Vaginal hysterectomy -- Tips and tricks

The most important step in vaginal hysterectomy is safe dissection of the bladder and pouch of Douglas.

1. The initial incision on cervix begins circumferentially at the reflection of the vaginal mucosa onto the cervix.
2. The position and depth of this circumferential incision is very important because they determine access to appropriate planes that will lead to opening of Utero vescial fold of peritoneum and Pouch of Douglas peritoneum.
3. Anteriorly appropriate location of the incision is at the site of the bladder reflection. The lower end of bladder reflection on the prolapsed cervix is indicated by a CREASE or SULCUS formed in the vaginal mucosa when the cervix is pushed slightly inward or back into the vagina. This can also be achieved by moving the cervix in and out of the vagina and at the same time try and identify the sulcus or the groove between the vagina and bladder reflection bulge. If this location is still not identified, one should make the incision low rather than high to avoid the potential bladder injury. Downward traction on the cervix and counter-traction by the retractors help to determine the appropriate depth of the incision. This incision should be continued down to the cervical stroma. Once the appropriate depth of the incision is reached, the vaginal tissue will fall away from the underlying cervical tissue because there is distinct plane between these two tissues.
4. Once the appropriate plane has been reached, blunt dissection of the posterior vaginal  wall lead to the posterior cul-de-sac which can be entered sharply
5. Sharp dissection should be used to mobilise the bladder off from the cervix  anteriorly.
6. No attempt should be made to enter the anterior cul-de-sac until the vesico-uterine space has been developed
7. Generally sharp dissection is required to incise the pubo-cervical fascia to enter the vesico-uterine space before the anterior cul-de-sac is opened
8. Clamping of  uterosacral ligaments :  The Haney clamp or Zippelin or Fours clamp should be placed as PERPENDICULAR AS POSSIBLE TO THE CERVIX.
9. Clamping of the uterine artery and vein pedicle: To clamp the uterine pedicle, the clamp should incorporate the anterior and posterior peritoneal reflections . This clamp should be placed perpendicular to the longitudinal axis of the cervix and the tips of the clamp should completely slide off from the cervix to make sure that there is no inadvertent lateral migration and to avoid ureteric injury