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

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

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

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

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

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

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

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

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

Clamp and ligate the pedicles in continuity to help avoid bleeding

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