Version May 2024
INTRODUCTION — Hysterectomy (ie, surgical removal of the uterus) can be performed vaginally, laparoscopically, or abdominally. It is also possible for two surgical routes to be combined in one operation, such as a laparoscopically assisted vaginal hysterectomy or a laparoscopic hysterectomy with a minilaparotomy to remove the uterus. When selecting a route for hysterectomy, the surgeon balances the medical indication, patient profile, risks and benefits, safety, and cost-effectiveness of each surgical approach. As vaginal hysterectomy is among the safest and most cost-effective routes for hysterectomy, it is the first-line approach whenever possible.
This topic will review the preoperative considerations, procedure, nuances, and complications of vaginal hysterectomy. Review of related topics can be found separately:
●(See "Hysterectomy (benign indications): Selection of surgical route".)
●(See "Hysterectomy: Abdominal (open) route".)
●(See "Hysterectomy: Laparoscopic".)
●(See "Robot-assisted laparoscopy".)
●(See "Prophylactic vaginal apex suspension at the time of hysterectomy".)
In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. We encourage readers to consider the specific counseling and treatment needs of transmasculine and gender-expansive individuals.
INDICATIONS — Vaginal hysterectomy is the preferred route for hysterectomy when possible [1,2]. While high safety and low cost make vaginal hysterectomy the preferred route, a meta-analysis of seven trials reported similar rates of visceral injury and long-term complications among vaginal and laparoscopic procedures [1]. Thus, if vaginal hysterectomy is not feasible, laparoscopic hysterectomy is typically the next alternative. A minimally invasive approach is associated with faster recovery compared with laparotomy; some patients may benefit from a robotic-assisted surgical approach [3]. Minimally invasive routes should be prioritized; surgeon preference for other operative routes is no longer considered an appropriate reason to avoid the vaginal approach if the appropriate skill set is present [4]. (See "Hysterectomy (benign indications): Selection of surgical route", section on 'Comparison of routes of hysterectomy'.)
●Relative contraindications – There are no absolute contraindications to vaginal hysterectomy [4,5]. Relative anatomic contraindications include malignancy, extremely enlarged uterine size, and significant pelvic adhesions. Patient characteristics that can make a vaginal approach to hysterectomy more challenging include nulliparity, increased body mass index, history of pelvic radiation, and lack of uterine descent [4].
●Predictive factors for successful surgery – There is no specific combination of patient size, uterine size, parity, and prolapse that predicts a successful vaginal hysterectomy, although normal body mass index, smaller uterine size, multiparity, and some degree of uterine laxity are characteristics that generally increase the success of the procedure. However, vaginal hysterectomy can be safely performed in women without these characteristics [6]. In our practice, ease of access to the uterine vessels is most predictive of a successful vaginal surgery. Thus, vaginal hysterectomy can be very challenging, or require abdominal conversion, in a woman with a narrow pelvis and a wide, bulky uterus or a woman with fibroids that block or limit access to the uterine vessels (eg, broad ligament or cervical fibroids). (See "Hysterectomy (benign indications): Selection of surgical route", section on 'Factors that influence surgical route'.)
●Declining frequency of vaginal surgery – Despite vaginal hysterectomy being the preferred route for hysterectomy [2], there are fewer vaginal hysterectomies performed compared with other routes. Obstacles to performing vaginal hysterectomy include limited training, fewer numbers of hysterectomies being performed by individual surgeons, and greater diversity of operative approaches, which further decreases the number of vaginal surgeries performed in training and in practice. Obesity and prior pelvic surgeries, including Cesarean deliveries, can increase surgical difficulty [7]. Both experience during training and maintenance of proficiency after training is completed are paramount to maintaining surgeon confidence in this approach. We would encourage mentoring, operating with another surgeon to assist with difficult cases (as opposed to a surgical technician or trainee), and pursuing vaginal hysterectomy whenever clinically appropriate as methods to increase utilization of this route.
SURGICAL PLANNING — Multiple adjunct issues are addressed by the surgeon when planning a vaginal hysterectomy.
Adhesions — In patients at high risk for significant pelvic adhesions (eg, women with prior pelvic surgery; history of inflammatory process such as appendicitis, diverticulitis, or pelvic inflammatory disease; or pelvic radiation), laparoscopy is often performed as a first step to visualize pelvic anatomy and lyse adhesions. The hysterectomy can also be started via the laparoscopic approach; the amount of surgery performed vaginally versus laparoscopically is influenced by the findings at the time of laparoscopy. Alternately, the surgeon can begin operating via the vaginal route and add laparoscopic visualization of the abdominal cavity only if there is difficulty entering the anterior or posterior peritoneum. The latter approach would likely reduce the number of laparoscopies performed as well as the operative time. (See "Hysterectomy: Laparoscopic", section on 'Procedure'.)
When unanticipated adhesions are discovered after the start of vaginal surgery, the surgeon can still perform laparoscopy to dissect adhesions. If the peritoneum has been opened, a surgical glove, bulb syringe, or vaginal pneumo-occluder balloon is placed in the vagina to seal the peritoneum and allow insufflation of the abdomen for laparoscopy. Prior surgery of the upper abdomen may result in abdominal adhesions but not pelvic adhesions. Thus, a total vaginal approach may be easier without the laparoscopic component in these patients.
Leiomyomata (fibroids) — Leiomyomata (fibroids) can increase the complexity of hysterectomy by blocking surgical access to the uterine vessels, particularly when located in the lower uterine segment, cervix, or broad ligament.
●Preoperative imaging – Preoperative imaging can help delineate the anatomic relationship of the fibroids, uterine fundus, cervix, and broad ligament. If we suspect an anatomic abnormality such as fibroids on examination, our first choice for imaging is transvaginal ultrasound. If the ultrasound study does not adequately delineate the anatomy, magnetic resonance imaging (MRI) can provide additional detail. However, we do not routinely obtain MRI prior to performing vaginal hysterectomy and only perform ultrasound if there is a clinical indication based on history and/or examination.
●Preoperative fibroid treatment – Preoperative treatment options for enlarged fibroids include gonadotropin-releasing hormone (GnRH) agonist therapy or uterine artery embolization. Preoperative GnRH agonist therapy reduces fibroid size and can facilitate vaginal hysterectomy. Typical treatment is three to six months prior to the surgery, which will reduce uterine size by 35 to 60 percent [8-10].
