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6. Surgical evaluation, and
7. Patient understanding and commitment to a
strict, small-volume, progressive liquid diet
postoperatively, and close dietician follow-up.
Additionally, the inclusion criteria for the
consideration for transvaginal sleeve gastrectomy
would include the following:
1. Female gender,
2. Age 18–65,
3. ASA Classification 1 or 2,
4. Morbid obesity per NIH criteria for weight
loss surgery,
5. Normal pap smear within 12 months to rule
out malignancy,
6. Normal OB-GYN exam within 12 months,
and
7. Desire for surgical treatment for obesity.
Exclusion criteria would include the
following:
1. Pregnancy,
2. Evidence of intra-abdominal abscess or mass,
3. Sepsis or peritonitis,
4. Prior major abdominal surgery (previous
cesarean section is a relative
contraindication),
5. History of ectopic pregnancy,
6. Pelvic inflammatory disease,
7. Severe endometriosis,
8. Previous perineal trauma, and
9. Pelvic or abdominal malignancy.
Equipment List
Endoscopic Equipment
Two standard single- or double-channel endo-
scopes (Olympus America, Center Valley, PA)
are used in this procedure. These scopes will be
separated during the procedure to prevent
cross-contamination, as one will used for intra-
luminal evaluation while the other is used for
transvaginal intra-abdominal visualization. This
also requires the use of two separate endoscopic
towers, although it is feasible to use only one
tower and switch between the two devices as
long as sterility is maintained for the transvaginal
scope. Endoscopic graspers or endoscopic snares
will also be needed. Because of the larger than
average amount of tissue expected to be handled
by the endoscope, a larger-toothed grasper
should be employed.
Laparoscopic Equipment
Standard bariatric laparoscopic equipment will be
needed. Laparoscopic linear staplers will also be
used to create the tubularized stomach. Though
devices may vary, stapler loads able to accom-
modate up to 4.5 mm in tissue thickness should
be used and adjusted on a case-by-case basis
during the operation. Finally, an advanced energy
tissue sealer device is needed for dissection. Our
experience has been using the ultrasound dissec-
tor (Harmonic Scalpel
TM
, Ethicon Endosurgery
Inc., Cincinnati, OH), but it may be up to surgeon
preference to use bipolar energy division.
Technique
Patient Positioning/OR Planning
Patients are placed in a split leg position with
hips lying flat in neutral position (Fig. 19.1).
This minimizes any interference between the
patient’s legs and the laparoscopic instruments.
Both arms can be extended. A urinary catheter
should be placed and the vagina prepared with
iodine-based surgical prep solution. Extra foam
padding is placed under the knees and ankles by
the surgical team in order prevent compressive
tissue and nerve injuries.
The head of the patient’s bed should have a
laparoscopic monitor and enough room for a
surgeon to perform upper endoscopy at the
beginning of the case. We typically place our first
endoscopy tower to the left of the patient, at the
head of the operating table. A second endoscopy
tower is placed just next to the patient’s left foot.
19 NOTES Transvaginal Sleeve Gastrectomy 223
There should be enough room between the
patient’s legs for the main operating surgeon to
stand and operate. The assistant surgeon should
be positioned on the patient’s left and the scrub
technician to the right of the assistant surgeo n.
The right side of the patient is reserved for sur-
gical towers, an additional monitor facing the
assisting surgeon, suction, and other equipment
(Fig. 19.1). There should also be enough space to
access the right side of the operating table at the
beginning of the case to secure a liver retractor
such as a Nathanson.
Perioperative Endoscopy
After intubation and initiation of general anes-
thesia, an upper endoscopy is first performed to
evaluate the intraluminal health of the stomach
and esophagus. We advocate only proceeding if
there is no evidence of gastritis, ulcer, or other
pathologies of the stomach or esophagus. If an
abnormality is detected, then the operation
should be aborted until a later time when optimal
medical management is complete. After evalua-
tion, either the scope or a separate sizing device
such as a bougie can be left in the stomach as a
guide for resection later.
Transvaginal Access/Colpotomy
The first step in performing a transvaginal sleev e
gastrectomy is to obtain transvaginal access.
Sterile surgical draping should be donned over
the patient’s abdomen and perineal area. The
vagina is examined for any inflammation or
infections, which would be a contraindication to
proceeding. Early on in our learning curve, this
examination should be done by a gynecologist
experienced in vaginal surgery, who would assist
for the colpotomy access as well. After several
procedures, the bariatric surgeon should be
comfortable performing the colpotomy access
independently, although they may need to get
separate operative privileges for this from their
institution.
