Special Surgical Procedures II
LESSON 2: Procedures in Gynecological and Obstetrical Surgery
Section Ii:
2-34
2-34. VAGINAL HYSTERECTOMY
a. General. In this procedure, the uterus is removed through an incision in the vaginal wall. This may be done unless there is pelvic malignancy or a large uterine tumor, both of which call for abdominal surgery.
b. Operative Procedure.
(1) The labia are retracted back with sutures of silk or chromic gut number 2-0 swaged to 3/8 circle, cutting-edge needles held by Crile short needle holders. Tissue forceps and suture scissors are needed. An Auvard or Sims vaginal retractor is inserted to retract the vaginal wall.
(2) A D and C is performed.
(3) A Jacobs vulsellum forceps or chromic gut number0 suture ligature is placed on both the posterior cervical lips to permit traction of the cervix.
(4) The vaginal wall is incised. The incision is made anteriorly on the cervix through the full thickness of the wall. The bladder is pushed off the cervix by the knife handle; the bladder is freed from the anterior surface of the cervix and positioned with Kelly retractors.
(5) The vesicouterine peritoneum is carefully opened and the incision is extended laterally as far as the broad ligament. The body of the uterus and the adnexa are palpated and the fundus is delivered through the opening.
(6) The vaginal incision is carried around the cervix; the posterior wall flaps are grasped with Allis forceps. The cul-de-sac peritoneum is opened with a knife. A suction set and small laparotomy packs may be used. The peritoneal edges are sutured to the posterior wall with silk or chromic traction sutures swaged to 1/2- circle, taper-point needles secured on Crile-Wood needle holders.
(7) The uterosacral ligaments containing blood vessels are doubly clamped, ligated, and cut. The ends of the ligatures are left long and tagged with a clamp.
(8) The uterus is drawn downward and the bladder held away with retractors and moist small laparotomy packs.
(9) If the bladder is entered, the opening is closed with two layers of interrupted chromic gut number 4-0 sutures swaged to 1/2- circle, taper-point needles secured to long needle holders. The vesicouterine reflection is sutured to the anterior vaginal wall by means of traction sutures and free ends held in a clamp.
(10) The cardinal ligament on each side is doubly clamped, cut, and doubly ligated. The uterine arteries are doubly clamped, cut, and ligated.
(11) The fundus is delivered through the anterior route with the aid of a uterine tenaculum.
(12) When the ovaries are to be left, a Kocher clamp is placed from below and two from above to grasp the pedicles, which are then cut and doubly ligated on both sides; the uterus is removed.
(13) The peritoneum between the rectum and vagina is approximated with a continuous suture of chromic gut number 2-0. The retroperitoneal obliteration of the cul-de-sac is done by sutures
that pass from the vaginal wall through the infundibulopelvic ligament and round ligament, through the cardinal ligament, and out through the vaginal wall. The suture is tied on the vaginal aspect of the new vault. The uterosacral ligament on each side is sutured in the midline. The round, cardinal, and ureterosacral ligaments may be individually approximated for additional support.
(14) An existing rectocele and the perineum are repaired, as described for vaginal plastic repair. In the presence of prolapse, reconstruction of the pelvic floor is done.
(15) An indwelling system of urinary drainage is established; the vagina may be packed; and a perineal pad is applied.