●Intraoperative removal – Intraoperatively, fibroids can be removed with the uterus, excised intact from the uterus, or hand-cut into multiple pieces for removal (figure 1 and figure 2 and figure 3). We prefer to leave fibroids intact rather than morcellate, if possible, because myomectomy can increase bleeding, particularly prior to the ligation of the uterine vessels. Once the uterine vessels have been ligated, the fibroid can be shelled out of the uterus, if needed, to provide for better visualization of the broad ligament and upper pedicles. If there is a concern for malignant uterine pathology, the uterus should be removed intact or in a specimen bag [11]. (See "Uterine fibroids (leiomyomas): Laparoscopic myomectomy and other laparoscopic treatments", section on 'Removal and morcellation of myomas' and "Uterine fibroids (leiomyomas): Differentiating fibroids from uterine sarcomas".)
Enlarged uterine size — Although the upper limit of uterine size for vaginal hysterectomy has not been established, many surgeons regard 16-week size as a reasonable and practical upper limit [12]. Surgeons skilled in intramyometrial coring (figure 4), bivalving techniques (figure 1 and figure 3), or vaginal myomectomy (figure 2) can remove even larger uteri vaginally [4,13,14]. The benefits of avoiding morcellation should be weighed against the benefits of a minimally invasive approach as there is increased morbidity with open procedures [15].
Pelvic organ prolapse — Mild to moderate uterine prolapse can make vaginal hysterectomy easier because some descent of the uterus improves access to the uterine vessels. However, severe uterine prolapse (Stage III or IV) can make vaginal hysterectomy more challenging because of significant anatomic distortion, particularly at the level of the bladder and ureters. (See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management".)
For women with severe prolapse, a Döderlein-Krönig vaginal hysterectomy can be helpful. In this technique, the anterior peritoneum is entered and the uterine fundus is delivered through the incision [16,17]. The hysterectomy is then performed in a manner similar to an open abdominal hysterectomy; the surgery starts with ligation of the round ligaments and progresses to the uterosacral ligaments. The posterior cul-de-sac is opened last. (See "Hysterectomy: Abdominal (open) route", section on 'Operative technique'.)
Removal of adnexa — Salpingectomy or salpingo-oophorectomy can be performed at the time of vaginal hysterectomy to remove pathology or to reduce the risk of ovarian cancer. We counsel women regarding elective salpingectomy and oophorectomy and create a surgical plan as part of preoperative counseling. (See "Opportunistic salpingectomy for ovarian, fallopian tube, and peritoneal carcinoma risk reduction".)
●Success rates – Successful vaginal bilateral salpingo-oophorectomy without laparoscopic assistance has been reported in 65 to 98 percent of women [18-20], and successful salpingectomy has been reported in 74 to 88 percent of women [21-23]. Therefore, the need for concomitant adnexal surgery is not a reason for choosing an alternate surgical route. The authors have found that using a bipolar vessel sealing device can increase likelihood of successful removal of adnexa. Surgeons may find transvaginal use of laparoscopic instruments helpful for removal of adnexa because their thin diameter and longer length provide adequate visualization without the instrument itself obstructing the view.
●Risk factors for unsuccessful removal – Reported risk factors for unsuccessful planned salpingectomy include prior adnexal surgery, uterine fibroids, older age, postmenopausal status, and elevated body mass index [22,23]. Additional reasons for not completing planned salpingectomy include adnexal anatomy (high in the pelvis), bowel or sidewall adhesions, absent tubes, and ovarian adhesions [22]. One study reported an average 11 minute increase in surgical time with salpingectomy, with no clinically significant increased blood loss [22]. If the surgeon is unsuccessful with vaginal removal of the adnexa, a laparoscopic removal can be performed after cuff closure.
Prophylactic suspension — We typically perform a vaginal suspension at the time of vaginal hysterectomy to reduce risk of future prolapse. The choice of support procedure varies based on the presence of prolapse or symptoms. However, the optimal approach for asymptomatic women with normal pelvic support is not known. (See "Prophylactic vaginal apex suspension at the time of hysterectomy".)
Disruption of apical support occurs when the uterosacral and cardinal ligament complexes are divided. This is thought to be one of the major contributors to the subsequent development of the posthysterectomy apical (or vault) prolapse (figure 5) [24,25]. While there is debate over the true risk of prolapse from hysterectomy, the surgical route of hysterectomy does not appear to impact prolapse risk [26]. (See "Prophylactic vaginal apex suspension at the time of hysterectomy", section on 'Impact of hysterectomy on future prolapse risk'.)
Cystourethroscopy — We perform cystourethroscopy when a suspension or anti-incontinence procedure is performed or any time there is a concern for injury. There is no standard regarding the use of cystourethroscopy at the time of vaginal hysterectomy [27]. (See "Diagnostic cystourethroscopy (cystoscopy) for gynecologic conditions", section on 'Examining the lower urinary tract'.)
The advantages of universal cystourethroscopy are early identification of perforation or foreign body (eg, suture) and confirmation of ureteral patency. However, thermal injuries that may result in delayed perforation are not typically evident intraoperatively. Disadvantages include additional operating time, risk of injury from the procedure itself, and identification of nonsignificant findings.
Exclusion of malignancy — Malignancy should be reasonably excluded prior to hysterectomy because presence of cancer would likely change the surgical treatment. Preoperative evaluation to identify malignancy may include appropriate use of imaging, cervical cancer screening, and endometrial tissue sampling (for patients with abnormal uterine bleeding) [15]. In addition, clinicians should inform patients of possible risk of disseminating occult malignancy or benign uterine tissue with the various surgical approaches.
Use of robot-assisted surgical device — Use of a robot-assisted system for vaginal surgery (commercial name Hominis), particularly for hysterectomy for benign indications, has been explored [28-31]. Specific patient groups who may benefit from addition of robot-assisted vaginal hysterectomy compared with traditional vaginal surgery are not yet defined.
Use of vaginal laparoscopy — Vaginal natural orifice transluminal endoscopic surgery (vNOTES) uses a specialized retractor similar to that used for single-site laparoscopic surgery. The retractor is placed vaginally, after colpotomy, to complete the hysterectomy through a vaginal route without any abdominal incisions. The first feasibility study was published in 2012 for cases completed in 2010 [32]. (See "Hysterectomy (benign indications): Selection of surgical route", section on 'Vaginal hysterectomy'.)
