When performing a supracervical hysterectomy, the uterus is separated from the cervix at the level of the internal cervical os with either a monopolar device (such as a spatula, scissor, hook, or loop) or harmonic scalpel. After transection of the uterine corpus, the endocervical canal may be desiccated in an attempt to decrease the occurrence of postoperative cyclic spotting. Specimen removal is then achieved with a mechanical tissue morcellation device or via minilaparotomy. Care should be taken whenever performing morcellation to do so in a contained fashion to avoid inadvertent spread of tissue within the abdomen.

In the case of total laparoscopic hysterectomy, the uterine vascular pedicle is further lateralized below the level of the cervix (Fig. 9.5) and care is taken to ensure the bladder has been mobilized below the level of intended colpotomy incision. Cephalad deflection of the uterus aids with identification of the vaginal fornices, and the colpotomy is made in a circumferential fashion with monopolar or harmonic device of choice (Fig. 9.6). In cases of a narrow introitus where it is not feasible to employ a uterine manipulator, laparoscopic upward traction is essential in order to distance the ascending uterine vessels from the ureters and allow for safe colpotomy performance. The specimen is then removed through the vagina or morcellated as necessary, either laparoscopically or vaginally. Following specimen retrieval, pneumoperitoneum is maintained by occlusion of the vaginal canal; one useful option for this purpose is a sponge-filled surgical glove. Vaginal cuff closure is performed with laparoscopic suturing techniques, with care to take bites of sufficient distance from the thermal margin and incorporate both the vaginal mucosa as well as rectovaginal and pubocervical fascia.