Vaginal Hysterectomy, Uterosacral Ligament Suspension, Anterior Repair, and Perineorrhaphy

1. Introduction

2. Surgical Approach

1. Expose Cervix
2. Inject Local Anesthetic

3. Gain Peritoneal Access

1. Circumferential Incision Around Cervix
2. Gain Peritoneal Access Posteriorly, Protecting Rectum
3. Gain Peritoneal Access Anteriorly, Protecting Bladder

4. Hysterectomy

1. Divide along Broad Ligament
2. Divide Utero-Ovarian Ligament

5. Isolate and Tag Uterosacral Ligaments

6. Cystoscopy

7. Anterior Repair

1. Expose Anterior Wall
2. Inject Local Anesthetic
3. Incision
4. Dissection to Isolate Cystocele
5. Reduce Bulge
6. Review Repair
7. Excise Redundant Tissue

8. Closure for Anterior Repair and Vaginal Cuff Closure

1. Anterior Repair Closure
2. Place Uterosacral Ligament Stitches Through Vaginal Cuff
3. Finish Closure of Anterior Wall and Vaginal Cuff
4. Tie Down Apical Suspension Sutures

9. Repeat Cystoscopy

10. Cut Uterosacral Ligament Stitches

11. Perineorrhaphy

1. Expose Posterior Wall and Examine Defect
2. Inject Local Anesthetic
3. Diamond-Shaped Incision
4. Excise Epithelium
5. Tag Apex
6. Rebuild Perineal Body

12. Rectal Exam

13. Post-op Remarks