This document describes a modified technique for performing a vaginal hysterectomy. The key aspects of the technique are: 1) Securing the pedicles (uterosacral ligaments, uterine vessels, ovarian ligaments) individually as they are clamped to ensure hemostasis and avoid vault prolapse. 2) Suturing the first pedicle, the uterosacral ligament, to the lateral vaginal angle to provide support to the vaginal vault after surgery. 3) Ligating the pedicles together in a "step ladder" fashion to further ensure hemostasis and support. 4) The results of this technique in over 279 patients showed low rates of complications like bleeding

1. Vaginal Hysterectomy: Modified
Safe Technique
Professor Galal Lotfi, MD, MRCOG
Obstetrics & Gynecology
Suez Canal University
Egypt

2. Suez Canal University Hospital

3. Aim?
• This is not a comparison between
vaginal and abdominal Hyst.
• This is not a comparison between
vaginal and laparoscopic Hyst.

4. Aim Of That Work
•Reviving, a Well Known
Technique for Hysterectomy.
•Implementing a Technique,
Safe Without the Tragic Vault
prolapse.

5. Material and Methods
• Women for hysterectomy.
• No prolapse.
• No contraindication for
vaginal hyst.

6. Indications
• Dub 188
• Fibroid uterus 79
• Adenomyosis 8
• CIN 3
• Contraception 1

7. Requirements
• Mobility; Especially downwards
• Uterus less than 12 weeks
• Cervix not atrophied
• Fornices adequate
• Healthy tissues
• Assessment under anesthesia, in
lithotomy

8. Broad Lines of the
Technique;
• To be safe: secure pedicles at
all times.
• To avoid a post operative
vault prolapse: secure
pedicles to vagina.

9. First Clamp

10. 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

11. 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

13. Stitching First Pedicle
to Vaginal Angle
• Occlusion of the space in
between
• Closure of small vessels
• Fixing uterosacral to vagina

14. 2 Ligatures, Step ladder
nd
•Almost always the 2nd bite will not
reach the level of uterine vessels and
we don’t intend to do so.
•The long thread of the 1st bite is tied
with one of the threads of the next
ligature so the whole uterosacral was
at the end taken to the vaginal angle.

15. Uterine, Ovarian Ligatures

18. 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

19. At the end, The pedicles
are 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.

20. Vaginal to Vaginal, Closing Vag

21. 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.

22. Results.
• Median opertive time 60min.
• Post operative analgesics
33%.
• Hospital stay 2.1 days.

23. 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%

24. 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).

25. 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.

26. 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.

27. 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.

28. Advantages of Vaginal Approach
• Time of operation
• Exposure and
Traumatization
• Good for high risk patients
• Post operative stay
• Cost

32. 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

33. Epilog
• Abdominal route: Surgery
• Laparoscopic: Technological surgery
• Vaginal: Art surgery

34. Thank You