Vaginal hysterectomy per op note

Reading File

Finding Sources

Reading File

I now have all the key steps. Let me compile this into a comprehensive operative note template.

Vaginal Hysterectomy — Operative Note

Based on Berek & Novak's Gynecology and Campbell-Walsh-Wein Urology

PREOPERATIVE

Patient Position: Dorsal lithotomy (high lithotomy), buttocks just over the table's edge. Hip flexion >60°, knee flexion 90–120°. Padding at all pressure points. 10–15° Trendelenburg.

Prep & Drape: 4% chlorhexidine-alcohol solution to vagina, vulva, mons, inner thighs, perineum, and perianal area. Adhesive barrier drape placed. Sterile technique throughout.

Catheter: Foley catheter inserted to decompress bladder.

Exam Under Anesthesia: Uterine mobility, descent, size, and shape confirmed. Vaginal hysterectomy deemed feasible.

INSTRUMENTS

Weighted specula (short and long), Breisky–Navratil vaginal retractors
Single- or double-toothed tenacula (Lahey or Jacobs)
Right-angle (Heaney) retractors
Heaney and Heaney–Ballantine hysterectomy clamps
Curved Mayo scissors, Metzenbaum scissors
Russian and rat-tooth pick-ups
Heaney needle holders
Lone Star self-retaining retractor (optional)
Babcock clamps, hemostats
Suture: 0-gauge delayed-absorbable polyglactin (Vicryl) or polyglycolic acid on tapered needle

OPERATIVE STEPS

1. Cervical Grasping and Circumscription

A short weighted speculum was placed in the vagina. Sidewall retractors were positioned laterally. The anterior and posterior lips of the cervix were grasped with a single/double-toothed tenaculum. Downward traction was applied and bladder position was confirmed. A circumferential incision was made through the full thickness of vaginal epithelium at the junction of the vaginal rugae and the smooth epithelium overlying the cervix, at least 1 cm distal to the bladder reflection. The incision was extended from the 10–2 o'clock position anteriorly and the 4–8 o'clock position posteriorly. Local injection of 1:200,000 epinephrine in saline was used for hydrodissection and hemostasis [optional].

2. Posterior Colpotomy and Entry into the Posterior Cul-de-sac

The cervix was placed on outward and upward traction. The posterior cul-de-sac peritoneum was identified using Allis clamps or tissue forceps applied to the outer edge of the incision. Traction was applied to tent the peritoneum. Curved Mayo scissors were used to enter the posterior cul-de-sac. Entry was confirmed by direct visualization and palpation. The posterior peritoneum was secured centrally to the posterior vaginal wall with a single stitch of 0-Vicryl. A long-bladed Steiner-Auvard weighted speculum was introduced into the posterior peritoneal cavity.

3. Uterosacral–Cardinal Ligament Ligation (Posterior)

The uterosacral ligaments were identified by palpation. Each was individually clamped with a curved Heaney clamp perpendicular to the uterine axis, with the clamp tip touching the cervix, incorporating the lower cardinal ligament. The pedicle was cut, leaving <0.5 cm distal to the clamp. A transfixion suture of 0-Vicryl was placed: needle point at the clamp tip, passed through the tissue by wrist-rolling, suture moved around the back of the clamp, needle through the middle of the pedicle, and tied behind the clamp. Each suture was tagged with a hemostat to mark the most inferior pedicles. The procedure was repeated on the contralateral side.

4. Anterior Colpotomy and Bladder Mobilization

With downward traction on the cervix, the anterior vaginal tissue was elevated in the midline. Using curved Mayo scissors directed toward the uterus, the vesicouterine plane was developed by sharp dissection. Once the vesicouterine peritoneal reflection was identified, it was elevated with forceps and entered sharply. Correct intraperitoneal entry was confirmed by direct visualization of intraperitoneal fat. A Heaney retractor was placed anteriorly between the bladder and uterus to protect the bladder throughout the remainder of the procedure.

