I place the Deaver retractor into the anterior space and move the tenaculum to the anterior lip of the cervix. This gives maximal space for downward traction on the cervix while anterior entry is attempted.
Once again, I inject the tissue with the bupivacaine solution before incising the vaginal epithelium at the level of the internal os. I use sharp dissection only when creating a plane between the lower uterine segment and the bladder.
Ensuring room to move and good visualization
If neither the anterior nor the posterior cul-de-sac can be accessed, it may be time to rethink the vaginal approach—but there is no harm in taking the uterosacral and cardinal ligaments extraperitoneally in an effort to gain some mobility. Hugging the uterus and leaving the anterior retractor in place to lift the bladder superiorly are essential steps to protect the ureters. The cervix can then be split in the midline (12 to 6 o’clock) to easily identify the peritoneal reflections.
Other tips
Sidewall retractors are rarely needed. They significantly impair placement of clamps and sutures by creating a long, narrow, parallel passageway. An alternative trick is to use the suction tip to retract the vaginal sidewall as the surgeon is working.
A disposable, fiberoptic, lighted suction irrigator is another option. The light can be directed precisely where it is needed, and the irrigation helps keep the field clean and tidy, simplifying identification of anatomy.
Skip the sutures whenever possible. Because it is difficult to place sutures with precision in a tight, poorly illuminated space, I use a vessel sealer for all pedicles above the uterosacral ligaments. Some of these instruments were designed specifically for vaginal hysterectomy in the same shape and size as Heaney clamps. They are remarkably efficient and permit the completion of a vaginal procedure when suture placement is difficult.
Use a Heaney needleholder, with the suture loaded precisely in the center of the needle curve, along with the lighted suction irrigator to retract redundant tissue away from the track of the needle, to facilitate suturing high in the pelvis.
VAGINAL HYSTERECTOMY CHALLENGE 2: Nulliparity
Many of us are reluctant to attempt vaginal hysterectomy in a woman who has never had children. Although this situation can be challenging at times, in my experience, the access issues tend to be more difficult in obese, multiparous women.
The same tricks and techniques addressed above will permit the vaginal approach in almost all nulliparous women.
VAGINAL HYSTERECTOMY CHALLENGE 3: Previous cesarean section
A prior cesarean delivery is sometimes considered an indication for laparoscopic hysterectomy. There are 2 concerns here: The patient may have a small pelvis, and there may be significant scar tissue and difficulty gaining access to the anterior cul-de-sac, as a result of repeated dissection between the lower uterine segment and the bladder. Several tricks may be useful:
Examine the patient under anesthesia to ensure that the fundus is not stuck to the anterior abdominal wall. This can occur if the peritoneum was not closed during the last cesarean section.
Empty the bladder before beginning the hysterectomy, and inject indigo carmine dye intravenously with the induction of anesthesia.
Use careful sharp dissection between the bladder and lower uterine segment using fine Metzenbaum scissors, with the tips pointed toward the uterus. Dissect only as far as you can easily see.
Secure the uterosacral, cardinal, and broad ligaments, if necessary, before pursuing entry into the anterior cul-de-sac. It is not essential to gain anterior access before taking these pedicles. The additional mobility and descensus enable safe sharp dissection.
If pedicles have been secured up to the fundus, and the anterior cul-de-sac remains difficult to assess, flip the fundus through the posterior cul-de-sac and reach your finger or an instrument around the top of the fundus to identify the peritoneum anteriorly, then incise it under direct vision.
VAGINAL HYSTERECTOMY CHALLENGE 4: Previous abdominal/pelvic surgery
This history is another often-cited rationale for avoiding the vaginal approach. In reality, the adhesions created from prior surgery tend to arise between the anterior abdominal wall and the omentum or small bowel. This situation makes laparoscopic or open abdominal entry riskier than vaginal peritoneal access through the cul-de-sac.
Two possible exceptions: a patient who has had surgery for deeply infiltrating endometriosis in the cul-de-sac or a woman who has undergone myomectomies with posterior incisions. These patients may have dense scarring in the cul-de-sac, which would preclude a vaginal approach. Whatever the surgical route, appropriate bowel preparation is necessary to permit simple closure of any intestinal injury at the time of hysterectomy. Why not begin vaginally if the exam under anesthesia demonstrates an accessible and reasonably free cul-de-sac?