In this video, we will examine techniques in anterior colpotomy and cystotomy repair in vaginal hysterectomy, a primer for resident education. At the completion of their training, the goal is for all OB-GYN residents to graduate feeling comfortable independently performing a vaginal hysterectomy. While the vaginal approach is preferred for hysterectomy, more difficult steps such as the anterior entry prevent barriers for the learner. Our goal is to review various techniques for anterior colpotomy and to recognize immediate signs of a cystotomy. Most importantly, we aim to expose residents to surgical cases performed by their colleagues acting as the primary surgeon. In vaginal hysterectomy, we gain access to the vesico-uterine pouch through dissection of the vesico-vaginal and vesico-cervical septum. Compared to posterior entry, this dissection is less straightforward to the learner, as it often reaches 4 centimeters in length. The vaginal hysterectomy is begun with creating a circumferential incision in a sharp fashion or with cautery. The vaginal epithelium is then gently retracted. The utero-sacral and cardinal ligaments have been taken at this point. Here, the vesico-cervical septum can be clearly seen. The septum consists of fibrous connective tissue, which can be confidently dissected once recognized. The resident is pointed the scissors toward the cervix and following its curvature. Once the septum is cut, the retractor is replaced, and the reflection of the vesico-uterine peritoneum can be seen, aptly referred to as the smiley face. The resident recognizes this fold, and again, pointing the scissors toward the cervix, will sharply enter the peritoneal cavity. The peritoneum is then tagged for future closure. Another approach to the anterior colpotomy is demonstrated here. After a direct posterior colpotomy and tagging the utero-sacral ligaments, attention is then turned anteriorly, where the dissection is begun between the outlined bladder pillars. The vesico-uterine space is then dissected in a blunt fashion, being sure to stay anterior to the uterus, and avoid lateral dissection or disruption of the uterine vessels. When first beginning to perform vaginal hysterectomy, it can be helpful for the resident to have a clear outline of where the subsequent clamp should be placed as anterior entry is approached. Here, the attending both trans-illuminates the cardinal ligament and places an Alice clamp to demonstrate the proper location. Even in a resident's first hysterectomy, as is seen here, this affords the attending some level of comfort and the ability to focus the teaching on how to properly place the clamp. An important step in anterior entry is not only learning how the peritoneal reflection should look, but also how the tissue should behave. After palpation, the resident is tasked with deciding where to make the incision to complete the colpotomy. They appreciate the fibrous nature of the tissue and realize the incision should be made just superior to this, where they initially palpated the sliding nature of the peritoneal reflection. When the uterus is small, we often encourage the resident to palpate the vesico-uterine pouch directly, as we find this helps correlate the vaginal hysterectomy with an abdominal approach in which the resident often has a view of both sides of the uterus. The vesico-cervical septum is seen here, communicating with the pubocervical connective tissue. Consequences of failing to recognize when the bladder has been properly dissected off the cervix can result in a cystotomy. In this case, the incision is made where the tissue is not easily mobile, is thick, and is relatively high off of the cervix. A cystotomy is made with the return of urine appreciated. With the bladder location now known given the cystotomy, the bladder can be retracted and the incision directed inferiorly to the previous attempt. The tissue is easily mobile and palpation confirms the characteristic sliding of the peritoneal fold. Following completion of the hysterectomy, a cystoscopy is performed to assess the cystotomy. When a known injury occurs, it is vitally important to survey the remainder of the bladder and assess bilateral ureteral patency. In this case, a 2-centimeter supertrigonal defect is visualized. Bilateral efflux of urine was found in the bladder. In this case, a 2-centimeter supertrigonal defect is visualized. Bilateral efflux of urine was confirmed from the ureteral orifices. Bilateral efflux of urine was confirmed from the ureteral orifices. We see the same defect from the vaginal perspective with the edges of the uroepithelium appreciated. The cystotomy is closed in two layers. The first layer must incorporate the uroepithelium and muscularis propria and is closed in a non-locking fashion. We prefer a second layer to imprecate our primary closure. The bladder was then backfilled to challenge the integrity of the closure itself. Upon repeat cystoscopy, a full bladder survey is again performed, ensuring that the defect is closed and that no other injury to the bladder is seen. Given that the closure can place the ureters at risk, bilateral ureteral patency is again confirmed. We plan to correlate this learning with cadaveric pelvic dissection, which is available in our residency program. We hope that this video will serve as a primer for familiarizing residents with vaginal hysterectomy and encourage video as a form of self-evaluation.

OB-GYN

residents

anterior colpotomy

cystotomy repair

vaginal hysterectomy