Steps of vaginal hysterectomy

1. Preparation and positioning
   • General or regional anesthesia.
   • Dorsal high-lithotomy position.
   • Bladder catheterization, vaginal preparation, and appropriate antibiotic prophylaxis.
   • Examine under anesthesia to assess uterine size, mobility, descent, and adnexal pathology.
2. Expose and grasp the cervix
   • Insert vaginal retractors.
   • Grasp the cervix with tenaculum or vulsellum and apply downward traction.
   • A paracervical infiltration with dilute vasopressin or local anesthetic containing epinephrine may be used for hemostasis.
3. Circumferential cervical incision
   • Make a circular incision at the cervicovaginal junction.
   • Mobilize vaginal mucosa from the cervix.
4. Posterior colpotomy
   • Identify and enter the posterior cul-de-sac.
   • Extend the posterior peritoneal opening laterally.
   • Insert a posterior vaginal speculum/retractor into the peritoneal cavity.
5. Divide and ligate uterosacral ligaments
   • Identify the uterosacral ligaments bilaterally.
   • Clamp, divide, and ligate them.
   • Keep sutures tagged for later vaginal vault suspension.
6. Anterior dissection and anterior colpotomy
   • Dissect the bladder off the cervix and lower uterine segment.
   • Identify the vesicouterine peritoneal reflection and enter the anterior peritoneal cavity.
   • Place an anterior retractor to protect and elevate the bladder.
7. Secure cardinal ligaments and uterine vessels
   • In sequential bilateral pedicles, clamp, divide, and ligate:
     • Cardinal ligaments
     • Uterine vessels
   • Keep pedicles close to the uterus to reduce ureteric injury risk.
   • With each pedicle, progressively deliver the uterus downward into the vagina.
8. Divide upper pedicles
   • Clamp, divide, and ligate the cornual pedicles containing:
     • Round ligament
     • Fallopian tube
     • Utero-ovarian ligament
   • Remove the uterus and cervix.
   • If salpingectomy or oophorectomy is planned, manage the infundibulopelvic or tubo-ovarian pedicles as appropriate.
9. Inspect for bleeding and injury
   • Inspect every pedicle and peritoneal cavity for hemostasis.
   • Confirm bladder and bowel integrity when indicated.
   • Cystoscopy may be used selectively or routinely according to local practice and operative risk.
10. Vault support and vaginal cuff closure

• Incorporate uterosacral ligaments into the vaginal angles to support the vault, such as with McCall culdoplasty or equivalent apical suspension.
• Close the vaginal cuff, ensuring inclusion of the peritoneal layer where the chosen technique requires it.
• Use delayed absorbable sutures, either interrupted, figure-of-eight, or running.

1. Final checks

• Ensure hemostasis, correct sponge/instrument count, and adequate vault support.
• Remove retractors, reassess vaginal bleeding, and transfer to recovery.

Key sequence to remember