Availability of the platform and surgeon training are still limitations for use, but it is increasingly an available option in the United States. There are some data that suggest benefits of vNOTES over traditional laparoscopy, including less postoperative pain, shorter hospital time, and faster recovery time [33,34]. A systematic review of six studies reported similar outcomes between vNOTES and laparoscopic hysterectomy for complications, readmission, and pain, but it did have lower surgery time, length of stay, and blood loss [35]. Purported benefits of vNOTES include improved visualization, ability to perform hysterectomy on larger uteri, and ability to address adhesions not otherwise amenable to traditional transvaginal approach. Choosing a route of hysterectomy is discussed separately. (See "Hysterectomy (benign indications): Selection of surgical route", section on 'Vaginal hysterectomy'.)
PREOPERATIVE PREPARATION — Many preoperative components are the same for vaginal hysterectomy, benign gynecologic surgery, and general surgery. All patients need medical optimization, surgical counseling, procedure consent, and plans for thromboprophylaxis and prevention of surgical site infection.
●(See "Overview of preoperative evaluation and preparation for gynecologic surgery".)
●(See "Informed procedural consent".)
●(See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)
Prior to surgery, we discuss nonsurgical outcomes including postoperative psychosexual function, satisfaction, and earlier menopause with all patients. (See "Hysterectomy (benign indications): Patient-important issues and surgical complications", section on 'Patient-reported outcomes'.)
Additionally, women undergoing vaginal hysterectomy are questioned for symptoms of vaginitis and examined for evidence of pelvic organ prolapse.
●Vaginitis: Women with vaginitis symptoms are tested for infectious causes including chlamydia, gonorrhea, trichomoniasis, and bacterial vaginosis. No testing is indicated in asymptomatic women. Identified infections are treated preoperatively to reduce potential vaginal cuff infection [36]. (See "Bacterial vaginosis: Initial treatment", section on 'Individuals undergoing gynecologic procedures' and "Vaginitis in adults: Initial evaluation", section on 'Diagnostic evaluation'.)
●Pelvic organ prolapse: Women with pelvic organ prolapse undergo a preoperative cough stress test (with simultaneous reduction of prolapse) to identify occult stress urinary incontinence (SUI). If occult SUI is present, we discuss concomitant anti-incontinence procedures with the patient. (See "Surgical management of stress urinary incontinence in females: Preoperative evaluation for a primary procedure" and "Urogynecologic surgery: Perioperative care issues", section on 'Urodynamic studies'.)
Mechanical bowel preparation is not indicated prior to vaginal hysterectomy as there is no proven benefit [24,36-39]. Women with constipation can use a rectal enema or suppository the night before surgery to reduce the bulk of the rectum, but this is not required. (See "Urogynecologic surgery: Perioperative care issues", section on 'General'.)
Choice of anesthetic — General anesthesia is commonly used for vaginal hysterectomy; neuraxial regional anesthesia is also possible. Women undergoing a prophylactic apical suspension typically do not need paralysis. Paralysis is helpful for women undergoing a high apical suspension because the resultant abdominal wall relaxation can make the intraperitoneal portion of the surgery easier to perform. (See "Overview of anesthesia", section on 'Types of anesthesia'.)
Instrument selection — Useful instruments specific to vaginal hysterectomy include the short-bill weighted speculum, Steinert (long-bill) weighted speculum (figure 6), Sims retractor, Breisky-Navratil retractors, Heaney or Glenner clamps, and advanced bipolar electric vessel-sealing devices. We often place a glove with fingertips cut off (to allow blood drainage) over the weighted end of the speculum, and clamp it to the drapes to hold it in place and keep it from falling onto the floor. Alternatively, use of a self-retaining vaginal retractor (lone-star) can provide the support to hold the speculum in place.
●The Sims retractor is used with the short weighted speculum to visualize the cervix.
●The Steinert speculum retracts the posterior vaginal and peritoneal surfaces once the posterior peritoneum has been entered.
●Breisky-Navratil retractors are used to hold back the vaginal side walls.
●Heaney or Glenner clamps are used to clamp vascular pedicles.
●Advanced bipolar electric vessel-sealing devices (eg, LigaSure, PlasmaKinetic, EnSeal) are used to clamp vascular pedicles.
For women with limited vaginal access, such as those with high body mass index, orthopedic conditions limiting hip abduction, or narrow pubic arch, advanced bipolar vessel-sealing instruments can be helpful because they require less operative space than traditional clamps and suture ligation. Bipolar vessel-sealing devices are preferred to ultrasonic vessel-sealing devices as the ultrasonic instruments are unable to achieve hemostasis on vessels larger than 4 to 5 mm. (See "Instruments and devices used in laparoscopic surgery", section on 'Electrosurgery'.)
We typically suture-ligate the pedicles for the hysterectomy portion of the procedure and then use an advanced bipolar vessel-sealing instrument for adnexa removal. We prefer the laparoscopic bipolar vessel-sealing device rather than the handheld as it is thinner and longer and thus more easily manipulated down the vaginal canal for adnexa removal. Use of a bipolar vessel-sealing device can provide a modest reduction in blood loss and operative time, but potentially increase cost [40-43]. Complication rates appear to be similar among traditional suture-ligation and vessel-sealing techniques. (See "Instruments and devices used in laparoscopic surgery", section on 'Electrosurgery' and "Overview of electrosurgery", section on 'Advanced electrosurgical devices'.)
Options to improve lighting include headlamps and handheld suction devices or retractors with illuminated tips. These can be particularly helpful when performing deep vaginal surgery such as oophorectomy or apical suspension.
When surgical assistants are not available, we use self-retaining vaginal retractors or clamps. If self-retaining retractors are not available, Allis clamps can be attached to tissue and then attached by their handles to the drape, often strung together with a sterile rubber band. Additionally, some surgeons place a Mayo stand in front of them a few inches below the level of the patient, where commonly-used instruments (eg, scissors, clamps, gauze, suction) can be easily accessed during the procedure. Use of an energy-sealing device may be particularly helpful in the setting of no surgical assistant. (See "Urogynecologic surgery: Perioperative care issues", section on 'Retractor use in surgery'.)
Patient positioning — Total vaginal hysterectomy is performed with the patient in dorsal lithotomy position using either candy cane or boot-type stirrups. With all stirrups, protective positioning is required to avoid pressure ulcers, nerve compression (figure 7), and compartment syndrome. (See "Urogynecologic surgery: Perioperative care issues", section on 'Positioning'.)
●Candy cane stirrups provide the most access and exposure for vaginal procedures because they are least bulky (figure 8). However, the leg position is fixed and there is an increased risk of positioning injury and postoperative neuropathy compared with boot-type stirrups [44].
●Boot-type stirrups allow the surgeon to change the patient's position intraoperatively but may decrease exposure because of their larger size (figure 9).