A 5-mm trocar is placed through the umbili-
cus under direct visualization and pneumoperi-
toneum is established via CO
2
through this
trocar. An exploratory laparoscopy is then per-
formed via a 5-mm laparoscope before proceed-
ing with the colpotomy. The abdomen is
examined for any aberrant anatomy, adhesions,
and mobility of the uterus. Once complete, we
proceed with the colpotomy.
A speculum is placed into the vagina for
visualization. Either a uterine manipulator or a
surgical clamp is placed on the cervix. This is
used in order to elevate the uterus into an antev-
erted position. At this point, the patient is placed
in steep Trendelenburg position. The posterior
vaginal mucosa is exposed, and an incision is
made through the cul-de-sac just anterior to the
rectum but posterior to the cervix. A 15-mm
dilating trocar is then inserted through the
colpotomy under direct visualization both exter-
nally as well as intra-abdominally (Fig. 19.2).
Fig. 19.1 Patient positioning along with layout of the
operating room
224 S. Liu et al.
Sleeve Gastrectomy
After establishing transvaginal access, a liver
retractor can be placed (though not required)
through the subxiphoid region to elevate the left
lobe of the liver in order for adequate visualiza-
tion of the crus and gastroesophageal junction.
A 5-mm transabdominal trocar is placed in the
right upper quadrant of the abdomen to assist in
the procedure. Finally, a 12-mm transabdominal
trocar is placed in the left upper quadrant to
accommodate the passage of a linear laparo-
scopic stapler. The insufflation throughout the
case will be provided through this trocar via
standard CO
2
laparoscopic insufflator. [9] At this
point, visualization is switched to the 15-mm
transvaginal port via the flexible endoscope.
The gastrocolic ligament and short gastric
vessels are divided with the ultrasonic dissector
or similar advanced energy dissector starting
8 cm from the pylorus, and extending cranially
to the left crus. The posterior aspect of the fundus
is cleared of its attachments until the decussation
of the left crus is identified as well to ensure
adequate mobilization.
A laparoscopic stapler is then placed through
the 12-mm transabdominal port to perform a
vertical gastrectomy and create a tubular gastric
remnant (Fig. 19.3). Sequential staple firings are
used with thicker staplers toward the antrum
(Fig. 19.4). The endoscope used at the beginning
of the case now serves as a bougie for the gastric
sleeve. If one is to use this method rather than a
larger bougie, care needs to be taken not to hug
the endoscope as this would result in a narrow
caliber sleeve, predisposing the patient to leak.
One must be extremely mindful of
over-narrowing the sleeve at the level of the
incisura, the result of which can be problematic.
Alternatively, the surgeon can use the bougie
they usually would employ for a sleeve gastrec-
tomy. It would be nice to completely remove the
larger abdominal trocars in favor of placement of
Fig. 19.2 Laparoscopic
view of the posterior
colpotomy trocar being
inserted
Fig. 19.3 Planned stapler routes for sleeve gastrectomy
19 NOTES Transvaginal Sleeve Gastrectomy 225
the stapler through the larger transvaginal port.
However, without the aid of a flexible linear
stapler, the angle that the rigid stapler approaches
the stomach from the transvaginal trocar tends to
be prohibitive. The sacral promontory puts the
stapler on a trajectory toward the anterior
abdominal wall precluding adequat e stapling of
the stomach. We have been unable to overcome
this limitation with standard staplers. This limi-
tation of reaching upper abdominal viscera with
rigid instrumentation from a transva ginal
approach has been noted before [10].
Once complete, the staple line is inspected for
leaks. Some surgeons advocate leak testing
intraoperatively, although it is of unclear benefit
as postoperative leaks tend to occur well after
discharge from the hospital. In our series, we
have imbricated the staple line with a running
suture, and this is all performed with laparo-
scopic suturing techniques (Fig. 19.5).
Organ Extraction
The resected stomach is grasped with a snare
from the transvaginal endoscope and remo ved
with the vaginal trocar (Fig. 19.6). The orienta-
tion of the excised stomach for extraction is key
in facilitating an easy extraction. Often times the
excised stomach has a jagged appearance on the
staple line side due to efforts taken to create a
smooth and rounded gastric remnant. Because of
this, extraction is greatly facilitated by grasping
the anatomical proximal portion (fundus) of the
excised stomach and removing it first with the
vaginal trocar. Large surgical clamps can be used
externally for traction during this process.
