This document describes a technique for performing vaginal hysterectomy that aims to prevent postoperative vaginal vault prolapse. The key steps of the technique are to circumferentially incise the vagina without dissecting the bladder, clamp the uterosacral ligaments as close to the uterus as possible, and suture the ligaments to the lateral vaginal wall to provide support to the vaginal vault. The technique proceeds in a "step ladder" fashion up to the ovarian ligaments. By approximating the ligaments together, it aims to provide strong support of the vaginal vault and prevent postoperative prolapse.

1. Safe Teaching Strategy for Vaginal Hysterectomy Professor Galal Lotfi, MD, MRCOG Obstetrics & Gynecology Suez Canal University Egypt 03/12/11

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3. Suez Canal University Hospital 03/12/11

4. Aim: Reviving, a Well Known Technique for Hysterectomy. Implementing a Technique, Safe Without the Tragic Vault prolapse. 03/12/11

5. Our Fears Access, mobility. Dissecting off the bladder. Opening POD. Pedicles. Slippage of a ligature, in so restricted field. Postoperative vault problems. 03/12/11

6. What we need during Hysterectomy? Safe: secure pedicles at all times. No post operative vault prolapse: secure pedicles to vagina. 03/12/11

7. Patients Women for hysterectomy. No prolapse. No contraindication for vaginal hyst. 03/12/11

8. Indications Dub Fibroid uterus Adenomyosis Cervical SL Contraception 03/12/11

9. Lessons to implement a safe technique. 03/12/11

10. Lesson 1: Selection Mobility; Especially downwards Uterus less than 12 weeks Cervix not atrophied Fornices adequate Healthy tissues Assessment under anesthesia, in lithotomy 03/12/11

11. Technique 03/12/11

12. The Start Circumferential incision of Vagina. Push up Vagina and bladder together, don ’t dissect. Open the POD now. 03/12/11

13. Lesson 2: First Ligature. After pushing up the bladder and opening the pouch of Douglas (POD), 1 st 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 03/12/11

14. If you are very close to uterus Good pedicle, we need long pedicle as the main difficulties to encounter is the lack of mobility of the uterus in the early steps of the operation that make the field tight; with good pedicle gives safeguard if the clamp- have slipped. Avoid damage surrounding structures like base of the bladder that is usually caught here. 03/12/11

15. First Clamp 03/12/11

16. Lesson 3: 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 03/12/11

17. The long thread of the 1 st bite is tied with one of the threads of the next ligature so the whole uterosacral at the end was taken to the vaginal angle. These ligaments afford the main support of the uterus and upper vagina ( Howkins & Bourne 1976). For that reason the proposed modifications entails suturing of the cardinal ligament and lateral vaginal wall together to create adhesive forces that help holding the vagina. 03/12/11

18. Stitching First Pedicle to Vaginal Angle Occlusion of the space in between Closure of small vessels Fixing uterosacral to vagina 03/12/11

19. Lesson 4: Step ladder till ovarian pedicles. Almost always the 2 nd bite will not reach the level of uterine vessels and we don ’t intend to do so. The long thread of the 1 st bite is tied with one of the threads of the next ligature.. The same process is repeated till ovarian pedicles. 03/12/11

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21. Uterine, Ovarian Ligatures 03/12/11

22. Ovarian to Ovarian, Closing Peritoneum 03/12/11

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26. Story of vault prolapse It should be noticed that the vagina lies parallel to the levator ani in a horizontal position. With increased intrabdominal pressure, the levator ani and cardinal ligament hold the cervix and upper vagina in their proper position. Distortion of vaginal axis due to weak support places the vaginal apex in an unsupported position over the uterovaginal hiatus i.e. the vagina cannot rest upon the levator plate resulting in prolapse. This illustrates the importance of normal; vaginal axis in the integrity of the vaginal support (Richter 1967, fun et al 1978). In the technique described, round ligament was attached to the cardinal ligament. Some authors used, round ligament as part of vaginal fixation (Symmond ’s et al 1982, Randall & Nichols 1971) to prevent posthysterectomy vaginal vault prolapse. I feel that the round ligament in that issue is trivial, however the used technique of attaching the round ligament to the cardinal ligament help to make peritonozation easier. This conclude that vaginal hysterectomy should be taken as an opportunity to prevent posthysterectomy vaginal vault prolapse by meticulous care of supporting ligaments. 03/12/11

27. 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 03/12/11

28. Lesson 5: Why 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. 03/12/11

29. 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 . 03/12/11

30. Vaginal to Vaginal, Closing Vag 03/12/11

31. Results. Median opertive time 60min. Post operative analgesics 33%. Hospital stay 2.1 days. 03/12/11

32. 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% 03/12/11

33. Cost. Lower costs compared with laparoscopically assisted vaginal or abdominal hysterectomy (van den Eeden 1998). #14,500$ laparoscopically-assisted vaginal hysterectomy. #12,500$ abdominal hysterectomy. #10,300$ vaginal hysterectomy. Better quality-of-life outcomes. 03/12/11

34. Discussion 03/12/11

35. Advantages of Step ladder Minimize well known postoperative vault prolapse, good support to vaginal vault. Minimize intraoperative bleeding. Minimize postoperative hematoma. Easy and versatile access to ligature. 03/12/11

36. Advantages of Vaginal Approach Time of operation Exposure and Traumatization Good for high risk patients Post operative stay Cost 03/12/11

37. 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. Always follow the rules: 03/12/11

38. Rules to follow: 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 03/12/11

39. Epilog Abdominal route: Surgery Laparoscopic: Technological costly surgery Vaginal: Art surgery 03/12/11

40. Thank You 03/12/11