Additional issues that impact positioning decisions for vaginal hysterectomy include:
●Concomitant anti-incontinence procedure – Women undergoing retropubic or transobturator sling procedures in addition to vaginal hysterectomy are typically positioned in candy cane stirrups (figure 8). Women undergoing concomitant Burch colposuspension are positioned in boot-type stirrups as the surgeon needs access to the abdomen as well as the vagina.
●Combined laparoscopic procedures – Women undergoing combined laparoscopic and vaginal procedures are positioned in boot-type stirrups so the patient's legs can be adjusted for both abdominal and vaginal access (figure 9). We prefer to tuck the woman's arms at her sides rather than use arm boards to protect them from unintended movement (figure 10).
●Limited patient mobility – Women with limited range of motion, such as after joint replacement, are positioned while awake to ensure there is no excessive flexion/extension or abduction/adduction of the affected joint.
●Trendelenburg position – Use of Trendelenburg position is very helpful for visualizing the utero-ovarian pedicles, performing adnexal surgery or apical suspension procedures, and closing the vaginal cuff. The operating table is adjusted into Trendelenburg position as needed to facilitate visualization.
●Pelvic tilt – Positioning the woman with a portion of the buttocks/soft tissue overhanging the end of the table rotates the pelvis toward the surgeon and improves visualization. This is particularly helpful when operating on obese women.
After the patient is positioned, the surgeon performs an examination under anesthesia to confirm the anatomy and surgical plan as well as evaluate for palpable adnexal pathology.
Bladder catheter insertion — Of the two authors, one inserts the bladder catheter at the start of the procedure, and the other drains the bladder following the anterior colpotomy, as needed for adequate visualization, or at the conclusion of the procedure. In the absence of compelling data to guide timing, the decision is the surgeon's preference. Immediate insertion of the bladder catheter decompresses the bladder and limits the bladder's protrusion into the operative field. If a bladder perforation were to occur, this would likely be identified during cystourethroscopy at the conclusion of the case. (See 'Cystourethroscopy' above.)
An alternate approach is to insert the bladder catheter after entry into the anterior cul-de-sac or at the conclusion of the procedure if the bladder is not protruding into the surgical field. The rationale is that delay of insertion results in a slightly distended bladder that would leak urine if perforation were to occur during the anterior colpotomy. Of note, this approach does not reduce the incidence of bladder injury but facilitates identification of the injury. Either time of catheter insertion is acceptable.
Abdominal vaginal preparation — Prior to surgery, we use a 4 percent chlorhexidine gluconate solution with 70 percent isopropyl alcohol for the abdominal preparation and 4 percent chlorhexidine gluconate with a lower isopropyl alcohol concentration (typically 4 percent) for the vaginal preparation [36].
PROCEDURE — The procedure presented below is a step-by-step approach that works well for most cases. (See "Urogynecologic surgery: Perioperative care issues", section on 'Surgical preparation of skin and vagina'.)
The main steps of a vaginal hysterectomy are:
●Cervix incision
●Entry into the peritoneal cavity
●Division of the vascular pedicles and removal of the uterus
●Adnexal surgery when indicated
●Apical support procedures when indicated
●Closure of the vaginal cuff
Cervix incision — We perform a circumferential incision in the vaginal epithelium at the junction of the cervix to aid entry into the peritoneum (figure 11). While this is not an essential step, it may preserve vaginal length at the time of closure. Once the incision is made with a scalpel or electrocautery, the surgeon then sharply dissects or bluntly pushes the overlying vaginal epithelium off the underlying cervical stroma with the aid of a surgical sponge (figure 12). Alternately, some surgeons omit the cervical incision and begin the surgery by cutting directly through the posterior vaginal epithelium into the posterior peritoneum. (See 'Posterior cul-de-sac entry' below.)
Prior to incision, we inject a vasoconstrictor circumferentially around the cervix for hemostasis and hydrodissection. Some surgeons also inject 10 mL of vasoconstrictor into the uterosacral and cardinal ligaments. We identify the vesicocervical fold prior to injection because the infiltrate can distort the anatomy. Injectable agents include bupivacaine or lidocaine (with or without epinephrine), vasopressin, and saline. We typically use bupivacaine/epinephrine or vasopressin that has been diluted with sterile saline. Common mixtures are 20 units of vasopressin or 50 mL of 0.5 percent bupivacaine with epinephrine diluted into 60 mL of normal saline. (See "Subcutaneous infiltration of local anesthetics", section on 'Bupivacaine' and "Techniques to reduce blood loss during abdominal or laparoscopic myomectomy", section on 'Vasopressin and other vasoconstrictors'.)
Entry into the abdomen — We enter the abdomen by dissecting along avascular planes anterior and posterior to the uterus (figure 13). If the bowel protrudes into the lower pelvis and posterior cul-de-sac after peritoneal entry, we place the patient in Trendelenburg position to reduce the bowel into the upper abdomen and thus decrease the need for bowel packing. If this maneuver is not adequate to move the bowel out of the operative field, then we pack the bowel into the lateral para-colic gutters with moist radio-opaque sponges, which are included in the operative count. In women with an enlarged uterus, the bowel is often blocked by the uterus and bowel packing is not necessary.
Posterior cul-de-sac entry — Initial posterior entry may be particularly helpful for women with potential scarring of the anterior cul-de-sac, such as after cesarean delivery.
We place upward traction on the cervix to expose the posterior cul-de-sac. After the vaginal epithelium is incised, the peritoneum bulges toward the surgeon. Prior to incising the peritoneum, the tissue is palpated for bowel. Once the cul-de-sac is clear, the posterior peritoneum is grasped with a toothed forceps and incised horizontally with Mayo scissors to expose the peritoneal cavity (figure 14). The peritoneal incision is extended by spreading the Mayo scissors and the short-weighted speculum is replaced with a Steinert speculum. We confirm the Steinert speculum is in the posterior cul-de-sac, over the posterior peritoneum, rather than retroperitoneal. Prior to placing the weighted speculum, some surgeons stitch the peritoneum to the posterior vaginal epithelium with a figure-of-eight suture or a running stitch. This optional suture can provide hemostasis and can be helpful at the time of vaginal cuff closure.
If difficulty is encountered isolating the posterior peritoneum with the above approach, a midline vertical incision is made to the point at which the posterior cul-de-sac becomes more apparent. The incision now has a "T"-shaped appearance. Once the peritoneal window is visible, then the above steps are followed.
In trying to identify the retroperitoneal window, the surgeon can erroneously dissect into the cervical stroma and create bleeding. In this situation, the surgeon can either begin the hysterectomy in a retroperitoneal fashion or open the anterior peritoneum. After the anterior peritoneum is opened, the posterior peritoneum is identified by placing a finger or instrument behind the uterus.
