The objective of this video is to make vaginal hysterectomy, vaginal salpingo-oophorectomy, and uterus sacral ligament colpopexy approachable by showing the key procedural steps from both the vaginal and abdominal perspectives. We hope the dual views allow you to better understand the spatial anatomy of these commonly performed procedures. Vaginal hysterectomy is the oldest and least invasive of the hysterectomy techniques. It fulfills evidence-based requirements for preferred route of hysterectomy in benign gynecologic disease. It is associated with shorter recovery, fewer complications, less cost, and better cosmetic results than other types of hysterectomy. For orientation, we will begin with a review of the abdominal pelvic anatomy in this cadaver. The pelvic ureter begins its course here at the bifurcation of the common iliac vessels. It crosses medial to the anterior division of the hypogastric artery. Here we see the branches of the hypogastric artery supplying the bladder, vagina, and uterus. The ureter passes through the tunnel of writhine beneath the uterine artery. Here the ureter is highlighted through the retroperitoneum in blue for identification later in the procedure. This is the bladder reflection, seen somewhat adherent in this cadaver, who appears to have had a prior cesarean section. We turn vaginally to begin the hysterectomy. The cervix is grasped with a Jacob's tenaculum and gentle traction applied. We inject lidocaine with epinephrine submucosally to help create clear planes. We then incise the vaginal mucosa circumferentially around the cervix and further dissect the bladder off of the cervix. It is common in our practice to attempt posterior entry first. For this, we will begin a series of picture-in-picture views so that you may see these crucial steps of the procedure from the abdominal view. Here we are palpating the posterior cul-de-sac. The posterior peritoneum is visualized and entered sharply with Mayo scissors. After confirming safe entry, the incision is extended and Steiner's speculum placed to aid in visualization and to protect the rectum. We often tag or reef the posterior peritoneum to the vaginal cuff to maintain hemostasis. We then return our attention anteriorly and dissect the bladder down until the vesicouterine peritoneum is clearly identified and it is entered sharply. Again, once safe entry confirmed, the incision is extended and a long right-angle retractor placed to protect the bladder. Next, we clamp, cut, and suture ligate the uterus-acral ligaments with Haney Transfixion Sutures. These pedicles are tagged for future identification and use in performing our uterus-acral ligament colpopexy. The steps are repeated bilaterally. This step provides some uterine descent and can be done prior to anterior entry in order to improve visualization and access. Next, we clamp across the uterine vessels, being sure to include both the anterior and posterior peritoneum. When placing our clamps, we swing the heel of the clamp out laterally to maintain continuity with our previous pedicle, providing excellent hemostasis. We then cut and suture ligate with a Haney Transfixion stitch. We then repeat the steps bilaterally. These steps could also be done with a vessel sealing device if desired by the surgeon. The ureter runs under the uterine artery approximately 1.5 centimeters lateral to the internal cervical os. This is the location where the ureter is most vulnerable to injury during hysterectomy. Continuing gentle traction on the uterus increases the distance between our uterine artery pedicle and the ureter. Here we have clamped the 0 centimeter mark in the uterine pedicle. The ureter is tagged with a yellow vessel loop and lies approximately 2 centimeters from our pedicle. With traction, this distance increases to at least 4 centimeters. We have doubly clamped, cut, and ligated the uterovarian ligaments on the right side and will now perform a left salpingo-oophorectomy. In order to safely reach the left adnexa, we identify and transect the round ligament. It is suture ligated and gently retracted laterally to help access the broad ligament. We will continue taking subsequent bites of the mesosalpinks until the ovarian vessels are isolated. The ureter lies inferior to the IP ligament traveling in close proximity to the ovarian vessels. This is a site vulnerable to injury and in this cadaver lies within 2 centimeters of our vessels. Next, in split screen, you can watch abdominally as the vaginal clamps are placed. The ovary and fallopian tube will be removed attached to the uterus. The IP ligament is doubly clamped and ligated with a free tie, followed by a transfixion suture ligation. In the abdominal view on the left, the ureter is highlighted in blue, inferior and medial to our pedicle. A prophylactic salpingectomy may be performed in a similar fashion, marching up the mesosalpinks with clamps or a vessel sealing device. This is done if the fallopian tubes are easily accessible vaginally and excision can be achieved with little additional risk. Once the vaginal hysterectomy is complete, we proceed with uterus sacral ligament colpopexy. You can identify the uterus sacral ligament by visualization or palpation. Here we pull to create traction on our tagged uterus sacral ligament pedicles and can palpate them easily. We grasp the uterus sacral ligament with a long alice clamp, being careful to avoid the ureter laterally and protect the rectum medially. As you can see, the ureter lies in close proximity, ranging from 1 to 4 centimeters along the length of the uterus sacral ligament. Sutures are placed from lateral to medial to help avoid injury to the ureter. Ureteral kinking is a common complication with rates ranging from 3 to 4 percent. Here we place sutures through the uterus sacral ligament, beginning distally and marching proximally towards the sacrum. Sutures are tagged to the drapes. You can see the final position of our suspension lies 7 to 8 centimeters from the sacrum and is at the level of the ischial spine. The ischial spine is palpated here by the gloved finger. The steps are repeated on the contralateral side and an anterior vaginal repair may be performed as desired. The suspension sutures are then driven through the length of the vaginal cuff. We often use delayed absorbable sutures and are therefore taken through full thickness vaginal epithelium. These sutures close the vaginal cuff. The intervening open portion is closed with a figure of 8 absorbable suture. The sutures are then tied down, elevating the vaginal cuff. Our repair is complete with shortened uterus sacral ligaments traced here. The ureters remain lateral and unobstructed. At this point, ureteral patency should be evaluated cystoscopically. The rectum lies in the midline and rectal examination is performed to confirm no injury or suture bridging. We hope this video has provided you with a unique anatomic perspective and helps you more confidently perform vaginal hysterectomy, vaginal oophorectomy, and uterus sacral ligament colpofexy. Visit us at www.ottobock.com

vaginal hysterectomy

vaginal salpingo-oophorectomy

uterus sacral ligament colpopexy

spatial anatomy

pelvic ureter location