Vaginal Hysterectomy Technique
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Direct answer
Vaginal hysterectomy is removal of the uterus through the vagina, in which the peritoneal reflections are opened and the uterine pedicles are clamped, divided and tied in a set order before the uterus is delivered. It is indicated for uterovaginal prolapse and benign enlarged uteri in a woman with an accessible vagina. Haemorrhage, bladder injury, ureteric injury and bowel injury are its main risks, and careful pedicle control reduces them.
What you must remember
- Indications: uterovaginal prolapse, and a benign uterus of modest size with abnormal bleeding, in a woman whose uterus descends easily and whose vagina is accessible.
- Contraindications: suspected malignancy or adnexal pathology needing evaluation, a very large uterus, severe adhesions and a uterus that cannot be brought down.
- Pedicle sequence: the uterosacral and cardinal pedicles are clamped and divided before the uterine vessels, with utero-ovarian pedicles last when the adnexa are removed.
- Key complications: haemorrhage from uterine or cardinal vessels, bladder injury at anterior dissection, ureteric injury near the cervix and bowel injury in the pouch of Douglas.
- Vault management: the vaginal cuff is closed in layers, and vault haematoma and later vault prolapse are recognised risks.
- Ureter position: the ureter lies about 2 cm lateral to the cervix, passing beneath the uterine artery, which is why the lateral pedicle needs direct vision.
A stepwise technique for a prolapsed uterus
A 52-year-old parous woman with a prolapsed, small and mobile uterus is booked for vaginal hysterectomy under spinal anaesthesia. The steps below show the usual order of dissection, with pedicles controlled one at a time. Textbooks differ on the exact sequence, so the operator follows a consistent and safe order.
- Deliver the cervix: Grasp the cervix with volsellum or a tenaculum and draw it down to define the vaginal incision and expose the cervicovaginal junction.
- Incise the vaginal mucosa: Make a circumferential incision at the cervicovaginal junction and begin dissecting the bladder away from the cervix anteriorly.
- Open the peritoneum: Enter the pouch of Douglas posteriorly and the vesicouterine peritoneum anteriorly, identifying the bowel and bladder edges before proceeding.
- Clamp the posterior pedicles first: Clamp, divide and tie the uterosacral ligaments, then the cardinal ligaments, and next the uterine vessels, using absorbable suture on each side.
- Address the adnexa if needed: Utero-ovarian pedicles are clamped and tied last when the ovaries are removed, and haemostasis is secured before the uterus is delivered.
- Close the vault: The vaginal cuff is closed in layers after checking haemostasis, the bladder and both ureters.
Where the exam tries to catch you
Examiners test whether you protect the ureter, recognise when to convert to abdominal surgery and avoid vaginal surgery for malignancy.
- Trap: Clamp the lateral pedicle blindly to speed up the operation. Correct: The ureter runs near the cervix beneath the uterine artery, so each pedicle must be identified and clamped under direct vision.
- Trap: Persist with a vaginal approach when the uterus is unexpectedly large or adherent. Correct: Conversion to abdominal or laparoscopic surgery is safer than forcing a vaginal dissection that risks injury.
- Trap: Repair an identified bladder injury without testing the repair. Correct: Close the bladder in layers and test for leaks with retrograde filling before finishing the operation.
- Trap: Offer vaginal hysterectomy for suspected cancer. Correct: Malignancy generally needs abdominal or radical surgery with staging, because vaginal removal does not allow adequate assessment.
Frequently asked questions
What are the main indications for vaginal hysterectomy?
Uterovaginal prolapse and a benign enlarged uterus with abnormal bleeding are the main indications for vaginal hysterectomy. The uterus should be of modest size and mobile, and the vagina should be accessible for the procedure.
Which pedicles are clamped first in vaginal hysterectomy?
The uterosacral ligaments are commonly clamped and divided early in vaginal hysterectomy, followed by the cardinal ligaments and then the uterine vessels. Books differ slightly on the exact sequence, so the operator should follow one consistent, safe order.
Where is the ureter at risk during vaginal hysterectomy?
The ureter is at risk near the cervix, where it passes beneath the uterine artery about 2 cm lateral to the cervix. Clamping and dividing the lateral pedicle under direct vision protects the ureter during vaginal hysterectomy.
Which complications must be anticipated in vaginal hysterectomy?
Haemorrhage from the uterine or cardinal pedicles, bladder injury, ureteric injury and bowel injury must be anticipated in vaginal hysterectomy. Careful pedicle control, identification of the ureters and layered vault closure reduce these risks.