Anterior cul-de-sac entry — We identify the anterior peritoneal reflection by sharply dissecting toward the anterior cervix with Metzenbaum or curved Mayo scissors at a 45-degree angle. Downward traction on the cervix facilitates dissection. The dissection advances until the anterior peritoneal reflection is seen as a white crescent (figure 15). In a study of 22 surgical patients, the median distance from the cervicovaginal incision to the anterior peritoneal reflection was 3.4 cm [45]. Palpation of this tissue is commonly described as feeling like "silk sliding on silk." Once visualized, the peritoneal reflection is grasped with a toothed forceps and incised to enter the anterior cul-de-sac (figure 16). A Heaney or Deaver retractor is placed into this space to elevate and protect the bladder and allow visualization of the abdominal anatomy.
If the dissection goes too deeply into the cervix, bleeding will occur. A new dissection is begun just cephalad to the erroneous deeper plane by placing the Metzenbaum scissors, closed, at a 90-degree angle and then spreading the tips perpendicular to the cervical stroma. Additionally, a bent uterine sound can be placed through the posterior incision and over the fundus to assist with identification of the anterior peritoneum.
If the anterior peritoneal reflection cannot be identified, we continue the hysterectomy by placing a retractor in the midline anterior space and elevating the bladder, thus moving the ureters superiorly and laterally. Serial clamping and dissection of the uterosacral and cardinal ligaments can then be performed until the peritoneal reflection is visualized. The clamps are placed on the inferior surface of the ligaments, rather than laterally, to minimize the risk of ureter injury. Prior to placing each clamp, the bladder is bluntly or sharply dissected off the underling cervical stroma until the vesicovaginal space is entered. Once the anterior cul-de-sac is opened, the bladder is elevated with a retractor and the ligament clamping proceeds as usual.
If the anterior cul-de-sac is scarred, such as from prior cesarean delivery, identification of the vesicouterine fold can be challenging. One solution is for the surgeon to pass a finger or instrument through the posterior incision, around the fundus, and into the anterior space to identify the vesicouterine fold. To facilitate this maneuver, the posterior cervix and uterus can be bivalved to the level of the fundus after the uterine vessels have been ligated. Bivalving the uterus allows the fundus to descend further into the vaginal canal and makes the vesicouterine fold easier to identify and incise.
Hysterectomy — A common approach to hysterectomy is the Heaney technique, in which the surgery starts with the uterosacral ligaments and proceeds to the utero-ovarian ligaments. This order is the opposite of abdominal or Döderlein-Krönig vaginal hysterectomy. (See 'Pelvic organ prolapse' above.)
After each clamp placement, we cut the pedicle to leave approximately 0.5 cm of tissue distal to the clamp. A transfixion suture is then placed at the tip of the clamp. We use Heaney transfixion sutures on all the pedicles, but this is surgeon preference. Use of an advanced bipolar vessel-sealing device, either laparoscopic or handheld, can also be used to seal and ligate each pedicle. The cutting blade of the device is positioned in the same manner as described for traditional clamps. While we typically use the traditional technique of clamp and suture-ligation at our institution, both techniques are acceptable as the outcomes are similar. (See 'Instrument selection' above.)
●Uterosacral ligaments – To clamp the uterosacral ligaments, we place the lateral blade of the clamp into the posterior recto-cervical fold and the medial blade on the inner edge of the ligament (figure 17) [4]. The ligament is clamped on the inferior surface, and not lateral, to minimize the risk of ureteral injury. We double ligate each pedicle and clamp the suture tail laterally to the drape for later use. Gentle traction on this suture will help to identify the most distal pedicle when assessing for hemostasis or when performing a suspension procedure. If a high apical suspension is to be performed and vessel-sealing technology is used, we find it beneficial to take this pedicle with a clamp and suture-ligate. This enables it to be easily identified and incorporated into the apical suspension later in the case.
●Cardinal ligaments – The cardinal ligaments are identified, clamped, cut, and suture ligated in a manner similar to that used for the uterosacral ligaments. Continued traction on the cervix aids with the identification of these structures and with hemostasis (figure 18).
●Uterine vessels – When clamping the uterine vessels (figure 19), we incorporate the anterior and posterior leaves of the peritoneum into the clamps to seal off the broad ligament. We start by placing the clamp parallel to the cervix, then grasp both peritoneal surfaces and the vessels, and lastly move the clamp handle laterally as the clamp is closed. When complete, the clamp tip is adjacent and perpendicular to the cervix (figure 20) [4]. The function of this movement is to clamp the uterine vessels perpendicular to their insertion, push the ureters laterally, and expose the clamp tip and a triangular portion of tissue beneath the clamp for retrieving the needle.
Although a double-clamp technique has been described, a single-clamp technique is adequate and decreases the potential risk of ureteral injury. In the patient with a large uterus, a second pedicle may be necessary to make certain that all branches of the uterine vasculature have been ligated. Back bleeding is limited by placing traction on the uterus.
●Broad ligaments – When clamping the broad ligaments, we place minimal traction on the uterus and the clamp because the broad ligament is primarily peritoneal tissue traversed by blood vessels that can be easily avulsed and bleed (figure 21). Each clamp is placed medial to the prior pedicle and no unclamped gaps of tissue are allowed because they can bleed.
●Utero-ovarian pedicles – We ligate the utero-ovarian ligament-fallopian tube complex twice, first with a suture tie followed by a suture ligature medial to the first tie (figure 22). A hemostat is placed on the second suture to aid in pedicle identification (should bleeding occur) and to assist with adnexa removal if indicated. A hemostat is not placed on the first tie, as traction on a suture tie risks loosening the tie and causing bleeding. Alternately, a double-clamp technique has been described, but is not necessary and can obstruct the surgeon's view.
For women with a small uterus, the surgeon can first deliver the uterine fundus through either peritoneal incision to better expose the utero-ovarian ligaments and facilitate clamp placement (figure 23). Uterine delivery is accomplished by placing a tenaculum on the uterine fundus in successive bites.
For women with a narrow pubic arch, long vagina, or obesity, we find a handheld or laparoscopic vessel-sealing device helpful for cauterizing the vascular pedicles. (See 'Instrument selection' above and "Overview of electrosurgery", section on 'Advanced electrosurgical devices' and "Instruments and devices used in laparoscopic surgery", section on 'Electrosurgery'.)
