The patient is examined under anesthesia. At this time, the vagina and abdomen should be surgically prepped, and a Foley catheter should be inserted into the bladder and connected to straight drainage.

The patient is placed in the supine position, and a transverse incision 12-14 cm in length is made following the skin lines above the mons pubis. By keeping the incision slightly above the mons pubis, the surgeon can avoid the vascular plexus within the mons and aid hemostasis.

The incision is carried down to the rectus fascia, which is incised transversely, exposing the rectus abdominal muscles.

The rectus abdominal muscles can be separated in the midline, and greater exposure can be achieved by undermining the rectus abdominal muscles lateral to the inferior epigastric artery. If greater mobility is required or if the rectus muscle needs transection, the inferior epigastric artery and vein should be ligated prior to extensive mobilization and/or muscle transection. The peritoneum is elevated and can be opened in the transverse or longitudinal plane.

A self-retaining retractor is placed in the incision. The pelvis and abdomen are explored. The patient is placed in the moderate Trendelenburg position, and the bowel is packed off with wet, warm gauze packs. Frequently, the bladder peritoneum has been closed over the cervical stump, and the only recognizable structures are (1) the round ligaments as they enter the pelvic wall and (2) the tubes and ovaries. The round ligaments should be identified first, elevated with an Ochsner clamp and suture ligated. By elevating the transected round ligament, a plane of dissection can be achieved that in most cases will allow the surgeon to free the bladder from the cervix. The round ligaments in these cases have generally been sutured back to the cervical stump and, therefore, appear to be originating from the upper lateral area of the cervical stump. The tube and suspensory ligament of the ovary are frequently involved in the attachment to the cervical stump; and to avoid hemorrhage, these structures should not be cut.

With adequate elevation of the cervical stump via the round ligaments, the anterior leaf of the broad ligaments can be identified. Sharp dissection is used to incise the bladder peritoneum as well as the posterior leaf of the broad ligament and the peritoneum overlying the cul-de-sac and the rectum.

By elevating the bladder and vesical peritoneum with the bladder blade of the retractor, the filmy attachments of the bladder to the cervix can be identified and taken down with blunt or sharp dissection. This is facilitated by placing cephalad retraction on the cervical stump.

If the tubes and ovaries remain, it may be advisable to remove them by identifying the infundibulopelvic ligament and undermining the ligament with the ovarian artery and vein below the brim of the pelvis. Care at this point should be taken to identify the ureter, since, as a result of previous scarring, it may have been diverted into the general field of the infundibulopelvic ligament and, therefore, be accessible to damage.

The infundibulopelvic ligament should be doubly clamped with Ochsner clamps and transected.

Two ligatures are customarily applied to the stump of the infundibulopelvic ligaments: a tie of 2-0 synthetic absorbable suture and a suture placed through the midportion of the stump and tied to both sides.

The cervical stump has now been freed form the round ligament and infundibulopelvic ligament. The peritoneum has been opened with a 360° arch around the cervical stump. The upper portions of the cardinal ligaments have been clamped and tied. The remaining cardinal ligaments and uretrosacral ligaments remain to be cut and tied.

Cephalad retraction is placed on the dome of the cervical stump. Straight Ochsner clamps are applied to the lateral edge of the cervix and allowed to slide off into a "groove" immediately lateral to the cervix, clamping any remaining portions of the uterine vessels and the cardinal ligament. The cardinal ligament is then transected with a scalpel, leaving an adequate stump protruding from the Ochsner clamp to prevent retraction of the stump of the cardinal ligament through the clamp.

A second or, possibly third application of the Ochsner clamp is needed to completely clamp and transect the cardinal ligament. The last application of the Ochsner clamp encompasses in one bite the remaining portion of the cardinal ligament and the uretrosacral ligament. By uniting the cardinal and uretrosacral ligaments in one pedicle, the first step in resuspension of the vaginal cuff is created. This is incorporated into the angle of the vagina in later steps to facilitate suspension and to prevent enterocele.

With cephalad retraction on the cervical stump, the anterior wall of the vagina is picked up by an Ochsner clamp, and the vagina is entered with curved Mayo scissors or by a stab wound with a scalpel. The curved Mayo scissors is then used to transect the remaining vaginal canal, and the cervical stump, the tubes, and the ovaries are removed.

The space between the rectum and the vagina is closed with 0 synthetic absorbable suture.

The 0 synthetic absorbable suture is continued in a running lock fashion around the edge of the vagina. Care is taken to place several sutures into the stump of the uretrosacral and cardinal ligaments to firmly attach them to the angle of the vagina.

The peritoneum of the pelvis is reestablished with a running 3-0 synthetic absorbable suture approximately the anterior peritoneum to the posterior peritoneum.