Vaginal Hysterectomy - Detailed Surgical Steps

Pre-operative Preparation

• Patient assessment: Bimanual examination under anesthesia to confirm uterine mobility, descent, and size. The lower uterine segment width should be <9-10 cm for safe uterine artery clamping. Pubic arch angle should be ≥90° and bituberous diameter >10 cm.
• Positioning: Dorsal lithotomy position with buttocks slightly off the table edge, using candy-cane or Allen stirrups. Careful padding of pressure points to avoid neuropraxia (common peroneal, femoral nerves).
• Antiseptic prep: Vulva and vagina prepped with antiseptic solution. Sterile draping.
• Antibiotic prophylaxis: Cefazolin 1-2 g IV within 60 minutes of incision.
• VTE prophylaxis: Sequential compression devices applied before induction; anticoagulants as indicated.
• Bladder drainage: Foley catheter inserted (some surgeons prefer to defer until after anterior colpotomy to enable cystotomy identification).
• Retraction: A self-retaining ring retractor (e.g., Lone Star) is placed to expose the vaginal introitus. A Lahey or Jacobs tenaculum grasps anterior and posterior lips of the cervix - placed as distally as possible since the bladder can descend low on the anterior cervix.
• Vasoconstriction/hydrodissection: Dilute vasopressin (20 units in 100 mL normal saline) or 1:200,000 epinephrine in normal saline is injected circumferentially at the cervicovaginal junction. This reduces bleeding and assists dissection in the correct tissue plane.

Step 1: Circumferential Cervical Incision (Colpotomy)

• Anterior incision: Made from 10 to 2 o'clock
• Posterior incision: Made from 8 to 4 o'clock
• If the cervix descends adequately with traction, the incision is extended all the way around circumferentially.

Step 2: Posterior Colpotomy - Entry into Pouch of Douglas

• The posterior vaginal wall is elevated with Allis clamps or tissue forceps on the outer edge of the posterior incision.
• The tissue is pulled downward to create tension on the exposed posterior peritoneum.
• The rectouterine pouch (pouch of Douglas / posterior cul-de-sac) is identified - it is typically readily visible as a glistening, translucent layer.
• The peritoneum is entered sharply with curved Mayo scissors.
• The posterior peritoneal edge is sutured centrally to the posterior vaginal wall with a single delayed absorbable suture to maintain access.
• The cul-de-sac is palpated to evaluate for adhesions, endometriosis, or other pathology, and the uterosacral ligaments are palpated.
• A long-bladed Steiner-Auvard weighted speculum is placed into the posterior peritoneal cavity - it sits in the cul-de-sac and provides posterior retraction and an excellent view of the operative field.

Step 3: Uterosacral Ligament Ligation

Berek & Novak's Gynecology - Uterosacral ligament cross-clamped and transected

• The cervix is placed on outward and upward traction.
• The uterosacral ligaments are identified by palpation bilaterally at the 4 o'clock and 8 o'clock positions.
• Each ligament is:
  1. Clamped with a curved Heaney clamp
  2. Transected
  3. Suture-ligated with 0-gauge delayed absorbable suture (e.g., Vicryl) using a transfixion stitch
• The free suture ends are tagged with hemostats and not cut - they are used later to attach to the vaginal cuff for support (McCall culdoplasty, vault suspension).
• Both sides are ligated in turn before progressing.

Berek & Novak's Gynecology - Cross-clamping, transection, and suture ligation steps (a, b, c)

Step 4: Anterior Colpotomy - Entry into Vesicouterine Space

• The cervix is pulled outward and downward with the tenaculum.
• The anterior vaginal tissue is elevated in the midline with forceps.
• Sharp dissection with Metzenbaum scissors is performed parallel to the cervix in the cervicovesical space - the correct plane is between the cervix and the base of the bladder. The key is to stay superficial on the cervical stroma, not to "dig in."
• A Deaver or Breisky retractor is placed under the anterior vaginal epithelium to expose the cervicovesical stroma.
• Dissection continues cephalad until the vesicouterine peritoneum is identified - a glistening, tented, translucent layer (the "silk sac sign" may be visible).
• The peritoneum is grasped, elevated, and entered sharply with Metzenbaum scissors (anterior colpotomy).
• Entry into the peritoneal cavity is confirmed by seeing intraperitoneal fat.
• A long right-angle retractor is placed into the anterior peritoneal cavity to elevate and protect the bladder for the remainder of the procedure - this retractor must remain in place throughout.