●Uterus removal – The fundus of a small uterus can be delivered anteriorly or posteriorly prior to ligation of the utero-ovarian ligaments. Once the ligaments are cut, the uterus is pulled gently through the vagina for delivery (figure 23).
Myometrial coring for intraoperative uterine size reduction — Women with an enlarged uterus can require intramyometrial coring (figure 4) to deliver the uterus. Requirements for uterine coring or hand morcellation include expectation of benign pathology, ligation of the uterine vasculature, and completed entry into the anterior and posterior cul-de-sacs. For vaginal surgery, size reduction is done with a wedge resection (figure 24) or hemisection (also known as bivalve technique) (figure 3). Myomectomy can also be performed to decompress the uterus (figure 2). If there is any concern for malignancy, uterine morcellation is either not done, is performed in a containment bag to prevent potential tissue seeding of the abdominal cavity, or is done in such a way as to keep the endometrial cavity intact [11]. (See 'Leiomyomata (fibroids)' above.)
Adnexal evaluation and surgery — After the uterus is removed, the fallopian tubes and ovaries are inspected for abnormalities. An atraumatic clamp such as a Babcock can be helpful to gently guide the ovary into the operative field for inspection. Bilateral salpingo-oophorectomy or salpingectomy is performed as indicated.
●We will use the last suture pedicle from the utero-ovarian ligation to place gentle traction on the adnexa, and then grasp the ovary or fallopian tube with a Babcock.
●A sidewall retractor, such as a Breisky-Navratil, will be used to help provide visualization by placing against the contralateral wall.
●A moistened laparotomy pack may be placed into the pelvis to help pack bowel out of the way.
●With gentle traction medially from the Babcock, a Haney or Glenner clamp can be placed on the lateral aspect of the adnexa, immediately adjacent to it. Use of an initial suture with flashing of the clamp and then a repeat transfixation suture is recommended. Hemostasis is confirmed prior to cutting the transfixion suture because the tissue may retract into the abdomen once off tension. This is then repeated on the contralateral side.
If the adnexa are not easy to remove in this manner, we often use laparoscopic and handheld electrosurgical vessel-sealing devices transvaginally to complete the surgery [46]. (See "Overview of electrosurgery", section on 'Advanced electrosurgical devices' and "Instruments and devices used in laparoscopic surgery", section on 'Electrosurgery'.)
For women whose adnexa cannot be safely removed vaginally, a laparoscopic resection can be performed after closure of the vaginal cuff, if desired. If the adnexa appear enlarged and are likely to be difficult to remove through the laparoscopic port sites, the open cuff can be packed with a glove or bulb syringe to provide an air-tight seal. Laparoscopic resection is then performed in the usual fashion, but the adnexa are placed in the posterior cul-de-sac rather than removed through the abdominal port sites. Once completed, the vaginal glove or bulb syringe is removed from the vagina, and the adnexa are extracted from the posterior cul-de-sac prior to vaginal cuff closure. (See "Oophorectomy and ovarian cystectomy", section on 'Oophorectomy'.)
Apical support — We perform an apical support procedure at the time of vaginal hysterectomy. Choice of procedure varies with degree of prolapse and patient symptoms. Techniques for suspension of the vaginal apex are reviewed separately. (See "Prophylactic vaginal apex suspension at the time of hysterectomy".)
Closure — Cystourethroscopy and rectal examination can be performed at this time, as indicated.
●Hemostasis – In addition to checking hemostasis throughout the procedure, we reevaluate all pedicles prior to cuff closure. Because blood drains into the upper abdomen when the patient is in Trendelenburg position, we level the operating table prior to final assessment.
Electrosurgical hemostasis can be safely used on the peritoneal and vaginal edges; vaginal edges are the most common site of bleeding [47]. We rarely use electrosurgical devices to achieve hemostasis of the pedicles themselves as thermal injury may loosen the stitch or spread to adjacent tissues such as the ureter. If cautery is unsuccessful or inappropriate, we place a running or interrupted suture, depending on the source of bleeding. When placing additional sutures on vascular pedicles, we stitch medially or adjacent to the prior suture to avoid injury to the ureter, which is lateral to the pedicle.
●Cuff closure – We close the vaginal cuff with an absorbable suture such as 1-0 or 0 polyglactin braided suture. Closure can be done in an interrupted, running, or running locking fashion and is the surgeon's choice. A running locking stitch may provide more hemostasis for bleeding vaginal edges. Closure can be performed either vertically or horizontally. If there is a concern about vaginal length, vertical closure has been shown to preserve vaginal length more than horizontal closure (figure 25) [48] and thus may decrease risk of subsequent dyspareunia [49].
Vaginal packing is optional [4]. We do not place packing in the vagina following routine hysterectomy as it does not appear to decrease postoperative bleeding after hysterectomy. Additionally, many women find packing uncomfortable, and it may inhibit the ability to void postoperatively. As many women are discharged on the day of surgery, avoidance of packing ensures the patient will not be inadvertently discharged with packing in place. If additional anterior and/or posterior repairs have been performed, packing may be placed at surgeon preference to provide pressure for up to several hours postoperatively. If packing is placed, the bladder catheter should remain in place until the packing is removed. (See "Urogynecologic surgery: Perioperative care issues", section on 'Vaginal packing'.)
●Bladder catheter removal – We prefer to leave the catheter in place until the patient is ambulatory and then perform a retrograde voiding trial at the time of catheter removal. As many patients go home on the day of the procedure, the backfill voiding trial can be done at any time after the patient is ambulatory. If the patient is staying overnight, removal can be delayed until the following morning. Alternately, the catheter can be removed in the operating room, and a voiding trial is performed in the recovery area. (See "Postoperative urinary retention in females", section on 'Retrograde voiding trial'.)
INTRAOPERATIVE COMPLICATIONS — The most common intraoperative complications for vaginal hysterectomy are hemorrhage, urinary tract injury, and bowel injury [50]. Additional complications of gynecologic surgery are reviewed separately. (See "Complications of gynecologic surgery".)
Hemorrhage — Excessive intraoperative bleeding occurs in approximately 2.5 percent of women and typically comes from a loose vascular pedicle or visceral injury [50]. General strategies to control hemorrhage are reviewed in detail elsewhere. (See "Management of hemorrhage in gynecologic surgery", section on 'Management of intraoperative bleeding'.)
To regain control of a bleeding pedicle, we pack the bowel out of the operative field and use Breisky-Navratil retractors to gain exposure. Next, we place gentle traction on the distal (uterosacral) and proximal (utero-ovarian) sutures to bring all the vascular pedicles into view. A forceps or Babcock can also be used to gently bring the tissue into the operative field. Once the bleeding area is identified, it can be clamped and ligated. We find a right-angle clamp is helpful. Another option is to use a handheld or laparoscopic vessel-sealing device to achieve hemostasis.
