After appropriate general anesthesia, the patient is placed in the dorsal lithotomy position with the buttocks well off the end of the table. A thorough bimanual examination is necessary prior to performing a hysterectomy. The vulva and vagina are fully prepped with a surgical soap solution. The cervix is exposed by placing a weighted posterior vaginal retractor into the vagina. A small right-angle retractor is used to elevate the anterior vaginal wall; a second right-angle retractor displaces one lateral vaginal wall and exposes the cervix. Two Jacobs tenacula are used to grasp the anterior and posterior lips of the cervix and pull them into the vaginal introitus.

The vaginal mucosa at its junction to the cervix is being injected with a dilute solution of Pitressin. Ten international units of Pitressin are diluted with 25 mL of sterile saline solution, and 10 mL of this mixture are injected into the vaginal mucosa to aid hemostasis. This solution should not be used on patients with hypertension or cardiac arrhythmias but is most useful in healthy premenopausal patients.

After the injection of Pitressin into the vaginal mucosa, the mucosa is incised with a scalpel around the entire cervix. The incision should stay above the pubovesical cervical fascia anteriorly and the perirectal fascia posteriorly.

While downward traction is applied on the Jacobs tenacula, the handle of the knife is used to dissect the bladder off the anterior lower uterine segment.

A sponge-covered finger dissects the bladder all the way up to the peritoneal vesicouterine fold. This step is frequently insufficiently performed for fear of entering the bladder. If dissection is not carried up to the peritoneal vesicouterine fold, entry into the anterior cul-de-sac is most difficult.

A right-angle retractor is placed under the vaginal mucosa and bladder. It is used to elevate the bladder. This maneuver aids in identifying the peritoneal vesicouterine fold. The peritoneal fold appears as a white transverse line across the lower uterine segment. Strong downward traction is applied to the Jacobs tenacula on the cervix, and the peritoneal vesicouterine fold is grasped with pickup forceps and incised with sharp curved Mayo scissors.

By elevating the peritoneal vesicouterine fold with the pickup forceps, a definite hole can be seen. It is advisable to insert a finger in this hole and explore the area (1) to be sure one is in the peritoneal cavity and not the bladder and (2) to uncover any unsuspected pathologic condition that was not identified during the examination. With the finger remaining in the hole, an anterior Heaney right-angle retractor is placed into the defect underneath the finger.

The Jacobs tenacula are brought acutely up toward the pubic symphysis, exposing the cul-de-sac. Pickup forceps are used to retract the posterior vaginal cuff, thereby placing the peritoneum of the cul-de-sac on tension. The peritoneum of the cul-de-sac is incised with curved Mayo scissors.

A finger is immediately placed in the cul-de-sac, and the area is explored as in the exploration of the anterior cul-de-sac. Approximately 75-100 mL of peritoneal fluid may be seen upon opening the cul-de-sac.  A second right-angle Heaney retractor is placed into the posterior cul-de-sac.

The weighted posterior vaginal retractor is removed. With the two Heaney retractors the broad ligament is exposed from the uetrosacral ligament to the tubo-ovarian round ligament. A finger placed in the posterior cul-de-sac and moved laterally reveals the uterosacral ligament as it attaches to the lower uterine segment.

With the cervix on upward and lateral retraction via the Jacobs tenacula, a curved Heaney clamp is placed in the posterior cul-de-sac with one blade underneath the uterosacral ligament and the opposite blade over the uterosacral ligament. The clamp is placed immediately next to the uterine cervix so that some tissue of the cervix is included in this clamp. This is done to prevent possible ureteral damage from clamping the uterosacral ligament in the lateral position.

The uterosacral ligament is cut with curved Mayo scissors.

A Heaney fixation 0 synthetic absorbable suture is used to suture-ligate the uterosacral ligament. In addition, the first of four steps is initiated for vaginal cuff suspension. In A, the suture has been placed from the inside of the uterosacral ligament at the tip of the Heaney clamp through the uterosacral ligament and brought out through the vaginal mucosa. In B, the suture is brought back through the vaginal mucosa and through the midportion of the uterosacral ligament underneath the Heaney clamp. This plicates the uterosacral ligaments to the angle of the vagina and aids hemostasis as well as vaginal cuff suspension.

When tied, the suture is held with a Kelly clamp for traction. This suture not only ligates the uterosacral ligament but plicates that pedicle to the vaginal cuff.

With the uterus on upward and lateral retraction via the Jacobs tenacula on the cervix, the cardinal ligament is clamped adjacent to the lower uterine segment and incised.

The cardinal ligament is suture-ligated with 0 synthetic absorbable suture. No fixation suture is used here for fear of producing a hematoma in the vascular cardinal ligament. Before proceeding farther up the broad ligament, the lateral retractor and cervix are moved to the opposite side, exposing the opposite uterosacral and cardinal ligaments, and they are likewise clamped and suture-ligated.

When the uterosacral and cardinal ligaments on each side have been clamped, incised, and suture-ligated, the remaining portion of the broad ligament attached to the lower uterine segment containing the uterine artery is clamped adjacent to the cervix. Use of a single clamp in the vaginal hysterectomy reduces the chance of damage to the ureter, whereas using two clamps will allow this portion of the broad ligament to be clamped in its lateral position, thus increasing the chance of ureteral injury.

