If the surgeon is concerned about unintentionally injuring the rectum, it may be important for the patient to cleanse the rectum with an electrolyte purgative or a Phospho soda enema given the evening before surgery. Bowel cleansing evacuates solid stool from the rectum, reduces the bacterial load of the intestinal tract, and reduces the incidence of postoperative ileus and constipation.

A single-dose antibiotic as a prophylactic measure, usually a first-generation cephalosporin, should be given within 1 hour before the operation is started. Prophylactic antibiotics have been documented to reduce the risk of postoperative infections. The vaginal pH may be checked at a preoperative visit and prior to prepping the patient. If the pH is elevated above normal (3.8 to 4.2), the normal vaginal ecosystem has been altered. A vaginal pH in the range of 5.0 or greater suggests the potential for bacterial vaginosis and the likelihood that the facultative bacteria normally present in the vagina at concentrations of 10³ have reached concentrations of 10⁸. This finding strongly suggests that the vagina is infected before the start of the operation. These patients may not be protected by routine prophylactic antibiotics but may benefit from postoperative therapeutic antibiotics and ideally correction prior to arrival in the operating room. In such patients, consider administration of 500 mg of metronidazole orally twice daily from the second to the seventh postoperative day. This practice reduces the postoperative infection rate following vaginal hysterectomy.

Gynecologists have long believed that a Betadine solution used as a preoperative vaginal scrub will remove most potential pathogens in the vagina, but this has recently been questioned. Some surgeons prep patients with 70% ethanol, even in the vagina, and use a self-adherent surgical drape that covers the rectum and conveniently keeps pubic hair and the labia from interfering with the operative field. Shaving of the pubic hair
is unnecessary, and shaven patients are more uncomfortable postoperatively. Clipping of pubic hair is preferred if hair removal is desired.

Copious lavage of the vaginal vault before, during, and after vaginal hysterectomy may also help to prevent postoperative infections by removing nonadherent bacteria from the vaginal epithelium. Lavage is not used as frequently in the vaginal approach as in other surgical approaches despite the fact that the vagina is a clean contaminated operative field.

The type of stirrups used for the lithotomy position is solely at the discretion of the surgeon. No matter what type is used, careful attention is required to protect vulnerable vascular, bony, and neurologic points in the lower extremities. Some surgeons prefer candy cane-type stirrups. The patient should be positioned with the buttocks at the end of the surgical table or just beyond. The table is placed at a zero horizontal position without Trendelenburg. In this manner, the surgeon can look directly into the vagina without having to look over the weighted speculum. Boot-type stirrups have achieved popularity and may also be used with the patient in the standard lithotomy position. Here, the femur is vertical, and the tibia/ fibula horizontal and oriented toward the contralateral shoulder. Hyperflexion of the femur is discouraged with either type of stirrup. If a procedure lasts more than 4 hours, the risk of neurovascular injury increases. For that reason, every 90 minutes to 2 hours, lowering the legs from the standard lithotomy position into a low lithotomy position for a period of approximately 10 minutes should be considered. Also, final positioning of the patient should protect the patient, allowing the surgeon to operate comfortably, and provide adequate room for surgical assistants to be effective. Assistants need to stand inside the stirrups to see the operative field to both observe and learn the operation. Pneumatic compression stockings are also recommended.

An examination under anesthesia before initiating the operation to confirm the preoperative findings is recommended in all cases. Undetected pathology may be appreciated during an anesthetized exam along with a more complete assessment of the subtleties of the patient’s anatomy. Placement of a tenaculum for applying traction on the cervix can document the degree of descensus. If more descensus is desired, strong traction on the cervix with vigorous massage of the uterosacral ligaments, especially the left uterosacral ligament, for approximately 30 seconds results in a further descensus of the cervix of approximately 2 to 3 cm.

Although some surgeons prefer to stand during vaginal hysterectomy, others prefer to sit. Assistants to the surgeon should be as comfortable as possible during the operation. The height of the operating table and the surgeon’s chair should be adjusted accordingly. If sitting, an instrument tray may be placed on the surgeon’s lap, making it easier to have access to the desired instruments during the operation. The number of instruments used during vaginal surgery should be kept at a minimum to prevent instruments from obscuring the surgeon’s vision.

