enter the posterior cul-de-sac. Beginning on the patient's left side, the vaginal epithelium is dissected off to allow access to the uterus sacral ligament. Utilizing a Haney clamp, the uterus sacral ligament is clamped, transected, and suture ligated. This is tagged for later identification using a Coker clamp. I will be showing different options for suture ligation of a pedicle during a vaginal hysterectomy. The first technique is the traditional Mayo technique, where the needle is passed through the tissue behind the clamp in the middle of the pedicle, after which a single tie is placed. The second technique is the traditional Mayo technique, where the needle is passed through the tissue behind the clamp in the middle of the pedicle, after which a single tie is placed. The suture is then carried around the tip of the pedicle and tied an additional four times while the assistant releases the clamp. In this technique, the needle is passed through the middle of the pedicle and each end of the suture is brought around the tip of the pedicle in opposite directions. Four ties are placed as the assistant releases the clamp. A DEVA retractor is used laterally and the ureter is identified by palpation with the left index finger. The first bite of the cardinal ligament is clamped. The hair elastic gives some resistance during transection to simulate real tissue. Again, it is suture ligated and tagged using a curved clamp. On the second cardinal ligament bite, the anterior and posterior peritoneum are brought together, including the uterine artery indicated by the red hair elastic. It is transected, ligated, and tagged with the first cardinal pedicle. Attention is then turned to the opposite side where the epithelium is inserted. The first cardinal ligament is clamped. Attention is then turned to the opposite side where the epithelium is trimmed back in a similar fashion. The uterus sacral ligament is taken and tagged, this time showing a different suture ligature technique. The ureter is again palpated. The first cardinal ligament bite is taken. The first cardinal ligament is clamped. The first cardinal ligament is clamped. The first cardinal ligament is clamped. The first cardinal ligament is clamped. The first cardinal ligament is taken and suture ligated. The second cardinal ligament bite is taken, including the uterine artery. A tenaculum is removed from the cervix, which is grasped and inverted, giving access to the uterovarian pedicles. The patient's right side is taken first, with the tips of the haney pointed inferiorly. The pedicle is transected and held. The tenaculum that was on the posterior fundus is now moved to the right uterine cornea. With traction on the uterus, the left uterovarian pedicle is easily accessed. It is clamped and cut, delivering the specimen. The uterovarian pedicles are ligated and tagged. A prophylactic apical suspension is done to resuspend the vagina and decrease the risk of posthysterectomy vault prolapse. We show a modified McCall coldoplasty technique. A suture passes to the left of the patient midline through the posterior vaginal cuff. The black PVC shrink tubing has been placed to mimic the uterus sacral ligaments, and a bite of this is taken using the same suture on the patient's left. The needle is reloaded, and the movement of reefing across the peritoneum is simulated. A bite of the right uterus sacral ligament is taken, and the suture is brought out the vaginal epithelium adjacent to the initial entry point. When tied, this brings the uterus sacral ligaments to the midline and resupports the vaginal apex. The uterovarian pedicle tags are cut. We then begin closing the vaginal epithelium. The uterus sacral and cardinal ligaments are pulled towards the patient's right side, and we begin at the vaginal cuff angle, incorporating a bite of uterus sacral ligament to add with apical resuspension. After tying, all tags on that side are cut. Sequential bites of the posterior and anterior vaginal epithelium are taken and tied until the midline is reached. Attention is then turned to the patient's right side, where a similar cuff closure is performed. This begins with a back, hand-loaded needle that incorporates the uterus sacral ligament into the corner of the cuff. After tying the corner, all tags are cut, and the remaining vaginal cuff is closed. This concludes our video. Thank you for your attention.

vaginal hysterectomy simulation trainer

surgical techniques

Mayo technique

operative case

closure of vaginal epithelium