Vaginal part of open or laparoscopic hysterectomy poses a challenging job to the Gynaecologist / Surgeon and assistants. It’s even more difficult when there is no associated uterocervical descent. All of us struggle in pulling the cervix, while ligating & dividing utero-sacral ligaments and uterine vessels. To overcome the problem, we have modified some of the existing instruments and innovated a few techniques for performing vaginal hysterectomy in an easy and better way.

Lateral Vaginal S-shaped Retractors
These retractors have been modified from Daever’s abdominal retractors and S-shaped retractors used for Total Extraperitoneal Hernia repair. Changes are made in the length and angulation of the instrument according to the curves of the body in lithotomy position. These instruments are available in 3 different sizes smaller, medium and larger one. The larger S-shaped retractor is being used to retract lateral vaginal walls for a much better field of view while ligating and dividing utero-sacral ligaments and uterine vessels.

Cat’s Paw cervix holder
This cervix holder has 3-4 sharp jaws (projections) which are approximated snugly on closing the instrument, thereby, providing a very firm grip. It is used to hold and pull cervix without slipping unlike Allis’s, Vulsellum forceps, while dividing utero-sacral ligaments.

Holding needle in forward oblique manner
If we hold the needle in forward oblique manner rather than at 900 (as shown in figure) it becomes easier to take bites from tissues at depth and less accessible areas. Moreover, the needle can be passed with movement at wrist joint only, without moving shoulder or elbow and pushing the assistants if we take the finger and thumb out of the rings of the needle holder.

Steps which are different during LAVH
• Using the “melting away effect” of harmonic scalpel in dessicating and dividing round and infundibulo-pelvic ligaments, uterine tubes and broad ligaments.
• Making posterior colpotomy during laparoscopy rather than through vaginal route.
• Injection of vasopressin (PitressinTM 20 units in 40 ml of saline) in paracervical tissue all around the cervix, makes the planes bloodless.
• Use of S-shaped lateral vaginal wall retractors and cat’s paw cervical holder for vaginal dissection.
• Holding the needle in forward oblique manner makes ligation and division of utero-sacrals and uterine vessels easier.
• Transfixing utero-sacral with vaginal vault and with each other, thus preventing vault prolapse.
• Check laparoscopy at the end to ensure proper hemostasis.