5. Cardinal Ligament Sequential Clamping

With the cervix on outward and lateral traction, the remaining cardinal ligament pedicles were sequentially clamped with Heaney clamps, cut, and suture ligated with 0-Vicryl transfixion stitches. Each suture was tagged with a hemostat. Steps were repeated on the contralateral side, advancing progressively toward the uterine vessels with each successive pedicle.

6. Uterine Artery Ligation

The cervix was placed on outward and lateral traction. The uterine artery was identified on each side, clamped with a curved Heaney clamp at the level of the internal os, and cut. A 0-Vicryl suture ligature was placed, secured with a transfixion stitch. The procedure was repeated on the contralateral side. Hemostasis was verified at both uterine pedicles.

7. Delivery of the Uterine Fundus

Following bilateral uterine artery ligation, the uterine fundus was delivered either anteriorly or posteriorly. The operator's finger was placed behind the utero-ovarian ligament to guide clamp placement safely around the pedicle.

8. Utero-Ovarian and Round Ligament Ligation

The utero-ovarian ligament and round ligament complex were cross-clamped with a Heaney clamp on each side, cut, and double ligated — a free tie followed by a transfixion suture ligature medial to the first. Sutures were tagged with hemostats as the most superior pedicles. The uterus was delivered and passed off the field.

9. Adnexectomy [if performed — bilateral salpingo-oophorectomy]

The round ligament was separated from the adnexal pedicle. The ovary was grasped with a Babcock clamp and drawn medially. A Heaney clamp was placed across the infundibulopelvic (IP) ligament, the ovary and tube were excised, and a transfixion suture ligature was placed on the ovarian vessels. Procedure repeated on the contralateral side. [For opportunistic salpingectomy: the fimbria was identified, the entire tube brought into view, and a clamp placed across the mesosalpinx lateral to the tube and medial to the IP ligament; the pedicle was cut and ligated.]

10. Hemostasis and Pedicle Inspection

All pedicles were systematically inspected: from the most superior (utero-ovarian) to the most inferior (uterosacral). Hemostasis was confirmed at each pedicle. All tagged sutures were individually identified and inspected.

11. Vaginal Cuff Closure and Support (McCall Culdoplasty [optional])

McCall culdoplasty: A purse-string suture incorporating the uterosacral ligaments bilaterally and the posterior peritoneum was placed to close the cul-de-sac and provide apical vault support. The suture was tied once the cuff was ready for closure.

Cuff closure: The vaginal cuff was closed with figure-of-eight or running locking 0-Vicryl sutures incorporating the posterior peritoneum, uterosacral ligament pedicles, and anterior peritoneum to re-peritonize the pelvis. The uterosacral ligament pedicles were incorporated at the angles to provide apical support.

12. Cystoscopy [if performed]

Cystoscopy was performed to confirm bilateral ureteral efflux and bladder integrity. Both ureters were noted to efflux clear urine. No cystotomy was identified.

CLOSURE / TERMINATION

The vaginal cuff was inspected and found to be hemostatic. The Foley catheter was left in place/removed per protocol. The patient tolerated the procedure well. Estimated blood loss: ___ mL. Specimens: uterus (weight: ___ g) ± bilateral adnexa submitted to pathology.

KEY ANATOMIC PRINCIPLES

Structure	When Clamped	Key Risk
Uterosacral–cardinal ligaments	Posteriorly first, after posterior colpotomy	Ureter (runs 1–2 cm lateral)
Uterine artery	At the level of the internal os	Ureter (crosses under uterine artery)
Utero-ovarian ligament	After fundal delivery	Ureter, ovarian vessels
Infundibulopelvic ligament (for BSO)	After round ligament separated	Ureter

Rule: Never clamp what you cannot see. The ureter is at greatest risk during uterine artery and uterosacral ligament ligation.

Sources: Berek & Novak's Gynecology; Campbell-Walsh-Wein Urology, Chapter on Vaginal Hysterectomy with McCall Culdoplasty Technique; Sabiston Textbook of Surgery.

This is a shared conversation. Sign in to Orris to start your own chat.