Kaidy Waterman & Emily Beacham Vaginal Hysterectomy Kaidy Waterman & Emily Beacham

Anatomy and Physiology Removal of uterus Possible removal of fallopian tubes and ovaries Ligature of uterosacral ligaments Ligature of cardinal ligaments Ligature of uterine arteries Possible ligature of round ligament, ovarian ligament and fallopian tubes

Reasons for Procedure Sterilization Endometriosis Fibroids Cancer Adhesions Uterine prolapse About 1/3 of all hysterectomies are done vaginally Doctors prefer vaginal because it is less invasive Laparoscopically assisted vaginal hysterectomies are becoming much more common

Anesthesia and Positioning General Details Anesthesia and Positioning Skin Prep and Draping Anesthesia is general Patient is in lithotomy position Candy cane stirrups Vaginal prep Lithotomy drape

Supplies, Equipment and Instruments Auvard weighted speculum Heaney/Deaver retracters Tenaculum/Lahey vulsellum #15 blade #7 knife handle 4X4 sponges Peri-Pad Heaney clamps Mayo scissors Long mayo Kelly clamps Schnidt Pean Jacob’s vulsellum Foley catheter Vag packing

Special Considerations Careful with catheterization after the procedure Care must be taken not to damage the fallopian tubes or ovaries if they are going to remain in the body

The Procedure

Auvard weighted speculum is placed in the posterior vaginal wall TIME OUT Auvard weighted speculum is placed in the posterior vaginal wall Heaney or Deavers retract the lateral vaginal walls Tenaculum/Lahey placed at the edge of cervix to permit traction and movement. D&C may be performed here

#15 blade on #7 handle, incise vaginal wall anteriorly around cervix Blunt dissection, index and middle finger with 4X4, free bladder from anterior surface of the cervix Deaver is placed anteriorly to elevate the bladder Protects bladder Visualization of peritoneum and anterior cul-de-sac

Use #15 knife blade, opening is made in the cul-de-sac Peritoneum of posterior cul-de-sac is identified and incised with #15 Uterosacral ligaments are doubly clamped with Heaney clamps, cut with Mayo and ligated. Ligatures are not cut-left long and tagged with kelly

Manipulate uterus posteriorly, cardinal ligaments on each side are doubly clamped and cut with Mayos and ligated Same is done with uterine arteries except the clamps are Kelly, Schnidt, or Pean Fundus is put into the vaginal canal with previously placed tenaculum/Jacob’s vulsellum

If ovaries are preserved: Round ligament Ovarian ligament Fallopian are doubly clamped with Heaney clamps, cut with mayo Uterus is removed Pedicles of the ligaments are ligated

Peritoneum between rectum and vagina is approximated with a continuous absorbable suture Cul-de-sac is closed by placing sutures from vaginal wall through infundibulopelvic and round ligaments and back out through the vaginal wall, tied down on the vaginal portion of the vault Round, uterosacral, and cardinal ligaments are individually approximated and reattached to the angle of the vagina Foley catheter is placed, vagina is packed, perineal pad is placed.

Postoperative Care Complications Care and Prognosis Bowel obstruction or damage Bladder injury Wound infection of dehiscence Ureteral injuries Hemorrhage Transport to PACU Return to normal activities

Pearl of Wisdom Some surgeons complete actions on one side of the uterus then move to the other side; some alternate sides as they move caudally. The STSR must adjust to the pattern and be sure to have an adequate supply of homeostasis.

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