Catheterization of the bladder before the initiation of vaginal hysterectomy is performed at the preference of the surgeon. Sometimes, it is easier to identify unintentional cystotomy when the bladder is moderately distended (approximately 200 mL) with urine, dyed fluid, or sterile infant milk. If the bladder becomes too distended, catheter drainage of the bladder may improve the visibility within the restricted operative space. If a cystotomy occurs, it is usually best to complete the vaginal hysterectomy before proceeding with repair of the bladder. In many cases, the cystotomy may make the bladder dissection easier because now, the location of the bladder is clear and the correct plane of dissection is more easily visualized. Sometimes, a finger in the bladder may also facilitate a difficult vesicocervical or vesicouterine dissection. The bladder must be mobilized adequately around the area of operative injury so that the surgeon can completely evaluate the extent of the cystotomy and be certain that the repair is completed without excess tension on the injured site.

The initial anterior vaginal incision should be made through the full thickness of the vaginal epithelium at the border of the vaginal rugae and the smooth epithelium covering the cervix (Fig. 32B.2). An initial circumscribing cervical incision made on the cervix at the junction of rugae and smooth epithelium preserves vaginal length and helps avoid unintentional entry into the bladder anteriorly and rectum posteriorly. In addition, an incision at the point where the vaginal rugae begin to reflect away from the smooth epithelium of the cervix appropriately places the epithelial incision closer to the point of entry into the posterior and anterior peritoneum (Fig. 32B.3). An incision in this location allows the surgeon to avoid excessive dissection of the connective tissues between the vagina and the peritoneum, reduces blood loss from cervical artery branches, shortens operative time, and facilitates identification of the peritoneal entry points.

Julian has reported on the benefit of infiltrating the vaginal wall with a mixture of 1:200,000 epinephrine diluted in normal saline to control small blood vessel bleeding from the vagina. However, in our experience, oozing from the incised
vaginal epithelium rarely results in significant blood loss when the incision is made where the vaginal rugae start. If oozing from the incised edges of the vagina becomes a problem, it is easy to control with electrocautery.

At the beginning of the operation, when the cervix is still within the vagina, a circumscribing incision around the cervix is difficult to perform with a scalpel or electrocautery instrument because it is difficult to maintain either device perpendicular to the circumscribing vaginal incision. This issue is not a concern when the cervix protrudes from the vagina. However, when the cervix cannot be brought out of the vagina with traction, the initial incision should be made on the anterior vaginal wall from approximately the 10- to 2-o’clock position and on the posterior vaginal wall between the 8- and 4-o’clock positions. These incisions provide adequate space for transection of the paracolpium allowing the cervix to descend for subsequent entry into the posterior and anterior peritoneum and ligation of the uterine vasculature at the appropriate time (Fig. 32B.4A, B).

After completing the vaginal incisions, the cervical tenaculum is replaced on the posterior lip of the cervix with taut traction of the cervix achieved by elevating the tenaculum anteriorly. If the posterior incision in the vagina is placed at the appropriate level where rugae are not present and at the point where the uterosacral ligaments join the cervix, the posterior cul-de-sac and peritoneum can readily be identified with an Allis clamp or tissue forceps. This step is facilitated by putting the vaginal epithelium and accompanying peritoneum on stretch as the peritoneum bulges outward
toward the surgeon (Fig. 32B.5). The importance of properly performing this step cannot be overstated. Entry into the posterior peritoneum is best accomplished by an incision directly above the tissue forceps that grasps the outward U-shaped bulge of the peritoneal fold (Fig. 32B.6). If the incision is placed closer to the cervix in an attempt to prevent injury to the rectum, the dissection often proceeds into the posterior cervical stroma. Unfortunately, an incision placed nearer to the cervix frequently results in a retroperitoneal dissection, which continues in this plane and ultimately pushes the peritoneum superiorly and posteriorly, obscuring identification of the peritoneum and frustrating the surgeon. Should this occur, the posterior lip of the cervix and vagina can be cut in a vertical direction that exposes the peritoneum at a higher level so it can be recognized and entered directly. This procedure is a cervicocolpotomy (Fig. 32B.7).

The posterior peritoneum is then opened with curved scissors, and a long-bladed Steiner Auvard weighted speculum is introduced into the posterior peritoneal cavity. Examination of the cul-de-sac can reveal further pathology, for example, endometriosis, leiomyomata, or adnexal pathology—that may need to be addressed later in the operation. Identification of the uterosacral ligaments by palpation can be accomplished during examination of the cul-de-sac by placing a digit medial to the ligament and identifying the rectouterine fold through the posterior colpotomy incision.

