Patients are encouraged to begin ambulation on their first postoperative day if possible and to increase their time out of bed progressively as their strength improves. On discharge, the patient is instructed to avoid lifting more than 20 pounds for 6 weeks, thereby minimizing stress on fascia to allow full healing. Sexual intercourse is not recommended until at least 6 weeks after surgery, when the vaginal cuff is fully healed. Patients are instructed to avoid driving until full mobility returns because postoperative pain and tenderness may hinder sudden braking or steering maneuvers in emergency situations. With these exceptions, the patient is encouraged to return to normal activities as soon as she feels comfortable doing so.
Wound Care The abdominal incision normally requires little attention, except for ordinary hygienic measures. The wound is kept covered with a sterile dressing for the first 24 hours after surgery, by which time the incision has sealed. After the dressing is removed, the incision should be cleaned daily with mild soap and water and kept dry.
Preoperative Evaluation Evaluation of Pelvic Support The most important observation in determining the feasibility of a vaginal hysterectomy is the demonstration of uterine mobility (51). A vaginal approach should be chosen only if the uterus is freely mobile. Pelvic support structures are elevated at the initial pelvic examination. In patients with no apparent prolapse, poor pelvic support can often be demonstrated by observing descent of the uterus with a series of Valsalva maneuvers. Although vaginal hysterectomy is easier to perform when the uterine supporting ligaments are lax, it is not an absolute requirement. The practice of applying traction to the cervix with a tenaculum to demonstrate descent of an apparently well-supported uterus is not recommended. Some gynecologists advocate the application of a tenaculum to the anterior cervical lip, with subsequent traction applied as the patient bears down. This exercise may give some indication of uterine mobility, but it is uncomfortable and not necessarily predictive of the success of vaginal hysterectomy.
Evaluation of the Pelvis After assessment of pelvic support, the bony pelvis should be evaluated. Ideally, the angle of the pubic arch should be 90 degrees or greater, the vaginal canal should be ample, and the posterior vaginal fornix should be wide and deep. The surgeon may use a closed fist to approximate the bituberous diameter, which should exceed 10 cm. The size and shape of the female pelvis contributes to increased exposure. The importance of a wide pubic arch was underscored by the result of a study of 25 failed vaginal hysterectomies that were compared with 50 successful vaginal hysterectomies. Risk factors, such as age, parity, body weight, surgical indication, uterine size, presence of leiomyomata in the anterior lower uterine segment, previous pelvic surgeries, adhesions, location and length of the cervix, and narrow pubic arch (less than 90 degrees), were examined. In the study, only the presence of a narrow pubic arch increased the risk of vaginal hysterectomy (52).
Surgical Considerations Patient Positioning When the patient is in the dorsal lithotomy position, the buttocks should be positioned just over the table’s edge. Several stirrup types are available, including those that support the entire leg and those that suspend the legs in straps. To avoid nerve injury, adequate padding should be used; marked ﬂexion of the thigh and pressure points should be avoided. Trendelenburg (10-to 15-degree) positioning aids in the intravaginal visualization needed during surgery.