1. Kaidy Waterman & Emily Beacham
Vaginal Hysterectomy
Kaidy Waterman & Emily Beacham

2. 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

3. 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

4. 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

5. 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

6. 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

7. The Procedure

8. 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

9. #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

10. 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

11. 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

12. 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

13. 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.

14. 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

15. 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.