Vaginal Hysterectomy: How to Accomplish
Successful opening of the anterior and posterior pouches
Applying clamps always medial to the previous pedicle and as close to the specimen as possible
Bisection and morcellation of the specimen after ligation of uterine arteries to facilitate descent and to obtain more space
Intermittent emptying of bladder to keep the bladder empty and to facilitate descent; this also helps in the prompt recognition of bladder injury which may have occurred
The challenges that a gynecologist faces during vaginal hysterectomy are inability to open the pouches especially where there has been a previous caesarean delivery and inability to proceed further due to lack of descent. Other problem that one encounters during vaginal hysterectomy is bleeding due to slippage of clamps or sutures. It is better to complete the surgery by laparotomy than compromise with patient safety; bladder and ureteric injuries and internal bleeding requiring exploration later are better avoided. However, there are certain techniques by which a vaginal hysterectomy and even salpingo-oophorectomy by the vaginal route can be successfully accomplished even in difficult cases.