Vaginal Preparation A povidone-iodine solution or chlorhexideine-alcohol is applied to the vagina, the bladder is drained, and the catheter is removed. Several methods for draping are proposed, including individual or single-piece drapes; the method chosen is at the surgeon’s discretion. There is usually no need to shave or clip the pubic hair. Individual drapes with an adhesive barrier should be used to hold them in place and prevent the pubic hair from compromising the field.
Instruments Instruments specific to and useful in performing a vaginal hysterectomy include right-angled retractors, narrow Deaver retractors, weighted specula, Heaney needle holders, and an assortment of Breisky–Navratil vaginal retractors. Heaney and Heaney–Ballantine hysterectomy clamps are preferable. Several other clamps are commonly used, including the Masterson clamp.
Lighting Overhead high-intensity lamps should be used and positioned to direct light over the operator’s shoulder. The surgeon may use a headlight, which can be worn to provide direct horizontal lighting. A fiberoptic-lighted irrigating suction system can provide additional light and transilluminate tissue planes.
Suture Material Various suture materials are advocated for gynecologic surgery. The type of suture material chosen is based on the surgeon’s preference. A synthetic delayed absorbable polyglactin or polyglycolic acid suture and atraumatic needles are preferable.
Procedure The patient is examined while anesthetized to confirm prior findings and to assess uterine mobility and descent. The decision whether to proceed vaginally or abdominally is made.
Grasping and Circumscribing the Cervix The anterior and posterior lips of the cervix are grasped with a single-or double-toothed tenaculum. With downward traction applied on the cervix, a circumferential incision is made in the vaginal epithelium at the junction of the cervix (Fig. 24.15).
Dissection of Vaginal Mucosa After the initial incision is made with a scalpel or a Bovie, the vaginal epithelium may be dissected sharply from the underlying tissue or pushed bluntly with an open sponge (Fig. 24.16). If the initial incision is made too close to the external cervical os, a greater amount of dissection is required and causes associated bleeding. This circumscribing incision should be made just below the bladder reﬂection. It is important to continue the dissection in the correct cleavage plane to minimize blood loss.
Posterior Cul-de-Sac Entry The peritoneal reﬂection of the posterior cul-de-sac (culde-sac of Douglas) can be identified by stretching the vaginal mucosa and underlying connective tissue with forceps (Fig. 24.17). If difficulty is encountered (e.g., if the cervix is elongated and the peritoneum is not evident), the vaginal mucosa may be incised vertically to the point at which the cul-de-sac becomes more apparent.
If the vaginal mucosa is dissected in the wrong plane, the hysterectomy may begin extraperitoneally by clamping and cutting the uterosacral and cardinal ligaments close to the cervix.
The posterior cul-de-sac will be readily identifiable. If the peritoneal reﬂection of the posterior cul-de-sac cannot be identified, entry into the anterior peritoneum is attempted, and a finger is hooked into the posterior cul-de-sac to place tension on the peritoneum. The peritoneum is opened with Mayo scissors. An interrupted suture is placed to approximate the peritoneum and vaginal cuff and provide hemostasis (Fig. 24.18). The posterior pelvic cavity is examined for pathologic alterations of the uterus or adhesive disease of the cul-de-sac. The weighted speculum is placed into the posterior cul-de-sac.