Closure
At the end of the procedure, pneumoperitoneum
is deflated and all the trocars are removed.
Although not all surgeons routinely leave a drain
after sleeve gastrectomy, we still prefer to do so.
A Jackson-Pratt drain is thus left through the
right upper quadrant 5-mm trocar site, with the
end terminating at the angle of His. The colpo-
tomy is sutured closed in figure-of-eight stitches
under direct visualization using absorbable
suture material such as 0-Vicryl (Fig. 19.7). The
rest of the abdominal trocar sites are closed with
subcutaneous closure only using absorbable
suture such as 4-0 Monocryl, and wound adhe-
sive is applied to the skin. In our experience, it is
not necessary to apply transfascial sutures to
trocar sites as long as the trocar used is no
greater than 12 mm. Given that transfascial
sutures tend to cause the most postoperative
discomfort, we see this approach as one that may
reduce postoperative pain and discomfort.
Fig. 19.4 Placing staples along the greater curvature
using the endoscope as camera
Fig. 19.5 Final evaluation of the cut edge of stomach
after imbrication
226 S. Liu et al.
Postoperative Care
The postoperative care of transvaginal sleeve
gastrectomy is identical to that of laparoscopic
sleeve gastrectomy. It is acceptable to place the
patients on a limited clear liquid diet postopera-
tively. Patients are expected to complete a Gas-
trografin swallow study on postoperative day 1 to
demonstrate passage of contrast without
extravasation. After this, patients are placed on a
strictly regimented small-volum e progressive
liquid diet as per the preoperative discussion. The
surgical drain can also be removed at this point if
output is clear and minimal. Patients are typically
discharged on postoperative day 1 or 2.
Surgical port pain after this procedure tends to
be minimal and should be controlled adequately
with acetaminophen or an oral narcotic as long as
the medication can be given in liquid form for the
first several days. Most patients do not complain
of perineal or vaginal discomfort; however, mild
spotting is to be expected. Patients should be
advised to avoid tampon insertion or intercourse
for at least 4 weeks to allow healing. They
should also be instructed to call immediatel y or
Fig. 19.6 Vaginal
extraction of resected
stomach
Fig. 19.7 Repair of the
colpotomy under direct
visualization
19 NOTES Transvaginal Sleeve Gastrectomy 227
come to the emergency room if they experience
any of symptoms of infection at the colpotomy
site including: heavy bleeding (>1 pad per hour),
foul smelling vaginal discharge, or erythema
involving the entire perineal area.
Results
Transvaginal solid organ extraction has been
previously described in 2012 in a series of 34
women [11]. In this study, 34 women underwent
transvaginal organ extraction over the course of
5 years, with mean follow-up of 24 months. All
patients were ASA classification of 2 or below.
Average time of sleeve gastrectomy was 135 min
with no conversions to open operations or
intraoperative complications. The mean hospital
stay of all cases was two days. In follow-up,
there were two pregnancies and two successful
vaginal deliveries. Six patients reported heavy
menses immediately following the operation.
There were no long-term complications and no
mortalities.
Conclusion
The transvaginal approach to sleeve gastrectomy
is an effective method to perform the operation. It
poses few complications from the vaginal wall
incision. The biggest benefit is that it avoids
additional abdominal incisions for trocar place-
ment and stomach extraction, which should
decrease the rates of hernia and may possibly
reduce postoperative pain. Other complications
due to the sleeve gastrectomy itself (leak, fistula,
stricture, gastric outlet obstruction, etc.) are not
reduced or eliminated by the transvaginal
approach and are presumed to occur at roughly the
same rate as in laparoscopic sleeve gastrectomy.
References
1. Pelligrini C, Wetter LA, Patti M, LeichterR Mus-
san G, et al. Thoracopscopic esophagomyotomy:
initial experience with a new approach for the
treatment of achalasia. Ann Surg. 1992;216
(3):291–6.
2. ASMBS. Estimate of bariatric surgery numbers.
www.asmbs.org. 2014;1. http://asmbs.org/2014/03/
estimate-of-bariatric-surgery-numbers/.
3. Mintz Y, Horgan S, Cullen J, Ramamoorthy S,
Chock A, et al. NOTES: the hybrid technique.
J Laparoendosc Adv Surg Tech A. 2007;17(4):
402–6.
4. Zorron R, Soldan M, Filgueiras M, Maggioni LC,
Pombo L, et al. NOTES: transvaginal for cancer
diagnostic staging: preliminary clinical application.
Surg Innov. 2008;15(3):161–5.
