What are the steps involved in a vaginal hysterectomy procedure?

Vaginal Hysterectomy: Operative Steps

Vaginal hysterectomy is performed through three primary operative stages: releasing the uterus from visceral connections, sequential ligation of supporting ligaments from cervix to fundus, and restoration of peritoneal and vaginal anatomy. 1

Preoperative Positioning and Access

• Position the patient in dorsal lithotomy to optimize surgical visualization of the pelvis and allow access to the vagina and bladder 2
• The lithotomy position provides superior exposure compared to supine positioning for vaginal procedures 2

Stage 1: Separation from Visceral Connections

• Apply continuous caudal traction on the cervix throughout the procedure to individualize the ligaments and facilitate dissection 1
• This downward traction is the fundamental manipulation that makes all subsequent steps safer and more efficient 1
• Circumferentially incise the vaginal mucosa around the cervix to create the initial plane of dissection 1
• Dissect the bladder anteriorly and rectum posteriorly away from the cervix and lower uterine segment 1
• Hold these visceral structures distant with retractors to maintain a clear operative field 1

Stage 2: Sequential Ligament Division

• Ligate the uterosacral and cardinal ligaments first, beginning at the cervix 1
• Progress with sequential clamping, cutting, and ligating of supporting ligaments moving from cervix toward the fundus 1
• The continuous caudal traction on the cervix creates progressively greater ureterical safety margins compared to abdominal hysterectomy at every stage 1
• Enter the anterior and posterior peritoneal cavities once the lower ligaments are divided 1
• Clamp, divide, and ligate the uterine vessels bilaterally, maintaining close proximity to the uterus 1
• Continue with ligation of the utero-ovarian ligaments and round ligaments at the cornua 1
• The spacing of ligatures progresses systematically from cervix to fundus throughout this stage 1

Stage 3: Restoration of Anatomy

• Reapproximate the peritoneum to restore the peritoneal cavity to its normal topography 1
• Close the vaginal cuff to restore the vaginal fornix to its anatomical position and maintain pelvic support 1
• This final stage is critical for maintaining proper pelvic statics and preventing future prolapse 1

Critical Technical Considerations

• Vaginal hysterectomy provides superior ureterical safety margins compared to abdominal approaches due to the craniocaudal direction of dissection and continuous cervical traction 1
• The anatomical limits depend on vaginal compliance, pelvic organ mobility, and the size relationship between vagina and uterus 1
• Avoid forced placental removal if performing peripartum hysterectomy, as this causes profuse hemorrhage; leave placenta in situ when accreta spectrum is present 2
• Total hysterectomy is usually required rather than supracervical approach, as lower uterine segment bleeding frequently precludes leaving the cervix 2

Advantages of This Approach

• Vaginal hysterectomy offers shorter operating times compared to both abdominal and laparoscopic approaches 2, 3
• The procedure results in faster return to normal activities and better quality of life compared to abdominal hysterectomy 2, 3
• Lower infection rates and shorter hospital stays are consistently demonstrated with vaginal versus abdominal routes 2, 3
• The absence of abdominal incision eliminates intestinal manipulation and reduces overall surgical trauma 1