1. Vaginal Hysterectomy: Techniques and Tips
Mickey Karram M.D.
Director of Urogynecology
The Christ Hospital
Clinical Professor of Ob/Gyn & Urology
University of Cincinnati

2. Objectives
Describe the important factors in choosing the best route of hysterectomy
Review some ways to optimize hysterectomy outcomes
Discuss and show videos of techniques to perform vaginal hysterectomy

3. Vaginal Hysterectomy - Chassar Moir
“If you are going to have your tonsils removed, would you prefer they be taken out through your throat or through an incision in the side of your neck?”
- Chassar Moir

5. Minimize Bleeding During Vaginal Surgery
Preoperative assessment
Discontinue NSAIDS, ASA 2 weeks pre-op
Bleeding diathesis
Careful entry into proper tissue planes
Normal saline injection
Lidocaine 1% with epinephrine 1:200,000
Pitressin

8. Difficult Entry into Posterior Cul-de-Sac can be caused by:
Shallow Pouch of Douglas
Long cervix
Endometriosis
Posterior cervical or lower uterine segment myomas
Pelvic adhesions

9. Difficult Entry into Posterior Cul-de-Sac
Traction-countertraction
Sharp dissection
Digital rectal exam
Extraperitoneal pedicle ligation
Palpation of cul-de-sac via anterior colpotomy
Division of posterior cervix

10. Difficult Entry into Anterior Cul-de-Sac
Try to see the peritoneum before cutting
Traction-countertraction
Sharp dissection
Extraperitoneal pedicle ligation
Digital palpation of anterior reflection via the posterior cul-de-sac
Uterine sound in bladder; retrograde bladder fill

11. Traction and Counter-traction help to increase the distance between the clamps and the ureter, thus
minimizing the risk of ureteral injury during vaginal hysterectomy

13. Use sharp dissection to separate the bladder from the cervix until you can see the peritoneal edge

19. Clamp and ligate the pedicles in continuity to help avoid bleeding

23. Route of Hysterectomy - George Morley
May the vaginal hysterectomy never be to gynecology what breech delivery has become to obstetrics.
- George Morley