5. Zornig C, Mofid H, Siemssen L, Emmermann A,
Alm M, et al. Transvaginal NOTES hybrid chole-
cystectomy: feasibility results in 68 cases with
mid-term follow-up. Endoscopy. 2009;41(5):391–4.
6. Fischer LJ, Jacobsen G, Wong B, Thompson K,
Bosia J, et al. NOTES laparoscopic-assisted
transvaginal sleeve gastrectomy in humans-
description of preliminary experience in the United
States. Surg Obes Relat Dis. 2009; 5(5):633–6.
7. Arribas D, Elía M, Artigas C, Jiménez A,
Anguilella V, et al. Incidence of incisional hernia
following vertical banded gastroplasty. Hernia.
2004;8(2):135–7.
8. Mintz Y, Horgan S, Savu MK, Cullen J, Chock A,
et al. Hybrid natural orifice translumenal surgery
(NOTES) sleeve gastrectomy: a feasibility study
using an animal model. Surg Endosc. 2008;22
(8):1798–802.
9. Meireles O, Kantsevoy SV, Kalloo AN, Jagan-
nath SB, Giday SA, et al. Comparison of intraab-
dominal pressures using the gastroscope and
laparoscope for transgastric surgery. Surg Endosc.
2007;21(6):998–1001.
10. Nakajima K, Souma Y, Takahashi T, Yamasaki M,
Miyazaki Y, et al. Anatomical measurements to
optimize instrumentation for transvaginal surgery.
Surg Endosc. 2013;27(6):2052–7.
11. Jacobsen GR, Barajas-Gamboa JS, Coker AM, Chev-
erie J, Macias CA, et al. Transvaginal organ extrac-
tion: potential for broad clinical application. Surg
Endosc. 2014;28(2):484–91.
228 S. Liu et al.
20
Transvaginal Tubal Sterilization
and Hysterectomy
Oz Harmanli
Abstract
In the growing world of ever less invasive surgery, minimalist approaches to
hysterectomy have begun to proliferate. Vaginal hysterectomy (VH) is an old
operation—dating to antiquity—that was widely used until the advent of
laparoscopic surgery, although its use has declined as minimally invasive efforts,
including the robotic approach, have grown in popularity. A thorough
knowledge of pelvic anatomy and positioning is required to safely perform
VH. This understanding of anatomy also allows for the performance of posterior
colpotomy, which can be utilized for transvaginal approaches to other
abdominal operations, as described in NOTES transvaginal surgery. Other
transvaginal procedures, such as culdocentesis, culdotomy, and culdoscopy, are
performed in a similar manner. Strategies for employing these techniques and
potential complications to avoid are discussed in detail. Transvaginal steriliza-
tion, or tubal ligation, is also described, as are the complications of the procedure.
Keywords
Hysterectomy
Transvaginal surgery
Culdocentesis
Culdotomy
Culdoscopy
Tubal ligation
Abbreviations
LH Laparoscopic hysterectomy
TAH Total abdominal hysterectomy
THL Transvaginal hydrolaparoscopy
VH Vaginal hysterectomy
Oz. Harmanli (&)
Chief, Yale Urogynecology & Reconstructive Pelvic
Surgery, Professor, OB/GYN/RS, Department of
OB/GYN/RS, Yale Medical School, 330 Cedar
Street, Suite FMB 329B, New Haven, CT 06510,
USA
e-mail: oz.harmanli@yale.edu
© Springer International Publishing AG 2017
J.R. Romanelli et al. (eds.), NOTES and Endoluminal Surgery,
Clinical Gastroenterology, DOI 10.1007/978-3-319-50610-4_20
229
Introduction
In any surgical discipline, the objective has
always been to develop the least invasive, fastest,
least complicated, and least expensive operative
technique, with the shortest hospital stay. The
motivation to achieve this goal has led to the
birth of minimally invasive surgery, primarily
with the advances in endoscopic instrumentation.
In this age of minimally invasive surgery and
growing interest in avoiding visible incisions, it
is intuitive to think that in the field of gynecol-
ogy, this would be best accomplished through the
vagina, the natural orifice to the female genital
system. Vaginal hysterectomy (VH), which has
unfortunately been eclipsed by today’s laparo-
scopic and robotic approaches, fits this definition
very well. Transvaginal intraperitoneal access
has a few other applications including tubal
sterilization, infertility assessment, and ovarian
and uterine surgery.
