Vaginal surgery is one of the defining procedures that sets gynecologic surgeons apart from surgeries of other specialties. For hysterectomy for benign indications, the vaginal route remains the most minimally invasive approach. The most recent Cochrane Review in 2015 that involved 47 studies and 5,102 women concluded that the vaginal route is superior to the abdominal, laparoscopic, and robotic-assisted approach due to fewer intraoperative visceral injuries, less major longterm complications of fistula, less pain, fewer urinary/bowel/pelvic floor and sexual dysfunction, faster return to normal activities, greater patient satisfaction, and improved quality of life.¹ The American College of Obstetricians and Gynecologists (ACOG) Committee Opinion (Committee Opinion No. 701) recommends vaginal hysterectomy as the preferred and most costeffective for benign hysterectomy.² ACOG also states that the need to perform adnexectomy should not be considered a contraindication to the vaginal approach. There is evidence that additional patient factors such as obesity, nulliparity, previous cesarean section or laparotomy, or an enlarged uterus should not preclude the patient from benefiting from the vaginal approach.³

The safety of vaginal hysterectomies as compared to other approaches has been well investigated. A recent meta-analysis indicated that there is a lower risk of vaginal cuff dehiscence and conversion to laparotomy in vaginal hysterectomy as compared to total laparoscopic hysterectomy.⁴ This same analysis found no difference in overall complications, risk of ureter and bladder injuries, and intraoperative blood loss between the two approaches.⁴ However, there is a greater risk of severe postoperative complications (Accordion complications grade 3 or higher) in robotic hysterectomy as compared to vaginal hysterectomy.⁵ Additionally, vaginal hysterectomy demonstrates lower rates of superficial surgical site infections as compared to total abdominal hysterectomy.⁶ These factors demonstrate that vaginal hysterectomy is a safer option with regard to several complications when compared to all other hysterectomy approaches.

Despite the evidence indicating that vaginal hysterectomy is the preferred surgical approach for benign conditions, there has been a decline in the last decade in not only the total number of hysterectomies but also the number of vaginal hysterectomies performed in the United States. The total number of inpatient hysterectomies peaked in 2002 and since then has demonstrated a steady decline as 36.4% fewer hysterectomies were performed in 2010 when compared to 2002.⁷ More recent data demonstrates a 12.4% decrease in rate of utilization of hysterectomy between 2010 and 2013.⁸ The rates of vaginal hysterectomies have mirrored this decline as the rate of total vaginal hysterectomy decreased from 51% to 13% between 2008 and 2018.⁹ In the same 10-year span, rates of total laparoscopic hysterectomy increased from 12% to 68%, making it the most common surgical approach for hysterectomy.⁸,⁹

With declining numbers in both total hysterectomies and vaginal hysterectomies, training and surgical skills of residents and practicing surgeons are adversely impacted. Previous studies using validated surgery skills assessment tools have demonstrated that an average of 27 vaginal hysterectomies are needed to achieve competency in this procedure.¹⁰ However, the minimum number of required vaginal hysterectomies as determined by the Accreditation Council for Graduate Medical Education is only 15, and the average number of vaginal hysterectomies logged by graduating residents was only 20 (standard deviation [SD] 10.9) in 2018 to 2019.¹¹ These patterns in training have impacted the level of preparedness of graduated residents when starting fellowship. For example, a 2015 study that surveyed female pelvic medicine and reconstructive surgery fellowship program directors demonstrated that only 20% of first-year fellows could adequately perform a vaginal hysterectomy.¹²

Decreased training in vaginal hysterectomy over the last decade has impacted both operative time and complication rates when using this approach. Traditionally, transvaginal hysterectomy is the fastest approach and was 73 minutes faster than a laparoscopic hysterectomy in 2002.⁹ However, in 2018, this difference has declined over the past decade as the transvaginal approach is only 20 minutes faster than the laparoscopic approach.⁹ This narrowed time differential can be attributed to both reduced median operating time in
total laparoscopic hysterectomies by 37 minutes and increased median operating time for vaginal hysterectomies by 20 minutes between 2002 and 2018.⁹ This same analysis noted a decrease in both major (adjusted odds ratio [OR] [95% confidence interval, CI]: 0.813 [0.750 to 0.881] vs. 0.873 [0.797 to 0.957]) and minor (0.723 [0.676 to 0.772] vs. 0.896 [0.832 to 0.964]) complications in total laparoscopic hysterectomy as compared to vaginal hysterectomy, respectively, although these results were not found to be statistically significant.⁹ Such changes in classically reported trends in operating time and complication rates may reflect the increasing focus on laparoscopic and robotic surgery in obstetrics and gynecology training rather than demonstrating true changes in the efficacy of vaginal surgery versus laparoscopic surgery.

Surgical volume impacts patient outcomes in benign gynecologic surgery. Studies across various surgical fields have demonstrated that patients operated on by low-volume surgeons or at low-volume hospitals have increased complications, morbidity, and mortality in comparison to those patients operated on by high-volume surgeons.¹³,¹⁴ These trends are also noted in gynecology as patients operated on by high-volume vaginal surgeons (performing greater than 13 vaginal surgeries a year) are 31% less likely to have an operative injury (OR [95% CI]: 0.69 [0.59 to 0.80]) in comparison to low-volume surgeons (performing less than 5.4 vaginal procedures annually).¹⁵ In addition to decreased preoperative, intraoperative, and postoperative complications, the cost of a vaginal hysterectomy is also decreased by more than $600 when performed by a high-volume vaginal surgeon in comparison to a low-volume vaginal surgeon (parameter estimate [95% CI]: -609 [-664.86 to -554.21]).¹⁵ Another study using the all-payer Maryland Health Services Cost Review Commission database found that 68.2% of general gynecologists are very low-volume surgeons (performing 0 to 5 hysterectomies annually) or low-volume surgeons (performing 6 to 10 hysterectomies annually), and both are associated with increased perioperative complications in comparison to high-volume surgeons (performing at least 21 hysterectomies annually) (adjusted OR [95% CI]: very low volume 1.73 [1.22 to 2.47]; low volume 1.60 [1.11 to 2.23]).¹⁶ The same study found that patients undergoing a procedure performed by a medium-volume surgeon (performing 11 to 20 hysterectomies annually) compared to a high-volume surgeon had a lower likelihood of having a minimally invasive approach (OR [95% CI]: 0.87 (0.78 to 0.97]).¹⁶ These findings indicate that higher-volume surgeons who perform more minimally invasive surgeries, including transvaginal surgeries, have better surgical outcomes and use more cost-effective approaches. Therefore, there is a need to increase both the volume of transvaginal hysterectomies performed and the time spent training in the vaginal approach at both the trainee and provider level.

There is a clear benefit in achieving proficiency in the steps of a transvaginal hysterectomy. Here, we describe and illustrate methods for setup in order to optimize exposure and visualization. Additionally, we provide a step-by-step approach to a transvaginal hysterectomy, including challenges such as entry to the anterior and posterior cul-de-sac, morcellation of a large uterus, and salpingectomy/adnexectomy. We present these steps to provide techniques to those who may have limited experience in transvaginal hysterectomy.