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Setelah pasien diposisikan, speculum diletakkan pada vagina posterior dan right-angle retractor
diletakkan pada anterior dari serviks sementara bibir anterior dan posterior serviks dijepit dengan
tenakulum. Beberapa dokter menginjeksikan vasopressin (10-20 U dalam 50 mL salin) atau
lidokain 0.5% ke jaringan servikal, paracervikal, dan submukosal untuk membantu
mengidentifikasi bidang jaringan dan mengurangi perdarahan.
Vaginal incision and opening of posterior peritoneum
The initial vaginal incision is made circumferentially, beginning at the level of the vaginal rugae
through the full thickness of the vagina, just below the bladder reflectionnot on the cervix (see
the image below). If an incidental cystotomy occurs, the vaginal hysterectomy should be
completed before the bladder is repaired. The vaginal epithelium is dissected bluntly or sharply
to the underlying tissue with an open sponge over the index finger and Mayo scissors.
The posterior peritoneum is then identified where rugae are not present and where the uterosacral
ligaments join the cervix. The peritoneum is grasped with tissue forceps and incised with Mayo
scissors in a generous bite (see the image below), and a Steiner-Anvard weighted speculum is
inserted into the posterior cul-de-sac.
If the peritoneal reflection is not readily identified, one can wait to make the entry, as long as the
bladder has been safely advanced cranially. A Deaver or Heaney retractor is placed in the midline
to keep the bladder out of the operative field. Blunt or sharp advancement of the bladder should
continue before each clamp placement until the vesicovaginal space is entered. Once this space is
entered, the Heaney or Deaver retractor is placed into the peritoneal cavity.
Division and ligation of cardinal ligaments
Next, the cardinal ligaments are identified, clamped, cut, and suture-ligated in a manner similar
to that previously described for the uterosacral ligaments. Alternatively, newer
electrocauterization devices (eg, LigaSure; Covidien, Boulder, CO) can be used in vessels up to 7
mm in diameter to accomplish the same task.
The uterine vessels are then clamped in such a way as to incorporate the anterior and posterior
leaves of the visceral peritoneum (an important step). A single-clamp technique reduces the risk
of ureteral injury (see the image below).
Intramyometrial coring
technique.
Uterine bisection is performed by cutting the cervix and the uterine fundus in the sagittal plane.
This technique is often combined with myomectomy or wedge morcellation to reduce the bulk of
the uterine halves so that the tubo-ovarian vessels can be ligated.[11]
Completion and closure
A sponge-stick or laparotomy pad is placed into the peritoneal cavity to allow the surgeon to
visualize each of the pedicles and confirm that hemostasis is adequate. If any bleeding points are
identified, a suture is used to ligate the bleeding vessel under direct vision. The pelvic
peritoneum is left open.
Finally, the vaginal epithelium is reapproximated either vertically or horizontally with either a
continuous suture or a series of interrupted sutures. These sutures are placed through the full
thickness of the vaginal epithelium, with care taken to ensure that the bladder is not entered.
Culdoplasty for prevention of enterocele
A culdoplasty is generally recommended to reduce the risk of subsequent enterocele formation
and potential vaginal vault prolapse. The 2 methods commonly described are the Moschcowitz
repair (ie, closing the cul-de-sac and bringing the uterosacral-cardinal complex together in the
midline) and the McCall culdoplasty (ie, obliterating the cul-de-sac, plicating the uterosacralcardinal complex, and elevating any redundant posterior vaginal apex). There is some evidence
to suggest that the McCall procedure is superior in preventing enterocele.[12]
In this procedure, an absorbable suture is placed through the full thickness of the posterior
vaginal wall at the apex of what will be the vaginal vault. This suture is passed through the left
uterosacral ligament pedicle, the posterior peritoneum, and the right uterosacral ligament and
completed by being passed from the inside to the outside at the same point where it was begun.
The suture is then tied, thus approximating the uterosacral ligaments and the posterior
peritoneum. It is not necessary to use a vaginal pack or leave a bladder catheter in place.
Complications of Procedure
The primary intraoperative complications are visceral injury and hemorrhage. Reported rates of
hemorrhage range from 1.4% to 2.6%, whereas reported rates of ureteral and bladder injury are
0.88% and 1.76%, respectively.[11]
The most common postoperative complication is pelvic infection. Febrile morbidity occurs in
approximately 15% of women who undergo vaginal hysterectomy and can be reduced by means
of prophylactic antibiotics. Infections after vaginal hysterectomy include vaginal cuff cellulitis,
pelvic cellulitis, and pelvic abscess. These infections occur in approximately 4% of women.[13]
Diagnosis banding