Vaginal Hysterectomy
If every hysterectomy candidate were made aware
of an approach which offers no abdominal inci-
sion, i.e., vaginal hysterectomy (VH), she would
undoubtedly not choose another route. If she were
also told that this least invasive approach has been
shown to minimize the complications, decrease
operative and recovery times, and shorten hospi-
tal stay, there would probably be very few hys-
terectomies performed by any other technique (1).
Systematic analysis provided by the Cochrane
group has established that VH offers the lowest
morbidity, least pain, fastest recovery, and
quickest return to normal activities at a lower cost
(2). Unfortunately, without the glamour of mod-
ern technology and support from the industry, VH
is becoming a lost art.
The only contraindications to VH are
advanced malignancy, pelvic mass of undeter-
mined origin, and tubo-ovarian abscess (3).
However, advanced skills may be required for
certain conditions such as uterine size greater
than 12 weeks’ pregnancy, prior pelvic surgery
such as cesarean delivery and myomectomy,
nulliparity, suspected severe endometriosis, and
suspected obliteration of cul-de-sac (3).
VH is typically performed for benign uterine
conditions such as uterine leiomyoma, abnormal
uterine bleeding, pelvic organ prolapse, and
chronic pelvic pain. However, after consultation
with gynecologic oncology, VH may also be
suitable for precancerous or early-stage cancer of
the cervix or endometrium, including severe
cervical intraepithelial neoplasia, in situ or stage
Ia1 cervical cancer, endometrial hyperplasia, and
stage I, grade I endometrial cancer.
VH should not be attempted without good
knowledge of fundamental pelvic anatomy. The
major blood supply to the uterus is provided by
the uterine arteries which reside in the cardinal
ligaments. They communicate with ovarian
arteries through their ascending branches on both
sides. The ovarian arteries must also be occluded
before removal of the uterus. The bladder is
attached to the cervix with 1–2-cm-long suprav-
aginal septum. Once it is incised, an avascular
vesicouterine plane is entered. Placement of a
retractor between the uterus and the bladder in
this area protects not only the bladder but also the
ureters. Although the ureters are just 1–1.5 cm
lateral to the uterus at the level of uterin e artery
insertion, traction on the cervix with tenacula and
deflection of the bladder by the retractor almost
always prevent injury to the ureters. It is impor-
tant to know that the rectum is not attached to the
apical vagina. Under normal circumstances, the
proximal posterior vagina is free by about 4 cm.
The informed consent process, for any type of
hysterectomy, must cover alternative treatment
options such as nonsurgical and uterine-sparing
modalities. As there is growing circumstantial
evidence associating fallopian tubes with the
development of ovarian cancer, opportunistic
salpingectomy is often recommended. While
elective oophorectomy in women with average
risk of ovarian cancer is not recommended before
menopause, it can be offered to those remotely
postmenopausal and with family history of
hereditary and genital cancers. In addition to the
general risks of surgery, those specificto
230 Oz. Harmanli
hysterectomy must also be reviewed, including
its association with future childbearing. Every
hysterectomy candidate must be made aware that
open or laparoscopic routes may be used if VH
does not appear feasible intraoperatively.
In cases of anemia, it is a common practice to
transfuse women until preoperative hemoglobin
level is 10 g/L or greater and cross-matching
blood products for them if there is not enough
time for transfusion. Storing autologous blood
for most hysterectomy procedures was not shown
to be cost-effective in a large study. Preoperative
Pap smear and endometrial sampling are indi-
cated in women who have abnormal uterine
bleeding, cervical intraepithelial neoplasia, or
endometrial hyperplasia. In the event of suspi-
cious pelvic masses and/or any abnormal uterine
bleeding, preoperative transvaginal ultrasound is
crucial. More invasive procedures such as
dilatation and curettage and hysteroscopy are
needed only in the presence of an inadequate
office biopsy or, in the postmenopausal stage, or
when endometrial thickness is greater than 4 mm
on transvaginal ultrasound. Mechanical bowel
preparation is not necessary.
Among all hysterectomy approaches, VH is the
only one amenable to spinal or epidural anesthe-
sia. Sequential compression boots and, when
indicated, chemoprophylaxis for the prevention of
venous thromboembolism are standard. Routine
use of single-dose antibiotics has effectively
reduced postoperative infectious complications.
Even though outpatient VH is possible when
stringent criteria are used and close telephone
follow-up is available, most gynecologists admit
their patients for an overnight stay. Women
should be advised to refrain from strenuous
physical activity and intercourse for approxi-
mately 6 weeks.
