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


  1. Uterovaginal Prolapse
  2. Dysfunctional uterine bleeding/Abnormal uterine bleeding(mechanical/anatomic)
  3. Fibroids
  4. Persistent dysplasia/CIS
  5. Atypical Endometrial Hyperplasia
  6. Failed permanent sterilization
  7. Dysmenorrhea and central pelvic pain or CPP with previous negative laparoscopy
  8. Grade 1 endometrial adenocarcinoma in obese patients

Criteria for successful procedure

  1. Decensus (Grade 1 or greater)
  2. Uterine size (operator dependent)
  3. Parity or adequate pelvic working space based on an appropriate distance between ischial tuberosities (operator dependent) and sufficient infrapubic arch angle
  4. No previous CS or other pelvic surgery (scarring may require conversion to LAVH)


  1. Bladder injury
    1. Cystotomy with urine leakage
    2. Fistula formation – vescovaginal, vesicoabdominal
  2. Ureteral injury
    1. Obstruction
    2. Ureteral leakage vaginally, abdominally
    3. Ureterovaginal fistula, ureteroabdominal fistula
  3. Postoperative bleeding
    1. Generalized
    2. Ovarian vessels
    3. Cuff
  4. Need for abdominal conversion
  5. Post procedure vaginal vault prolapse
  6. Pelvic cuff abscess
  7. Bowel injury
  8. Nerve injury
  9. Burn injuries

Complication Prevention

  1. Bladder injury
    1. Cystotomy entering anterior cul-de-sac
      1. Inject saline solution or pitressin/saline solution at junction of vagina and cervix to hydrodissect along the pubovesical cerivical fascia
      2. Keep field clean to aid in clearly identifying pubovesical fascia when making anterior incision
      3. Dissect plane with blunt dissection (rather than sharp dissection)
      4. Dissect to above the internal os of the cervix
      5. Cut peritoneum below retractor and pick-up with scissors pointed toward cervix and away from the bladder
    2. Vesicovaginal fistula
      1. Recognize injury by leaving urine in bladder to identify damage
      2. Instill sterile milk or indigo carmine if unsure of damage
  2. Ureteral injury
    1. Maintain downward traction of cervix
    2. Roll clamps off of the cervix and uterine corpus
    3. Keep vaginal cuff sutures as superficial as possible
    4. Diagnose any injury using indigocarmine and cystoscopy
  3. Postoperative bleeding
    1. Generalized
      1. Discontinue ASA (5 days), Plavix (3 days) and other anti-clotting meds prior to surgery
    2. Ovarian vessels
      1. Double-ligate, with first tie being an anchor stitch, then a free tie
      2. Avoid unnecessary tension on first throw of suture (use surgeon's knot)
    3. Cuff
      1. Run and lock posterior cuff
      2. Identify bleeding before closure
      3. Run and lock cuff closure (as opposed to interrupted sutures)
  4. Abdominal conversion
    1. Make sure uterus is mobile
    2. Check bituberous distance to be >10 cm
    3. Check infrapubic arch to be >75 deg
    4. Check uterine size to be < 12 weeks gestation (or your preference)
    5. Be familiar with coring, bivalving morcellation techniques to reduce uterine mass
    6. Be familiar with inverting the uterus to gain exposure
  5. Post procedure vaginal vault prolapse
    1. Identify uterosacrals and incorporate the intact uterosacral ligaments into the vaginal cuff (uterosacral vault suspension, modified McCall’s culdoplasty, using Ethibond suture or other permanent suture)
  6. Pelvic cuff abscess
    1. Avoid using epinephrine injection (Pitressin preferable)
    2. Avoid use of cautery to incise vaginal mucosa/muscularis around cervix
    3. Good hemostasis of cuff
    4. Use prophylactic antibiotics, at least 30 minutes before incision
    5. Screen and treat patients for BV or consider repeating antibiotics (up to three doses) for affected or higher risk patients
  7. Bowel injury
    1. During EUA, check that posterior cuff is free from cul-de-sac endometriosis
    2. In posterior dissection, avoid being too posterior and angle Mayo scissors parallel to the cervix to avoid damaging sigmoid
    3. Use minilap packs to avoid small bowel injury (can tie sutures to blue string to aid in place entire pack in pelvis)
    4. Use Trendelenberg position
    5. Check for adhesions of bowel to fundus upon enteringNerve injury
  8. Nerve injury
    1. To prevent femoral nerve injury from tension to inguinal ligaments, use Allen’s (Yellow fin) stirrups
    2. Avoid candy cane stirrups
  9. Burn injury
    1. Avoid accidental electrocauterization of weighted speculum, retractors or hemostats

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