First Clamp• After pushing up the bladder and opening the pouch of Douglas (POD), 1st clamp is applied to uterosacral ligament as close to the uterus as possible; Confirming that the inside blade is inside the peritoneal cavity to include the small vessels between the peritoneum and the base of the pelvis
Ligatures.• First ligatures is left with long threads, one with needle will be used to have a bite in the lateral vaginal angle so: – Support the vaginal vault by ligating it to the main supporting structures of the pelvis – Shares in the homeostasis of that vascular area
Stitching First Pedicle to Vaginal Angle• Occlusion of the space in between• Closure of small vessels• Fixing uterosacral to vagina
2 Ligatures, Step ladder nd•Almost always the 2nd bite will notreach the level of uterine vessels andwe don’t intend to do so.•The long thread of the 1st bite is tiedwith one of the threads of the nextligature so the whole uterosacral wasat the end taken to the vaginal angle.
So, At the End..• The whole three pedicles are ligated together on one side with marked stitch. During peritonization, one thread from round ligament was tied to its counterpart on the other side and peritoneum was approximated
At the end, The pediclesare sutured to the vagina:• That vaginal angle was sutured to the uterosacral ligaments as a first step, giving a strong support to vaginal vault at the end of operation, preventing vault prolapse.
Approximating Pedicles:• The marker stitch can help in pulling down any part of any pedicle when bleeding has to be secured.• Ligaturing the pedicles together will occlude the small vessels in between making good hemostasis.• These structures give good support to the vagina preventing posthysterectomy vaginal vault prolapse.
Results.• Median opertive time 60min.• Post operative analgesics 33%.• Hospital stay 2.1 days.
Complications:• Post op bleed 4%• One day fever 3%• Post op fever 2%• UTI 1%• Post op vault 0%• Stress Incont 1%• Det. Inst 1%
Cost.• In 1998, the average charge for a laparoscopically-assisted vaginal hysterectomy in the united states was $14,500; An abdominal hysterectomy was $12,500: that for a vaginal hysterectomy was $10,380; And that for (stat bull Metrop Insur co 2000).• Vaginal hysterectomy resulted in better quality-of-life outcomes and lower costs compared with laparoscopically assisted vaginal or abdominal hysterectomy (van den Eeden 1998).
Conclusion..• Vaginal hysterectomy should be considered whether there is associated prolapse or not.• With proper selection, continued training, its rate will increase in front of abdominal or laparoscopic route.• Good access and assessment of uterosacrals.• Good support to the vagina.
Step Ladder• Easy access to all pedicles at any time.• Good inspection of the pedicles at the conclusion of surgery.• Minimizing oozing vessels in- between pedicles.
Advantages of Technique:• Minimize well known postoperative vault prolapse, good support to vaginal vault.• Minimize intraoperative bleeding.• Minimize postoperative hematoma.• Easy and versatile access to ligature.
Advantages of Vaginal Approach • Time of operation • Exposure and Traumatization • Good for high risk patients • Post operative stay • Cost
Rules• Opening the POD in proper plane• Don’t dissect the bladder from fascia• In clamping uterosacral, inner blade includes the peritoneum• Clamping the pedicle in two steps is better than a big sizeable pedicle• First pedicle to be fixed to vaginal angle• Keep your clamps adjacent to the uterus• Step ladder procedure
Epilog• Abdominal route: Surgery• Laparoscopic: Technological surgery• Vaginal: Art surgery