History
It is not surprising that utilization of the vaginal
route for gynecologic problems can be traced
back to ancient Greek history. Vaginal excision
of prolapsed uteri with urinary fistula formation
was reported as early as 50 B.C. (4). VH in the
modern world predates introduction of anesthe-
sia. The German surgeon, Conrad Langenbeck,
performed the first successful planned VH in
1813. It was not until 1843 that the first
abdominal hysterectomy was performed by
Charles Clay of England. He opened the abdo-
men hoping to remove an ovarian tumor, but ran
into a leiomyomatous uterus instead. Unfortu-
nately, the patient did not survive. Johann
Nepomuk Sauter and Joseph Claude Recamier
performed VH successfully in 1822 and 1824,
respectively, and are also considered among the
pioneers of VH in the German literature (5).
Alexander Freund, Vinzenz Czerny, and Jules
Pean helped standardize VH in the ensuing years.
Radical hysterectomy for gynecologic cancer
was later introduced and popularized by Schu-
chardt and Ernst Wertheim for the abdominal
approach, and by Friedrich Schauta for the
vaginal route (6). Mortality from VH, which was
at around 10–15% just before the turn of twen-
tieth century, was reduced to 2.5% with the new
improvements in instrumentation, anesthesia, and
antisepsis. However, mortality from abdominal
hysterectomy, which remained as high as 70% in
1880, started to decrease in the early twentieth
century so dramatically that the abdominal route
became more widely preferred (6).
Until the first total abdominal hysterectomy
(TAH) performed by Richardson in 1929 in the
USA, abdominal supracervical hysterectomy was
a more common practice (5). TAH was widely
adapted to prevent cervical cancer in the fol-
lowing decades. The morbidity and mortality of
hysterectomy was further reduced with the
advent of antibiotics and the availability of blood
transfusion after World War II. Hysterectomy
became one of the most common major surgical
procedures performed by gynecologists, second
only to cesarean deliveries. The abdominal route
was chosen in approximately three quarters of
hysterectomies until the first laparoscopi cally
assisted hysterectomy by Harry Reich in 1988.
The rate of laparoscopic hysterectomy (LH) has
increased dramatically from 0.3% in 1990 to
14% in 2005, predominantly at the expense of
abdominal hysterectomy rate which was reduced
to 64%. Unfortunately, this enthusiasm for
20 Transvaginal Tubal Sterilization and Hysterectomy 231
laparoscopy resulted in a small drop in the VH
rate from 24 to 22% (7). As the laparoscopic
approach became more popular, interest in
supracervical hysterectomy resurfaced and
gained increasing acceptability. Despite some
new efforts to increase interest and skills for VH,
gynecologists have been adapting to the robotic
trend very quickly in recent years. The effects of
more recent trends such as single-port laparo-
scopy remain to be seen.
Procedure
Possibly the most important factor for success in
VH is positioning (Fig. 20.1a, b). The dorsal
lithotomy position must allow enough space for
the surgeon and two assistants between the
patient’s lower extremities. The thighs should be
elevated to provide at least a 60° angle between
the thigh and the torso, and at least 90° at the
knee. Stirrups supporting the entire leg or “candy
cane stirrups” are both appropriate. It is critical to
extend the patient’s buttocks slightly over the
edge of the table. Trendelenburg position may
improve access but it should not be too
steep. Today, most vaginal surgeons stand during
this procedure but those who sit prefer to elevate
the chair/stool so that the assistants do not have
to bend down.
Essential instruments for VH include weigh-
ted specula, retractors, tenacula, scissors, and
clamps with special design and length. Some
vaginal surgeons prefer a self-retaining vaginal
retractor system. Lighting is also critically
important, which can be improved with a head-
light, lighted retractor, or suction/irrigation
devices with lighting option.
The use of an indwelling urinary catheter is
optional. Leaving some urine in the bladder may
help the surgeon recognize cystotomy in a timely
fashion. The procedure is initiated by grasping
the cervix with tenacula anteriorly and posteri-
orly. Some may choose to inject vasoconstricting
agents into the cervix before making an incision.
This initial incision should be made outside the
cervical transformation zone, at point of
decreased vaginal rugae. Electrocautery can be
used to make this incision.
To make the posterior colpotomy (Fig. 20.2a,
b), one should first palpate the uterosacral
ligaments and posterior fornix to identify the
Fig. 20.1 Positioning for vaginal hysterectomy: both a stirrups supporting the entire leg and b candy cane stirrups are
appropriate
232 Oz. Harmanli