Steps of Vaginal Hysterectomy

Note: Te Linde's Operative Gynecology is not available in the textbook library. The following is referenced from Berek & Novak's Gynecology (an equally authoritative operative gynecology text), which describes the procedure in comparable detail to Te Linde's. The steps below follow the standard sequence described in both texts.

Preoperative Evaluation

• Assess uterine mobility (the most important factor for feasibility) - test descent with Valsalva or tenaculum traction under anesthesia
• Evaluate uterine size: width of lower uterine segment >9-10 cm makes uterine artery clamping unsafe; uterine size >16-18 weeks is a relative contraindication for most surgeons
• Assess the bony pelvis: pubic arch angle should be ≥90 degrees; bituberous diameter should exceed 10 cm
• Review imaging if bimanual exam is inadequate

Patient Positioning and Preparation

1. Dorsal lithotomy position - buttocks just over the table edge; hip flexion >60°, knee flexion 90-120°; 10-15° Trendelenburg to aid visualization
2. Examination under anesthesia - confirm uterine mobility and descent with tenaculum
3. Perineal preparation - pubic hair clipped; vagina, vulva, perineum prepped with dilute 4% chlorhexidine-alcohol
4. Foley catheter insertion
5. Draping with adhesive barrier around operative site

Surgical Steps

Step 1 - Grasping and Circumscribing the Cervix

• Weighted speculum placed in the vagina; sidewall retractors positioned
• Anterior and posterior lips of the cervix grasped with a single- or double-toothed tenaculum
• Downward traction applied; bladder location identified (incision planned ≥1 cm distal to the bladder)
• The vaginal epithelium at the cervicovaginal junction is injected with dilute local anesthetic + epinephrine
• A circumferential incision is made at the cervicovaginal junction with a scalpel; the posterior incision is angled toward the cul-de-sac to facilitate posterior entry

Step 2 - Dissection of Vaginal Epithelium

• Additional dissection perpendicular to the cervix is made to reach the cervical stroma plane
• The vaginal epithelium is dissected sharply from the cervix using curved Mayo scissors, circumferentially, until the anterior and posterior reflections are exposed

Step 3 - Posterior Cul-de-Sac Entry (Posterior Peritoneal Entry)

• The posterior peritoneal reflection (cul-de-sac of Douglas) is identified
• The peritoneum is entered sharply (Fig. 27-10); one finger confirms entry; the incision is extended
• The posterior peritoneum is secured to the posterior vaginal epithelium with a figure-of-eight suture (for hemostasis and orientation)
• The pelvic cavity is examined for adhesions or pathology

If posterior entry is difficult: start extraperitoneally by clamping the uterosacral ligaments first, or attempt anterior entry first, then return to posterior.

Step 4 - Anterior Peritoneal Entry (Anterior Cul-de-Sac Entry)

• The anterior vaginal epithelium is placed on upward traction
• Blunt dissection in the vesicocervical space separates the bladder from the cervix
• The anterior peritoneum (vesicouterine peritoneal fold) is identified and entered sharply
• A Deaver or right-angle retractor is placed into the anterior peritoneal space to retract the bladder
• The anterior peritoneum is secured to the anterior vaginal cuff with a suture

If anterior entry is difficult: a sound can be bent into the bladder to aid identification; back-filling the bladder is also useful.

Step 5 - Uterosacral and Cardinal Ligament Ligation

• A Heaney or Heaney-Ballantine clamp is placed on the uterosacral ligament close to the cervix
• The ligament is cut and suture ligated (transfixion or ligature); these sutures are tagged with hemostats
• The cardinal ligament is similarly clamped close to the cervix, cut, and suture ligated
• Steps are repeated on the contralateral side
• Progressive successive bites on the parametrium are taken sequentially, advancing superiorly with each step

Step 6 - Uterine Artery Ligation

• The uterus is delivered further by progressive traction
• The uterine vessels (uterine artery and vein) are identified at the level of the internal os
• A Heaney clamp is placed across the uterine vessels perpendicular to the uterus
• The vessels are cut and double ligated (suture tie + transfixion ligature medial to it)
• Repeated on the contralateral side
• After uterine vessel ligation, the remaining broad ligament pedicles are taken

Step 7 - Delivery of the Uterine Fundus

• Once the uterine vessels are secured, the uterus is delivered - either anteriorly or posteriorly, depending on mobility
• A tenaculum is placed on the uterine fundus and traction is applied posteriorly
• The surgeon's index finger is placed behind the utero-ovarian ligament to guide clamp placement safely

Step 8 - Utero-Ovarian and Round Ligament Ligation

• The utero-ovarian ligament and round ligament complex is clamped (clamp tip guided by the surgeon's index finger)
• The pedicle is cut and double ligated (suture tie + ligature medial to the first)
• If the pedicle is large, the assistant briefly applies a second clamp while the first tie is placed
• Hemostats are placed on sutures to mark the upper pedicle
• The uterus is now free and removed

Step 9 - Removal of the Ovaries and/or Fallopian Tubes (if indicated)

• The round ligament is separated from the adnexal pedicle
• The ovary is drawn medially with a Babcock clamp
• A Heaney clamp is placed across the infundibulopelvic (IP) ligament (ovarian vessels)
• The ovary and tube are excised; IP ligament is transfixed and suture ligated
• For opportunistic salpingectomy: the fimbria is identified, the round ligament isolated, mesosalpinx taken in sequential bites from the cornua toward the fimbriated end

Step 10 - Closure of the Vaginal Cuff and Pelvic Floor Reconstruction

• Hemostasis is confirmed at all pedicles
• McCall culdoplasty or similar suspension procedure is performed if prolapse repair is required (incorporating the uterosacral ligaments into the vaginal cuff closure to prevent future vault prolapse)
• The vaginal cuff is closed with interrupted or figure-of-eight absorbable sutures, incorporating the peritoneum and pubocervical/rectovaginal fascia
• Upper pedicles (utero-ovarian/round ligament) may be incorporated into the angles of the vaginal cuff closure
• The peritoneum may or may not be formally closed (evidence supports leaving it open)

Key Instruments

• Heaney and Heaney-Ballantine clamps, Breisky-Navratil retractors, weighted speculum, Heaney needle holders, curved Mayo scissors, single/double-toothed tenacula

Suture

• Synthetic delayed-absorbable (polyglactin / polyglycolic acid) with tapered needles preferred

Re: Te Linde's reference - Te Linde's Operative Gynecology is not currently in the available textbook library. The steps above are sourced from Berek & Novak's Gynecology, which presents the same procedure in identical sequence. The core steps in Te Linde's are: (1) circumferential cervical incision, (2) posterior peritoneal entry, (3) anterior peritoneal entry, (4) uterosacral/cardinal ligament ligation, (5) uterine vessel ligation, (6) fundal delivery, (7) utero-ovarian/round ligament ligation, (8) vaginal cuff closure - which matches exactly what is described above.