With the uterosacral ligament, the cardinal ligament, and the uterine artery pedicle on both sides now clamped, incised, and suture-ligated, the cervix is retracted upward in the midline via the Jacobs tenacula. Thyroid clamps are used to grasp the posterior uterine wall, and with a hand-over-hand "walking out" technique the fundus is delivered posteriorly.

The Jacobs tenacula and the thyroid clamp are held in one hand, and the finger of the opposite hand is inserted under the tubo-ovarian round ligament, exposing the ligated portion of the lower broad ligament.

Two Heaney clamps are applied to the tubo-ovarian round ligament, and it is incised close to the fundus.

The tubo-ovarian round ligament is tied twice. In A, a tie of 0 synthetic absorbable suture is placed behind the second clamp. The tubo-ovarian round ligament is tied with a simple 0 synthetic absorbable suture. After the clamp at the rear of the pedicle is removed, the forward clamp is "flashed" (i.e., slightly opened and immediately closed), to allow the suture to securely ligate all the structures in this pedicle.

In B, a second suture ligature is tied in a fixation stitch, placing the suture in the midportion of its pedicle. In C, the suture is tied in front of and behind the pedicle prior to removing the first clamp. In D, the pedicle is tied, and the second suture is held in a straight clamp for traction.

The anterior and posterior Heaney right-angle retractors are removed, and the weighted posterior vaginal retractor is placed in the vagina. The anterior vaginal wall is elevated with a short-angle retractor. This allows better vaginal cuff exposure. The entire broad ligament and its respective pedicles are exposed from the tubo-ovarian round ligament anteriorly to the uetrosacral ligament posteriorly. A free sponge is pushed into the peritoneal cavity to displace the ovaries, tubes, and bowel and give better exposure to the broad ligament structures. The tail of the sponge is used to wipe the pedicles of each of these ligaments to check for hemostasis. If there is bleeding from any pedicle or portion thereof, the bleeding points can be clamped with a curved Heaney clamp and suture-ligated. It is preferable that the suture be brought through the tip of the Heaney clamp and out through the vaginal mucosa. If the surgeon encounters a wide area of bleeding, the entire broad ligament can be suture-ligated by a running 0 synthetic absorbable suture plicating the pedicles of the broad ligament to the lateral vaginal mucosa. Care should be taken not to go deeper than the original ties on the broad ligament pedicles to prevent damage to the ureter.

The vesical peritoneal edge can be identified by grasping the anterior vaginal wall with tissue forceps. By using a hand-over-hand technique, the surgeon can progressively pull the bladder wall down into the vagina and easily identify the peritoneal edge.

The reperitonealization of the pelvis, carried out with pursestring sutures, provides the second of four steps in suspension of the vaginal cuff. The suture is started on the anterior peritoneal edge and brought through the stump of the tubo-ovarian round ligament. After the stump of the tubo-ovarian round ligament is sutured, the suture ligature held for retraction can be cut. The pursestring is continued down through one or more of the pedicles and is finally brought through the uterosacral cardinal ligament pedicles and the vaginal mucosa, plicating these pedicles to the vaginal mucosa to provide additional suspension of the upper vagina. The suture is continued posteriorly across the peritoneum of the cul-de-sac with one or two stitches. The traction sutures in the uterosacral ligaments should not be cut, as they are needed in a later step. The suture is brought from the inside of the opposite uterosacral ligament out through the vaginal mucosa and carried up the pedicles of the opposite side until the tubo-ovarian round ligament on the opposite side has been sutured. The traction suture on this pedicle can be cut. The suture is passed through the anterior vesicoperitoneal edge. When this suture is tied, the pelvis is reperitonealized, and the stumps of the broad ligament are retroperitonealized.

The vaginal cuff is never closed and is left open for drainage to prevent postoperative pelvic abscesses. A running locking 0 synthetic absorbable suture is started at the 12 o'clock position on the anterior vaginal cuff and is carried around the entire edge of the vagina until the cardinal and uterosacral ligaments are reached. At that point, the suture is brought through the cardinal and uterosacral, and the surgeon again plicates these ligaments to the vaginal cuff, completing the third of four steps in vaginal suspension. The same is done for the uterosacral and cardinal ligaments on the opposite side. The running locking suture is continued until the entire cuff has been sutured. The two retraction sutures held by Kelly clamps on the uterosacral ligaments are tied in the midline. This aids in obliterating the cul-de-sac and reduces the incidence of enterocele.

The final step is to observe the upper vaginal area for hemorrhage. We prefer to catheterize the bladder at the end rather than at the beginning of the procedure because there may be less chance of injuring a bladder that is partially filled with urine than one that is empty. No vaginal pack is left in the vagina, and no Foley catheter is placed in the bladder. All patients undergoing vaginal hysterectomy are given antibiotics preoperatively.

VAGINAL BILATERAL SALPINGO-OOPHORECTOMY DURING TOTAL VAGINAL HYSTERECTOMY

Under certain conditions the Fallopian tubes and ovaries may be removed at the time of vaginal hysterectomy. Salpingo-oophorectomy can be performed during the hysterectomy, although it is easier to perform immediately after the uterine specimen has been removed.

If the tubes and ovaries are to be removed with the specimen, the uterus is delivered into the vagina as in Figure 18.

Exposure is facilitated by clamping and cutting the round ligament on each side. The thyroid clamp on the fundus, which has been placed on traction (Fig. 18), is removed to expose the anatomy.