Vaginal hysterectomy operative procedure

A. A prophylactic antibiotic agent (eg, cefazolin [Ancef] 1g IV) should be given as a single dose 30 minutes prior to the first incision for vaginal or abdominal hysterectomy.

B. The patient should be placed in the dorsal lithotomy position. When adequate anesthesia is obtained, a bimanual pelvic examination is performed to assess uterine mobility and descent and to confirm that no unsuspected adnexal disease is found. A final decision can then be made whether to proceed with a vaginal or abdominal approach.

C. The patient is prepared and draped, and bladder catheter may be inserted. A weighted speculum is placed into the posterior vagina, a Deaver or right angle retractor is positioned anterior to the cervix, and then the anterior and posterior lips of the cervix are grasped with a single- or double-toothed tenaculum.

D. Traction is placed on the cervix to expose the posterior vaginal mucosa. Using Mayo scissors, the posterior cul-de-sac is entered sharply, and the peritoneum identified. A figure-of-eight suture is then used to attach the peritoneum to the posterior vaginal mucosa.

E. A Steiner-Anvard weighted speculum is inserted into the posterior cul-de-sac after this space is opened. The uterosacral ligaments are clamped, with the tip of the clamp incorporating the lower portion of the cardinal ligaments. The clamp is placed perpendicular to the uterine axis, and the pedicle cut so that there is 0.5 cm of tissue distal to the clamp. A transfixion suture is then placed at the tip of the clamp. Once ligated, the uterosacral ligaments are transfixed to the posterior lateral vaginal mucosa. This suture is held with a hemostat.

F. Downward traction is placed on the cervix to provide countertraction for the vaginal mucosa and the anterior vaginal mucosa is incised at the level of the cervicovaginal junction. The bladder is advanced upward using an open, moistened gauze sponge. At this point, the vesicovaginal peritoneal reflection is usually identified and can be entered sharply using scissors. A Deaver or Heaney retractor is placed in the midline to keep the bladder out of the operative field. Blunt or sharp advancement of the bladder should precede each clamp placement until the vesicovaginal space is entered.

G. The cardinal ligaments are identified, clamped, cut, and suture ligated. The bladder is advanced out of the operative field using blunt dissection technique. The uterine vessels are clamped to incorporate the anterior and posterior leaves of the visceral peritoneum.

H. The anterior peritoneal fold is now visualized, and the anterior cul-de-sac can be entered. The peritoneal reflection is grasped with smooth forceps, tented, and opened with scissors with the tips pointed toward the uterus. A Heaney or Deaver retractor is placed into this space to protect the bladder.

I. The uterine fundus is delivered posteriorly by placing a tenaculum on the uterine fundus in successive bites. An index finger is used to identify the utero-ovarian ligament and aid in clamp placement. The remainder of the utero-ovarian ligaments are clamped and cut. The pedicles are double-ligated first with a suture tie and followed by a suture ligature medial to the first tie.

0 0

Post a comment