The Natural Orifice Surgery: Vaginal Hysterectomy

Both Amy and Mark stress the critical importance of selecting a surgical approach that aligns with a patient's medical history and anatomical considerations. Amy asserts that a patient is a suitable candidate for a vaginal hysterectomy when they possess a tall and mobile uterus, with ample vaginal space, and a pelvic outlet of sufficient width. Furthermore, she highlights that patients with a cervix located within 6 cm from the hymenal remnant are good candidates for vaginal hysterectomies.

The physicians delve into the topics of competency and confidence within the operating room. They agree that the volume of surgeries, repeated practice, pattern recognition, and experience in managing complications are pivotal factors contributing to a surgeon's growing competence with each case. Both doctors concur that it typically takes approximately three to five years to achieve confidence and a reduction in anxiety levels regarding surgical cases.

Amy proceeds to describe each step of a vaginal hysterectomy and shares her preferred practices in the operating room. To ensure patient comfort and safety, she positions her patients in the dorsal lithotomy position, taking special care to avoid exerting pressure on the peroneal and femoral nerves. While providing sacral support, she positions the remainder of the perineum as close to the edge of the table as possible to maximize vaginal access. Amy initiates the procedure with a posterior colpotomy using a 10-blade after administering lidocaine. Gradually, she progresses anteriorly, retracting the vaginal epithelium until the peritoneal folds become visible. She tags the uterosacral ligaments and proceeds to access the pelvis anteriorly, paying careful attention to avoid injuring the ureters. She systematically advances to the utero-ovarian ligament and artery, concluding by addressing the fallopian tube and ovary. Amy emphasizes her preference for two-handed knotting in all vaginal cases to achieve optimal tension and mentions her infrequent use of energy devices.

Finally, Mark and Amy discuss the evolution of training within the operating room over the years, acknowledging the changing landscape due to advancements in technology and varying case volumes. They underscore the significance of mastering technical skills outside of the operating room, which enables trainees to dedicate the necessary time to enhancing their operative abilities.