Vaginal Hysterectomy

Kaidy Waterman & Emily Beacham

Anatomy and Physiology

Removal of uterus Possible removal of fallopian tubes and ovaries Ligature of uterosacral ligaments Ligature of cardinal ligaments Ligature of uterine arteries Possible ligature of round ligament, ovarian

ligament and fallopian tubes

Reasons for Procedure Sterilization Endometriosis Fibroids Cancer Adhesions Uterine prolapse

About 1/3 of all hysterectomies are done vaginally

Doctors prefer vaginal because it is less invasive

Laparoscopically assisted vaginal hysterectomies are becoming much more common

General DetailsAnesthesia and

Positioning Anesthesia is general Patient is in lithotomy

position Candy cane stirrups

Skin Prep and Draping

Vaginal prep Lithotomy drape

Supplies, Equipment and Instruments

Auvard weighted speculum

Heaney/Deaver retracters

Tenaculum/Lahey vulsellum

#15 blade #7 knife handle 4X4 sponges Peri-Pad

Heaney clamps Mayo scissors Long mayo Kelly clamps Schnidt Pean Jacob’s vulsellum Foley catheter Vag packing

Special Considerations Careful with catheterization after the procedure Care must be taken not to damage the fallopian

tubes or ovaries if they are going to remain in the body

The Procedure

1. TIME OUT2. Auvard weighted speculum is placed in the

posterior vaginal wall3. Heaney or Deavers retract the lateral vaginal

walls4. Tenaculum/Lahey placed at the edge of cervix to

permit traction and movement.o D&C may be performed here

5. #15 blade on #7 handle, incise vaginal wall anteriorly around cervix

6. Blunt dissection, index and middle finger with 4X4, free bladder from anterior surface of the cervix

7. Deaver is placed anteriorly to elevate the bladdero Protects bladdero Visualization of peritoneum and anterior cul-de-sac

8. Use #15 knife blade, opening is made in the cul-de-sac

9. Peritoneum of posterior cul-de-sac is identified and incised with #15

10. Uterosacral ligaments are doubly clamped with Heaney clamps, cut with Mayo and ligated.o Ligatures are not cut-left long and tagged with kelly

11. Manipulate uterus posteriorly, cardinal ligaments on each side are doubly clamped and cut with Mayos and ligated

12. Same is done with uterine arteries except the clamps are Kelly, Schnidt, or Pean

13. Fundus is put into the vaginal canal with previously placed tenaculum/Jacob’s vulsellum

14. If ovaries are preserved:o Round ligamento Ovarian ligament o Fallopian

are doubly clamped with Heaney clamps, cut with mayo

15. Uterus is removed16. Pedicles of the ligaments are ligated

17. Peritoneum between rectum and vagina is approximated with a continuous absorbable suture

18. Cul-de-sac is closed by placing sutures from vaginal wall through infundibulopelvic and round ligaments and back out through the vaginal wall, tied down on the vaginal portion of the vault

19. Round, uterosacral, and cardinal ligaments are individually approximated and reattached to the angle of the vagina

20. Foley catheter is placed, vagina is packed, perineal pad is placed.

Postoperative Care

Complications Bowel obstruction or

damage Bladder injury Wound infection of

dehiscence Ureteral injuries Hemorrhage

Care and Prognosis Transport to PACU Return to normal

activities

Pearl of WisdomSome surgeons complete actions on one side of the uterus then move to the other side; some alternate sides as they

move caudally. The STSR must adjust to the pattern and be sure to have an adequate supply of homeostasis.

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