Vaginal Hysterectomy

Table of contents

1. Operative Note
2. Postoperative Considerations
3. Patient Education

Operative Note

_ indicates a section that needs to be reviewed or completed.

I (or a fellow) will do the operative notes for procedures that I perform (and you assist). These notes are included here so that you can read about the procedure before we get to the OR - allowing you to familiarize yourself with both the steps of the procedure and nuances/dogma of my technique compared to another surgeon’s that you may have seen in the past. As you read the note, consider the instruments and anatomy. Consider how we maximize exposure and where the high risk portions of the procedure lie. Bonus points if you can customize the risk to the patients and their anatomy/history.

See Also: Uterosacral Ligament Suspension

After informed consent was obtained, the patient was taken to the operating room where she was placed in the dorsal supine position. She then underwent uncomplicated induction of general endotracheal anesthesia. She was repositioned in dorsal lithotomy with her legs in yellow fin stirrups. She was prepared and draped in a normal sterile fashion. A surgical timeout was performed. A Foley catheter was inserted into the bladder and the vaginal Bookwalter was set up to aid in retraction.

The anterior and posterior lips of the cervix were grasped with Jacobs tenaculum and the cervicovaginal junction injected with a dilute solution of epinephrine in normal saline (1:800,000). We then made a circumferential incision about the cervix with the scalpel. The anterior vaginal epithelium was dissected off the anterior cervix using the Metzenbaum scissors. The bladder pillars were cauterized laterally with the Bovie and the anterior vaginal epithelium gently swept off the anterior surface of the uterus and cervix. We then entered the posterior cul-de-sac sharply using the curved Mayo scissors.

A posterior blade was placed into the cul-de-sac and the uterosacral ligaments were clamped, cut, and suture ligated bilaterally. The cardinal ligaments were then clamped, cut, and suture ligated bilaterally. We then identified the vesicouterine peritoneal folds and entered the anterior cul-de-sac sharply. The broad ligament was then clamped, cut, and suture ligated bilaterally. The uteroovarian ligaments were then clamped, cut, and suture ligated bilaterally. The uterus and cervix were handed off the field and sent to pathology to be evaluated as a permanent specimen.

======= IF SALPINGECTOMY WAS PERFORMED =======

The bowels were then packed with a moist laparotomy sponge. The patient’s left fallopian tube was identified and grasped with Babcock clamp. The tube was dissected off the meso-ovarium using the Bovie. Hemostasis was excellent. The tube was passed off the field and to pathology with the prior specimen.

======= // IF SALPINGECTOMY WAS PERFORMED =======

We then performed the uterosacral ligament suspension by placing three 2-0 PDS sutures on each side. These were passed from lateral to medial, starting on the patient’s right. The process was repeated on the left. We then placed an interrupted stich of 0 Vicryl at the corners of the cuff to aid long term hemostasis. The PDS sutures were then passed through the vaginal cuff with the most inferior sutures nearest the vaginal cuff corners. One arm of the stich was passed anteriorly and the other posteriorly such that, when tied, they would close the cuff. A cystoscopy was performed. Bilateral ureteral jets were noted.

_ ANTERIOR REPAIR GOES HERE IF APPLICABLE

We then removed the vaginal packing and sequentially tied down all 3 sets of uterosacral ligament sutures performing cystoscopy after each one to ensure continued patency of the bilateral ureteral orifices. Brisk ureteral jets were noted following the suturing of all uterosacral sutures. We then replaced the Foley catheter.

_ SLING GOES HERE IF APPLICABLE

Attention was then turned to the posterior repair following the injection in the perineal body and posterior vaginal wall with 1:800,000 dilute epinephrine solution. An inverted triangular incision was made along the perineal body and carried up to the posterior vaginal wall. The vaginal epithelium was dissected off the underlying endopelvic connective tissue in the midline using the Metzenbaum scissors. The excess vaginal epithelium was excised. The epithelium and underlying tissue was plicated in the midline using an 0 Vicryl. We then dissected out laterally to reach the fascia of the levator muscles at the level of the hymen. This was plicated in the midline using 0 Vicryl in an interrupted fashion. We then reapproximated the perineal body using a 0 Vicryl in an interrupted fashion. The perineal skin was then reapproximated using a 3-0 Vicryl in a running subcuticular fashion.

Sponge, lap, and needle counts were correct. The patient tolerated the procedure well, and was taken to the recovery room in stable condition.

Postoperative Considerations

Patient Education

Preop

• Voices for PFD (AUGS) - Pelvic Organ Prolapse
• Voices for PFD (AUGS) - Vagnial Hysterectomy for Pelvic Organ Prolapse
• Voices for PFD (AUGS) - Vaginal Suspension Surgery

Postop

Patient Education

Cerner > Discharge Tab > Patient Education > Custom

• Stewart - Vaginal Surgery Postop (Custom)
• Stewart - Sling Postop (Custom) ← IF THE PATIENT ALSO HAD A SLING
• Stewart - Postop Pain Control (Custom)
• Stewart - Contacting IU Urogyn (Custom)
• ANY/ALL LEAFLETS FOR PRESCRIBED MEDICATIONS

Patient Instructions

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