Step 5: Cardinal Ligament Ligation

• The cervix is placed on traction.
• The cardinal ligaments (which contain the main blood supply to the uterus) are identified, clamped, transected, and suture-ligated bilaterally.
• The anterior and posterior peritoneum are incorporated into the clamp when possible - this aids anatomic definition and hemostasis.
• If bowel is encountered in the operative space, a moistened tagged laparotomy sponge can pack it cephalad.
• Each pedicle is suture-ligated with 0 delayed absorbable suture. Suture ends are tagged and not cut.

Step 6: Uterine Artery Ligation

Berek & Novak's Gynecology - Cardinal ligament / uterine vessel pedicle clamped medial to prior pedicle

• Contralateral and downward traction is placed on the cervix to bring the uterine vessels into view.
• The clamp is placed medial to the previous cardinal ligament pedicle to avoid slippage and to reduce ureteral injury risk.
• With effort to incorporate both anterior and posterior leaves of the visceral peritoneum, the uterine vessels (uterine artery and veins) are:
  1. Clamped with a Heaney clamp
  2. Transected
  3. Suture-ligated (single suture and single clamp technique is preferred - reduces ureteral injury)
• If the uterus is large or a fibroid distorts anatomy, a second suture may be required to control remaining branches.
• This is the most critical step for hemorrhage prevention. The ureter runs within 1-2 cm of the uterine artery at this level.

Step 7: Delivery of the Uterus and Ligation of Upper Pedicles

• A second tenaculum is placed onto the uterine fundus.
• The fundus is delivered posteriorly (flipped through the posterior colpotomy) by applying traction inferiorly.
• The operator's index finger is placed behind the utero-ovarian ligament to guide clamp placement safely.

Utero-ovarian and Round Ligament Ligation

• The utero-ovarian ligament + fallopian tube + round ligament complex on each side is:
  1. Clamped (clamp tips guided by the operator's index finger)
  2. Transected
  3. Double-ligated: a suture tie followed by a ligature medial to the first suture (since this is the highest pedicle and retracts cephalad into the abdomen if it slips)
• A hemostat is placed on the suture ends to identify this pedicle.
• The procedure is repeated on the contralateral side.
• The uterus is now completely free and is removed.

If larger pedicles are encountered, the assistant can briefly "flash" (partially release) the second clamp while the first tie is placed to ensure security.

Step 8: Adnexal Removal (Optional - Bilateral Salpingo-oophorectomy)

• The utero-ovarian pedicle is not transected at Step 7; instead, the infundibulopelvic (IP) ligament containing the ovarian vessels is identified, clamped, cut, and doubly ligated.
• The ovary is delivered and removed along with the fallopian tube.
• This requires adequate uterine descent and access to the IP ligament.

Step 9: Hemostasis Check and Peritoneal Closure (Retroperitonealization)

• All pedicles are inspected for bleeding.
• A purse-string suture (Moschcowitz-type) or running suture closes the peritoneum to retroperitonealize all pedicle stumps - this constitutes the first layer of vault support.
• The cul-de-sac is obliterated by plication of the uterosacral ligament sutures in the midline (reduces risk of enterocele).

Step 10: McCall Culdoplasty / Vault Suspension

• The previously tagged uterosacral ligament sutures (from Step 3) are tied together in the midline - this approximates the uterosacral ligaments and suspends the vaginal apex.
• Alternatively, a formal McCall culdoplasty is performed: one or more permanent or delayed absorbable sutures incorporate the posterior vaginal wall, the uterosacral ligaments bilaterally, and the anterior peritoneum to plicate the pouch of Douglas and elevate the vault.

Step 11: Vaginal Cuff Closure

• The tagged suture ends of the utero-ovarian, uterine artery, cardinal, and uterosacral pedicles are used to reinforce the cuff angles.
• The vaginal mucosa is reefed (not formally closed in many protocols, to allow drainage): a running locking 0 synthetic absorbable suture (e.g., 0-Vicryl) approximates the cut edges of the vaginal epithelium.
• Alternatively, the cuff is closed in a figure-of-8 or continuous locking fashion depending on surgeon preference.
• The angle sutures incorporate the nearest ligament pedicle to give the cuff corners additional strength.

Step 12: Final Inspection and Bladder Check

• The vaginal cuff is inspected for hemostasis.
• A Foley catheter is passed (if not already in situ) to confirm the bladder is intact and there is no haematuria.
• In some protocols, cystoscopy is performed routinely at the end to confirm bilateral ureteral efflux and exclude cystotomy.
• Vaginal packing may be placed at surgeon discretion.

Summary of the Four Core Phases

Key Technical Points and Safety Principles