Case Description
- The patient was a 59 year-old woman with stage III uterine prolapse.
- A vaginal hysterectomy with vault closure, bilateral sacrospinous ligament suspension, anterior and posterior vaginal repairs, and perineorrhaphy was planned.
- The patient will be placed in the dorsal lithotomy position and general anesthesia administered. A Foley catheter will be inserted and a self-retaining retractor employed.
- A colpotomy will be performed to separate the uterus from the vagina. In prolapse surgery, this incision should be as distal as possible to preserve vaginal length.
- Care is taken throughout the procedure to protect the bladder, ureters and rectum from injury.
- Following the colpotomy, the anterior and posterior peritoneum will be incised providing entry into the vesicouterine space anteriorly and posterior cul de sac posteriorly.
- In cases where the peritoneum cannot be accessed due to cervical elongation, the uterosacral ligaments may be divided first, allowing descent of the peritoneum.
- Following division of the peritoneum and uterosacral ligaments, the cardinal ligaments, uterine vessels and broad ligament will be divided. The number of pedicle bites for these structures will depend on the size of the patient's uterus.
- For non-vascular pedicles, a Heaney stitch may be performed. A stitch will be placed at the tip of the clamp holding the pedicle, followed by a stitch through the centre of the pedicle, the two ends tied and tagged with a Kocher clamp for later use.
- Following the hysterectomy, there are several options for vault suspension and closure. Depending on the patient's condition, a bilateral salpingectomy (BS) or bilateral salpingo-oophorectomy (BSO) may be performed.
- A cystoscopy will be performed at the end of the hysterectomy to inspect the bladder for injury and ensure ureteric function.