Figure 24.15 Circumferential incision in the vagina to infiltrate a vaginal hysterectomy. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)
Figure 24.16 Dissection of the vaginal mucosa. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)
Figure 24.17 Entry into the posterior cul-de-sac. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)
Figure 24.18 Interrupted suture is placed on posterior vaginal cuff and peritoneum for hemostasis. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)
Figure 24.19 Ligation of the uterosacral ligaments. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)
Uterosacral Ligament Ligation With retraction of the lateral vaginal wall and countertraction on the cervix, the uterosacral ligaments are clamped with the tip of the clamp incorporating the lower portion of the cardinal ligaments (Fig. 24.19). The clamp is placed perpendicular to the uterine axis, and the pedicle is cut and sutured close to the clamp. A small pedicle (0.5 cm) distal to the clamp is optimal because a larger pedicle becomes necrotic and the tissue sloughs, which may become a culture medium for micro-organisms. The pedicle should be incised no more than one-half to three-fourths of the way around the tip of the clamp. Limiting the incision prevents the next pedicle, which may be vascular, from being cut.
When suturing any pedicle, the needle point is placed at the tip of the clamp, and the needle is passed through the tissue by a rolling motion of the operator’s wrist. Once ligated, the uterosacral ligaments may be transfixed to the posterolateral vaginal mucosa (Fig. 24.20). This suture may lend additional support to the vagina and provide hemostasis at this point on the vaginal mucosa. This suture is held with a hemostat to facilitate location of any bleeding at the completion of the procedure and to aid in the closure of vaginal mucosa.
Entry versus Nonentry into the Vesicovaginal Space (Cul-de-Sac) Downward traction is placed on the cervix. Using either Mayo scissors, with the points directed toward the uterus, or an open moistened 4 × 4 gauze sponge, the bladder is advanced. If the vesicovaginal peritoneal reﬂection is easily identified at this point, the vesicovaginal space may be entered. Otherwise, it may be preferable to delay entry. There is no danger in delaying entry so long as the operator ascertains that the bladder was advanced.
After the bladder is advanced, a curved Deaver or Heaney retractor is placed in the midline, holding the bladder out of the operative field. This process precedes each step of the vaginal hysterectomy until the vesicovaginal space is entered.
Cardinal Ligament Ligation With traction on the cervix continued, the cardinal ligaments are identified, clamped, and cut. The suture is ligated (Fig. 24.21).
Advancement of Bladder The bladder again is advanced out of the operative field. A blunt dissection technique may be used; sharp dissection may be helpful if the patient had previous surgery, such as cesarean delivery, which may have scarred the bladder reﬂection.