Vaginal hysterectomy can be a challenge even for the experienced surgeon due to limited surgical working space and exposure, large uteri, entry into the cul-de-sacs, adenexae that are high in the pelvic brim, and limited visualization. This video will cover the use of devices and techniques and will aid in making the difficult vaginal hysterectomy successful. Key principles include achieving adequate exposure, sharp dissection and delay of entry into the anterior cul-de-sac, securing vascular pedicles in a limited space, morcellation of large uteri, round ligament technique for removal of high adenexae, detection of urinary tract injury. Adequate exposure sets the stage to being successful with vaginal hysterectomies. A self-retaining retractor is very useful to get adequate exposure and allows for the surgical assistant to focus and help with other tasks. We use the Magrina Bookwalter vaginal retractor system. The table post is anchored to the foot of the surgical table. The ring is then positioned so that the 20-degree break is at the level of the posterior vagina and flush with the patient's skin. The posterior blade is then inserted and attached to the ring. The lateral blades can then be inserted below the ring curvature, parallel to the vaginal walls so as not to place excessive traction on the vaginal and pelvic walls. Once the retractor is in place, there should be adequate space to complete the hysterectomy. If however, there is a very narrow introitus, a small superficial incision through the distal 2 to 3 centimeters of the posterior vaginal mucosa can be made with cautery. This widens the diameter of the posterior wall and can provide the additional space that is necessary to complete the procedure with good exposure. The anterior blade is held manually behind the vaginal ring until the anterior cul-de-sac is entered. Double-toothed tenaculi are placed on the anterior and posterior cervix to manipulate the uterus while performing the surgery. The posterior blade is removed to allow better deflection of the cervix. We begin with sharp dissection of the anterior vaginal cuff from the cervix. Dissection is performed sharply with Mayo scissors until the vaginal cuff is off the cervix anteriorly. This is confirmed with entry into the avascular vesicouterin space, allowing the index finger to bluntly push the bladder pillars superiorly and laterally. We prefer to delay entry into the anterior cul-de-sac until the vesicouterin-peritoneal fold is clearly visualized. The anterior blade is then used to retract the vaginal mucosa and bladder. Attention is turned to the posterior cul-de-sac. Traction is applied anteriorly to the cervix using the tenaculums and counter traction is applied to the posterior vaginal wall using the posterior blade. Sharp dissection is used to enter the cul-de-sac and the posterior blade is replaced into the peritoneal cavity. The utero-sacral ligaments can then be ligated. To overcome the challenge of ligating pedicles with traditional clamps and suture technique, particularly in cases with limited vaginal access, we advocate the use of a vessel sealing device during vaginal hysterectomy to facilitate the procedure. Sealing and dividing the cardinal ligament can be performed in the same way. The jaws of the vessel sealing device can get hot. It is important not to lean the device against the vulva, vagina, or bowel. The use of a suction irrigator helps to dissipate the heat. A lighted irrigator can also aid in visualizing deep spaces with limited lighting. The anterior blade is used for retraction of the bladder during ligation of the cardinal ligaments since entry into the anterior cul-de-sac has not yet been achieved. Ligating the utero-sacral and cardinal ligaments allows for additional uterine descensus and facilitates entry into the anterior cul-de-sac. The cervix is pulled downward while the anterior vaginal mucosa is retracted upward. This allows for direct visualization of the vesicle uterine peritoneal fold. The peritoneal fold is grasped with forceps and the peritoneum is entered sharply. The anterior blade is then replaced and secured to the vaginal ring. The uterine arteries can then be secured. If the uterus is large, as in this case, morcellation can be helpful to decompress the uterus and obtain access to the utero-ovarian pedicles. Morcellation is performed with both wedge and coring techniques. The tenaculi are moved to the 3 and 9 o'clock positions to maintain orientation during morcellation. We begin with dividing or bivalving the cervix using a number 10 blade. The uterus is incised from the lower uterine segment to the end of the cervix. A double-tooth Schroeder tenaculum is then placed on the posterior segment of the uterus and the scalpel is used to wedge out a segment of the uterus. This maneuver is repeated until a sufficient portion of the uterus is removed to facilitate with access to the utero-ovarian pedicles. Vaginal traction on the cervix should be avoided during this morcellation as this can cause vascular pedicles to avulse. This technique is especially useful for large fibroids or bulky uteri. Finally, removal of the ovaries can be challenging during a vaginal procedure. In order to facilitate removal of the ovaries, we use the round ligament technique. Traditionally, the meso-salpinks and meso-ovarium are clamped and ligated together as seen in this slide. However, this has several limitations including having a thick pedicle, retraction of the ovarian vessels, incomplete removal of the tube, and the close proximity of the ureter. The round ligament technique allows for complete removal of the tube, thins out the pedicle, and pulls it away from the pelvic sidewall. Gentle traction is applied to the utero-ovarian pedicle. The round ligament is identified and is divided with bovie cautery. The round ligament can be seen retracting. This serves to isolate the IP ligament. A clamp is then placed across the IP ligament and the tube and ovary are removed. An endoloop can be used to ligate the pedicle. The endoloop makes ligation of the pedicle easier and this minimizes the risk of bleeding. The vaginal cuff can then be closed in a standard fashion. Although the risk of urinary tract injury is low, we perform cystoscopy after every vaginal hysterectomy to aid in early diagnosis and repair. In conclusion, the difficult vaginal hysterectomy can be facilitated and accomplished with the use of new devices and techniques that overcome the challenges of limited exposure, removal of large uteri, and high adnexa, and entry into the cul-de-sac.

vaginal hysterectomy

exposure

sharp dissection

morcellation

urinary tract injury