This is part of the Gynsurgery guidelines used in an educational setting for residents in Ob-Gyn.


  1. Uterovaginal Prolapse with pressure symptoms
  2. Dysfunctional Uterine Bleeding/Abnormal Uterine Bleeding (mechanical/anatomic)
  3. Fibroids (symptomatic)
  4. Persistent dysplasia/CIS
  5. Atypical Endometrial Hyperplasia
  6. Failed permanent sterilization
  7. Dysmenorrhea and central pelvic pain or CPP with previous negative laproscopy
  8. Endometriosis
  9. Grade 1 endometrial adenocarcinoma


  1. Inability to perform hysterectomy through chosen incision
  2. Bleeding – Intraoperative, postoperative
  3. Bladder injury
    1. Cystotomy with urine leakage
    2. Fistula formation – vescovaginal, vesicoabdominal
  4. Ureteral injury
    1. Obstruction
    2. Ureteral leakage vaginally, abdominally
    3. Ureterovaginal fistula, ureteroabdominal fistula
  5. Bowel injury
  6. Postoperative ileus
  7. Pelvic/pelvic cuff infection
  8. Nerve injury
  9. Burn injuries
  10. Post procedure vaginal vault prolapse
  11. Low back pain
  12. Post operative persistent pain

Complication Prevention

  1. Inability to perform hysterectomy through chosen incision
    1. Prevention - Careful planning and physical exam
    2. Make sure of uterine width and ovarian size
    3. Check interspinous distance
    4. Check umbilical to symphysis distance
    5. Check uterine size for height above symphysis
    6. Choose incision type
      1. Midline for chance of malignancy 5% or more or uterus at or above umbilicus
      2. Maylard for wide uterus or midline if previous midline incision
      3. Pfannenstiel if previous pfannenstiel, midline if previous midline
    7. Be familiar with myomectomy, subtotal hysterectomy, coring, bivalving , and morcellation
  2. Bleeding
    1. Intraoperative bleeding (average EBL 150-300cc)
      1. Discontinue ASA, Plavix and other anti-clotting meds prior to surgery
      2. Identify bleeding and cauterize or ligate
      3. Avoid sharp dissection near large vessels
      4. Avoid excessive blunt dissection
      5. Tie square knots - 5 throws at least
    2. Recovery room bleeding
      1. To prevent from cuff:
        1. Run and lock anterior and posterior cuff
        2. Identify and rectify any bleeding before closure
      2. To prevent from ovarian or uterine vessels:
        1. If single ligature is used it should be a suture ligature and no tag (hemostat) is used to put tension on suture.
        2. If tagged suture is used, double ligate, with first tie being an anchor stitch, then second a free tie behind suture ligature which can be tagged.
        3. Avoid unnecessary tension on first throw of suture when performing second throw during knot tying
  3. Bladder Injury
    1. Visualize anterior bladder edge upon peritoneal entry by transillumination.
    2. Incise anterior peritoneum from round ligament, to just below the uterovesical reflection, to opposite round ligament
    3. Identify pubovesicocervical fascia either by sharp or blunt dissection at the vesicouterine fold, then proceed to blunt dissection in midline of cervix to move bladder off of anterior cervix to about 1 cm below edge of the palpated cervix
    4. If there is difficulty identifying the correct plane between the bladder and the cervix, incise into the cervical fascia and place clamps intrafascially to avoid bladder or ureters
  4. Ureter Injury
    1. At the level of the ovarian vessels
      1. Identify the ureter on the posterior leaf of the broad ligament
      2. Maintain medial and anterior traction of the ovary when clamping the IP ligament
    2. At the level of passing under the uterine artery 1.2 cm from the cervix
      1. Roll curved clamps off of the cervix
      2. Suture ligate immediately underneath the metal clamps
      3. Elevate the uterus constantly during the placement of clamps allowing ureters to fall away
      4. Dissect posterior parietal peritoneum off of cervix to the uterosacral ligaments
    3. At the level or ureter entry into the bladder
      1. Use curved clamps at the vaginal angles
      2. Bladder should be dissected off the vagina for about one cm.
      3. Suture ligate immediately underneath the metal clamps
      4. Diagnosis of injury to prevent later fistulae
      5. Indigo carmine and cystoscopy
  5. Bowel Injury
    1. Pack bowel away from the surgical field as much as possible
    2. During adhesiolysis sharply or with cautery:
      1. Identify bowel wall closest to the adhesion where lysis will occur
      2. Expose adequate distance between bowel wall adhesion (2-3 cm if cautery being used
      3. If using cautery, use cutting current for lysis (coag current will draw bowel into field)
  6. Ileus
    1. Use moist laparotomy packs
    2. Minimize the amount of packing used and handling of the bowel
    3. Avoid patient controlled analgesia with opiate derivatives as much as possible.
    4. avoid ureter/bladder injury
  7. Infection
    1. Screen and treat patients for BV (prevent vaginal cuff infection)
    2. Prophylactic antibiotics at least 30 min prior to procedure
    3. Avoid irrigation with open cuff
    4. Avoid placing suction tip in the vagina
    5. Avoid vaginal contents from entering abdominal cavity
    6. Avoid hematoma formation at the cuff
      1. Compartmentalize any venous oozing retroperitoneal space by closing parietal peritoneum
      2. Consider JP drain into the vagina
  8. Nerve Injury - Femoral nerve
    1. Retractor placement - check to be sure lateral blades are not impinging the femoral nerve
    2. Thin patients may need packing between the blade and tissue
    3. Maylard incisions are at higher risk
  9. Burn Injury - See bowel cautery injury
    1. Confirm that patient is grounded
    2. When cauterizing using metal instruments check for any unintended skin contact
  10. Vaginal vault prolapse post procedure
    1. Check cuff mobility
      1. If hypermobile, perform culdoplasty/colposuspension
      2. Close the anterior to posterior vaginal cuff
  11. Low Back Pain
    1. Avoid hyperflexion of femurs in lithotomy position.
  12. Persistent postoperative pain
    1. Dyspareunia
      1. Ensure adnexae are away from the cuff prior to abdominal closure
    2. Other pain
      1. Assess pain threshold preoperatively to know if high, normal or low
    3. Avoid adhesions - adhesions form at devascularized tissue
      1. Avoid excessive use of coag cautery
      2. Avoid excessive use of suture

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