Bilateral Salpingectomy During Vaginal Hysterectomy: Surgical Technique
Bilateral salpingectomy at the time of vaginal hysterectomy is feasible in approximately 80% of cases and should be performed using posterior uterine rotation to optimize tubal visualization and access. 1, 2, 3
Surgical Approach
The key technical modification that makes vaginal salpingectomy consistently achievable is posterior rotation of the uterus, which provides excellent access to the fallopian tubes before separating the adnexa 1. This technique allows the tubes to be removed prior to division of the utero-ovarian ligaments, fundamentally changing the sequence of the traditional vaginal hysterectomy.
Step-by-Step Technique
After completing the anterior and posterior colpotomy:
- Rotate the uterus posteriorly through the vaginal opening to bring the adnexa into view
- Identify the fallopian tube along the superior aspect of the broad ligament
- Isolate the tube from the mesosalpinx using careful dissection
- Clamp, cut, and ligate the tube at both the fimbrial end and the cornual insertion
- The proximal tube can be managed in two ways: removed completely with the uterus, or ligated and left in situ 4
- Repeat on the contralateral side before proceeding with standard utero-ovarian ligament division
- Complete the hysterectomy using standard vaginal technique
Expected Outcomes
The evidence consistently demonstrates that vaginal salpingectomy adds minimal operative burden:
- Mean additional operative time: 11 minutes 2
- Additional blood loss: 6 mL 2
- Success rate: 81-88% when attempted 2, 3
Factors Predicting Difficulty
You should counsel patients preoperatively about potentially unsuccessful salpingectomy if they have:
- Prior adnexal surgery (OR 2.9 for failure) 2
- Uterine fibroids (OR 5.8 for failure) 2
- Nulliparity (OR 0.12 for success) 3
- Older age and elevated BMI 5
Conversely, pelvic organ prolapse as the indication significantly favors successful completion (OR 3.20) 3.
When Bilateral Salpingectomy Cannot Be Completed
If tubes are positioned high in the pelvis, obscured by adhesions, or inaccessible vaginally:
- Unilateral salpingectomy is acceptable when only one tube is accessible 2
- Do not convert to laparoscopy solely for salpingectomy unless other indications exist
- Document the reason for incomplete removal in the operative note
Ovarian Preservation Context
When preserving ovaries (particularly in premenopausal women <45 years with low-risk endometrial cancer), bilateral salpingectomy is specifically recommended 6, 7. This approach:
- Reduces ovarian cancer risk while maintaining ovarian function
- Is contraindicated in Lynch syndrome carriers or those with BRCA mutations unless part of risk-reduction strategy 6, 7
The 2025 ESGO guidelines explicitly state: "In cases of ovarian preservation, bilateral salpingectomy is recommended" 7.
Safety Profile
Vaginal salpingectomy demonstrates no increase in complications compared to hysterectomy alone 3. When comparing successful versus unsuccessful attempts, successful salpingectomy actually showed:
This counterintuitive finding likely reflects case selection—surgeons successfully complete salpingectomy in anatomically favorable cases.
Clinical Rationale
The recommendation for opportunistic salpingectomy stems from evidence that most high-grade serous ovarian cancers originate in the fallopian tube fimbriae 4, 5. While the absolute cancer prevention benefit remains under investigation, the minimal additional surgical burden (11 minutes, 6 mL blood loss) with no increased complications makes this a reasonable risk-reduction strategy 2.
The posterior rotation technique specifically addresses the historical barrier to vaginal salpingectomy—poor visualization—making what was once technically challenging now routinely feasible in experienced hands 1.