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
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
2nd Ligatures, Step ladder
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.
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 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.
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).
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.