Pedicles that loosen from the suture or retract into the abdominal cavity can cause intraabdominal or retroperitoneal bleeding. If the pedicle cannot be reclamped vaginally, laparoscopy can be performed to locate and control the pedicle. If there is brisk bleeding, conversion to laparotomy may be necessary, particularly if there is not enough time to close the vaginal cuff and set up laparoscopic equipment. If the only obstacle to laparoscopy is cuff closure, laparoscopy can be performed with an open cuff and sealed vagina. A bulb syringe or surgical glove stuffed with a surgical sponge can be inserted into the vagina to create a seal for gas insufflation of the abdomen. Laparoscopy can then proceed as usual.
Bladder injury — Bladder injuries occur in up to 2 percent of vaginal hysterectomies; concomitant pelvic floor repair does not appear to increase the risk [46,50-53]. Bladder perforation typically occurs during entry into the anterior cul-de-sac. While there is no consensus regarding the role of routine cystourethroscopy to identify bladder injury during simple hysterectomy [27], we typically perform apical support procedures and therefore perform cystourethroscopy. Identification and repair of bladder injury is reviewed separately. (See "Urinary tract injury in gynecologic surgery: Epidemiology and prevention" and "Urinary tract injury in gynecologic surgery: Identification and management".)
Ureteral injury — Ureteral injuries occur in 0.1 to 0.5 percent of women undergoing vaginal hysterectomy [50,54,55]. Ureteral injury can include transection, crush injury, or anatomic distortion from an adjacent suture. The addition of pelvic floor reconstructive procedures does not appear to increase the risk of injury [52,53]. Identification and repair of ureteral injury is reviewed separately. (See "Urinary tract injury in gynecologic surgery: Epidemiology and prevention" and "Urinary tract injury in gynecologic surgery: Identification and management".)
Bowel injury — Bowel injury has been reported in approximately 0.4 percent of women undergoing vaginal hysterectomy [50]. If bowel injury occurs, an atraumatic instrument (bowel grasper, Babcock clamp) is placed next to the injury to mark the location and hold the bowel so it does not slip back into the peritoneal cavity. In our practice, we consult the general surgery service to assist with the repair when a bowel injury occurs. Information on repair of bowel injuries is presented separately. (See "Traumatic gastrointestinal injury in the adult patient", section on 'Management of intestinal injuries'.)
Abdominal conversion — Indications for visualization of the abdominal cavity, with either laparoscopy or laparotomy, can include:
●Bleeding without access to vascular pedicles – In instances when the surgeon encounters continued bleeding that is not coming from the vascular pedicles, or if the vascular pedicles cannot be accessed, we advise placing a pack (eg, laparotomy sponges with a marker) in the vagina and lower pelvis to create a vascular tamponade. This pack is placed while the remainder of the surgical team is converting the procedure to the abdominal route. Laparoscopic abdominal exploration can be considered if the bleeding is lighter or successfully tamponaded. In situations requiring rapid abdominal access, laparotomy is typically faster.
●Significant intraabdominal adhesions – When significant intraabdominal adhesions are encountered during vaginal surgery, concomitant laparoscopic visualization of the abdominal cavity allows the surgeon to see and then lyse the adhesions. Laparotomy is less commonly used, but can be necessary in some cases. However, in the setting of dense adhesions, entry into the abdomen can also be more challenging with either laparoscopy or laparotomy.
●Abnormal or unusual uterine anatomy – Atypical uterine anatomy can result from adhesions, fibroids, prior surgical interventions, or congenital malformations. Anatomic variants that obscure vaginal surgical access to the vascular supply of the uterus can result in need for abdominal conversion to complete the procedure.
If conversion is necessary, placing a moistened laparotomy sponge or pack, aseptic syringe, pediatric nasal bulb syringe, surgical glove filled with a sponge, or a pneumo-occluder into the vagina can create an adequate seal to allow for laparoscopy insufflation. If conversion to a laparotomy is intended, no additional vaginal preparation is needed, other than ensuring that the bladder is emptied via bladder catheter.
POSTOPERATIVE COMPLICATIONS — Common postoperative complications for gynecologic surgery are reviewed in detail elsewhere. (See "Complications of gynecologic surgery".)
Complications more commonly seen after vaginal hysterectomy include:
●Urinary retention – Rates of posthysterectomy urinary retention vary widely. In a study of 233 women undergoing vaginal or laparoscopic hysterectomy, the women with a vaginal approach were nearly three times as likely to have postoperative urinary retention compared with the laparoscopic approach [56]. Of note, the urinary retention resolved in all women by 48 hours postoperatively. Evaluation and management of urinary retention is reviewed separately. (See "Postoperative urinary retention in females".)
●Abscess – Common sites for abscess formation after hysterectomy include the vaginal cuff and the adnexa. Cuff abscess occurs in approximately 1 percent of women. Abscesses that are visible at the vaginal cuff are typically drained vaginally. Pelvic abscesses that cannot be drained vaginally can be drained by an interventional radiologist. (See "Posthysterectomy pelvic abscess".)
●Bleeding – We counsel patients that they may have vaginal spotting for a few weeks postoperatively. Bright red bleeding a few weeks following surgery should prompt an examination. Heavy vaginal bleeding requires urgent assessment for a vaginal cuff dehiscence or disruption of a vascular pedicle. (See "Vaginal cuff dehiscence after total hysterectomy", section on 'Clinical presentation' and "Complications of gynecologic surgery", section on 'Hemorrhage'.)
●Cuff dehiscence – If cuff dehiscence occurs, either vaginal or abdominal/laparoscopic cuff closure can be performed. If bowel evisceration is present, the bowel needs to be examined to ensure no injury exists prior to closure of the cuff. This topic is reviewed in detail elsewhere. (See "Vaginal cuff dehiscence after total hysterectomy".)
●Fallopian tube prolapse – Fallopian tube prolapse has been reported in 0.1 to 8 percent of women [56]. The wide range likely reflects inclusion of historical procedures that left the vaginal cuff open. (See "Hysterectomy: Abdominal (open) route", section on 'Fallopian tube prolapse'.)
●Fever – Studies report unexplained fever rates of 10 to 20 percent after vaginal hysterectomy [50]. Women with postoperative fever undergo routine evaluation. (See "Fever in the surgical patient".)