Oozing of blood from the posterior incision between the vagina and peritoneum may occur. Placement of a weighted speculum into the posterior peritoneal cavity will compress
most bleeding points in this area until completion of the surgery and cuff closure. If the vaginal epithelium has not been completely circumscribed, once posterior dissection has been developed, the vaginal epithelial incision should be completed by connecting the previous anterior and posterior incisions before the supportive ligaments of the uterus can be clamped.

Transection of the uterosacral ligaments is the single most important step in successfully completing a vaginal hysterectomy. The uterosacral ligament pedicle should be completed by placing the medial jaw of the clamp within the rectouterine fold while holding the clamp vertical and not try to swing around the cervix in a more horizontal plane. The medial tip of each clamp should be placed within the peritoneal cavity in the rectouterine fold and the lateral tip around the outside of the ligament. Special hysterectomy clamps have been developed to improve on the traditional Heaney clamp (Fig. 32B.8A-C). After transection of the pedicle, rotating the handles of the clamp laterally and superiorly facilitates suturing at the tip of the clamp. This rotation brings the tip of the clamp into full view and exposes a triangular area beneath the clamp for easier retrieval of the needle. Placement of a double clamp for uterine supportive or vascular structures is not necessary. Each uterosacral ligament should be secured by a transfixation suture to the posterolateral surface of the vagina and tied behind the clamp at about the 4- and 8-o’clock positions. Lateral traction on this suture provides the best exposure to the remaining structures that need to be transected to complete hysterectomy (Fig. 32B.9). This traction and the use of large hysterectomy clamps largely replace the need for lateral retractors in the vagina. Clamping and tagging the uterosacral ligaments separately allows for their identification, later use in cuff repair, and, if desired, a McCall culdoplasty at the end of the procedure. The uterosacral ligament pedicle is the only one that needs to be tagged during a vaginal hysterectomy and the only one that may safely be placed under traction.

After making sure the tips of the clamps are within the posterior peritoneal cavity, the cardinal and pubocervical (bladder pillar) ligaments are clamped by placing a clamp horizontally
and clamping from the apex of the uterosacral pedicle to a point on the anterior cervix medial to the bladder pillar encompassing all the remaining connective tissue of the paracolpium (Fig. 32B.10). If already entered, the anterior peritoneum should not be pulled into this clamp at this point of the operation. A complete anterior dissection is needed to safely complete this pedicle. Bringing the anterior and posterior peritoneal edges together should only be accomplished with the uterine artery pedicle as this maneuver serves to seal off the broad ligament and effectively prevents bleeding from the vascular plexus located within the leaves of the broad ligament. Because the anterior peritoneum usually begins at the level of the uterine vessels, there is not enough peritoneal mobility to bring both the anterior and posterior peritoneal surfaces together at the level of the cardinal ligaments. Therefore, to be certain that the surgeon can seal both leaves of the broad ligament together with the uterine artery, it is best to avoid any attempt to bring the peritoneal edges together when the uterosacral or cardinal ligament is clamped. A simple suture ligature first at the tip and then around the end of the clamp is usually sufficient for hemostasis of the cardinal ligament without the need for transfixation. This suture ligature is not tagged or held.

If exposure is good, the uterine arteries may be clamped, divided, and ligated at the point before entering the peritoneum anteriorly under the bladder. They are best clamped in their entirety and under direct visualization. In contrast to the uterosacral and cardinal/pubocervical clamps that are placed perpendicular to the body of the cervix, the uterine artery clamp is placed parallel to the long axis of the uterus as the tip of the clamp secures the uterine artery as it bifurcates into ascending and descending branches (Fig. 32B.11). As traction is placed on the uterus when the artery is cut, there is a definite sensation that the uterus descends signifying that the entire uterine vascular bundle has been transected, including the ascending and descending branches. If descent of the uterus is not noted, often an additional portion of the uterine artery remains and must be secured with another clamp. A single well-tied suture is all that is required for the uterine artery pedicle. Limiting the tissue within the clamp to the vascular bundle helps to make the pedicle manageable and the suture ligature more secure. Many surgeons try to include middle portions of the broad ligament with the uterine artery because they feel a need to place clamps on the remaining portions of the broad ligament as they proceed up on each side of the uterus.

Complete development by dissection of the vesicocervical and vesicouterine spaces is a prerequisite to identifying and opening the anterior peritoneum. This step is perceived to be the most difficult portion of the vaginal hysterectomy procedure. Adequate exposure, by division of the paracolpium and full dissection of the anterior avascular spaces, makes this key step of hysterectomy much easier to complete.