●Fistula – Vesicovaginal, rectovaginal, or enterovaginal fistulas can develop postoperatively and may not become symptomatic until several weeks from surgery. Vesicovaginal fistula is reported in 0.1 to 0.2 percent of women [50]. Patients often note new-onset copious foul-smelling vaginal discharge or urine leakage. Women with these complaints are evaluated promptly. (See "Complications of gynecologic surgery", section on 'Fistula formation' and "Urogenital tract fistulas in females".)
●Ileus and bowel obstruction – Vaginal hysterectomy is less likely to cause postoperative ileus compared with open abdominal hysterectomy [57]. Paralytic ileus rates of 0.2 percent have been reported [50]. (See "Postoperative ileus".)
●Venous thromboembolism (VTE) – The rate of VTE after vaginal hysterectomy varies with the patient population and extent of surgery. For women of low to moderate risk, VTE rates of 0.3 to 2.3 percent have been reported after hysterectomy (vaginal and abdominal) [50]. (See "Clinical presentation and diagnosis of the nonpregnant adult with suspected deep vein thrombosis of the lower extremity".)
●Urinary incontinence – Studies have reported a variable impact of hysterectomy on urinary incontinence [58-62]. Possible reasons include differences among studies in baseline urinary symptoms and other pelvic floor disorders, study methods, indications for hysterectomy, surgical techniques, and length of follow-up.
POSTOPERATIVE CARE — Common postoperative issues such as pain management, bladder catheter removal and voiding trial, postoperative antibiotics, bowel function, resumption of vaginal estrogen, and activity are reviewed elsewhere. (See "Urogynecologic surgery: Perioperative care issues", section on 'Postoperative'.)
There is no standard timing for postoperative follow-up. We typically call the patient within the first postoperative week, and then we evaluate the patient four to six weeks from surgery. In the postmenopausal patient with significant vulvovaginal atrophy, we schedule the initial postoperative visit at two weeks to ensure there is no agglutination of the vaginal walls. (See "Urogynecologic surgery: Perioperative care issues", section on 'Follow-up care'.)
SPECIAL POPULATIONS
●Obesity – For obese women, vaginal hysterectomy is associated with better outcomes and fewer complications than laparoscopic or abdominal hysterectomy [63]. Because these women are more likely to have comorbid conditions such as diabetes, hypertension, and sleep apnea, we request a preoperative anesthesia consult. For very obese women, we discuss the use of Trendelenburg position with the anesthesia team as these women can be difficult to ventilate when in steep Trendelenburg position. (See "Anesthesia for the patient with obesity".)
Additional preoperative planning includes requesting long or bariatric instrument kits and electrical vessel-sealing devices as well as using specially designed operating tables that can safely accommodate the patient's weight and prevent slippage as the table position is changed.
●Frailty – Frailty is associated with an increase in wound infections, severe complications, and overall complications after hysterectomy [64]. Measurement of performance status and function, rather than chronological age, is an important predictor of surgical outcome [65,66]. For women with poor functional status, we obtain a preoperative anesthesia consult and position these women while awake to avoid joint strain or injury. (See "Anesthesia for the older adult" and 'Patient positioning' above.)
OUTCOME — After hysterectomy, most women report relief of symptoms, improved quality of life, no adverse effect on sexual function, and satisfaction with their surgery. (See "Hysterectomy (benign indications): Patient-important issues and surgical complications", section on 'Patient-reported outcomes'.)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Deciding to have a hysterectomy (The Basics)")
●Beyond the Basics topics (see "Patient education: Abdominal hysterectomy (Beyond the Basics)" and "Patient education: Vaginal hysterectomy (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Preferred route for hysterectomy – Vaginal hysterectomy is the preferred route for hysterectomy when feasible. A surgeon's preference for other routes is not a reason to avoid vaginal surgery. (See 'Indications' above.)
●Relative contraindications – There are no absolute contraindications to vaginal hysterectomy, although malignancy, significantly enlarged uterus, and dense pelvic adhesions are relative contraindications. Nulliparity, increased body mass index, history of pelvic radiation, and lack of uterine descent can make the surgery more challenging but are not contraindications to vaginal hysterectomy. (See 'Indications' above.)
●Adjunct issues for preoperative consideration – Adjunct issues that are addressed preoperatively include adhesions, leiomyomata (fibroids), enlarged uterine size, pelvic organ prolapse, adnexal surgery, prophylactic apex suspension, and cystourethroscopy. (See 'Surgical planning' above.)
●Preoperative management – Prior to surgery, we treat women with vaginitis with antibiotics to reduce the incidence of vaginal cuff infection. We evaluate women with pelvic organ prolapse for occult stress urinary incontinence. For obese and frail women, we request preoperative anesthesia consultations and obtain appropriate equipment for positioning and operating. (See 'Preoperative preparation' above and 'Special populations' above.)
●Surgical technique
•Peritoneal entry – Vaginal hysterectomy is typically done with an intraperitoneal approach. The order of anterior and posterior incisions varies with patient characteristics and surgical ease. If neither peritoneal space can be opened, a retroperitoneal technique can be used. (See 'Entry into the abdomen' above.)
•Uterus removal – Intramyometrial coring or hand morcellation may be needed to remove uteri that are enlarged by benign processes. (See 'Myometrial coring for intraoperative uterine size reduction' above.)
•Inspection of adnexa – After the uterus is removed, the fallopian tubes and ovaries are inspected for abnormalities. Bilateral salpingo-oophorectomy or salpingectomy can be performed as indicated. An electrosurgical vessel-sealing device may be useful for securing these pedicles. (See 'Adnexal evaluation and surgery' above.)
•Apical support procedure – Prior to closure, we perform an apical support procedure as indicated by the patient's symptoms and anatomy. (See 'Apical support' above.)
●Complications – Intraoperative complications typically encountered in vaginal hysterectomy include bleeding and injury of the urinary or gastrointestinal tract. Postoperative complications include abscess formation, bleeding, cuff dehiscence, fever, fistula formation, ileus or bowel obstruction, and venous thromboembolism. (See 'Intraoperative complications' above and 'Postoperative complications' above.)
●Postoperative care – There is no standard timing for postoperative follow-up. We typically call the patient within the first postoperative week and then evaluate the patient at two weeks and again six weeks after surgery. Women who develop copious vaginal discharge, urinary incontinence, or bleeding are urgently evaluated for vaginal fistula or cuff dehiscence. (See 'Postoperative care' above and 'Postoperative complications' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Thomas Stovall, MD, and William Mann, Jr, MD, who contributed to an earlier version of this topic review.
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