Supracervical Amputation: Preparation and Transection
Any intervention begins with a thorough inspection of the pelvic and abdominal organs. Afterward, a specialized Cohen uterine probe is inserted into the uterine cavity.
The main surgical course includes the following steps:
- Transection of the ligamentous apparatus and tubes. On both sides, the round ligaments of the uterus, fallopian tubes, and ovarian proper ligaments are transected sequentially. The surgeon uses a bipolar coagulator combined with scissors, or a monopolar coagulator for dissection with simultaneous hemostasis.
- Management of the peritoneum. The vesicouterine peritoneal fold is opened and separated downwards as a single unit along with the urinary bladder.
- Opening of the broad ligament. The posterior leaflet of the broad ligament of the uterus is opened close to the uterine margin, and the incision is directed toward the uterosacral ligament.
- Vascular management. Uterine vessels are coagulated (using mono- or bipolar methods) and transected, or ligated and tied with Vicryl sutures.
- Transection. The uterine body is transected from the cervix strictly at the level of the internal os using monopolar coagulation.
Tissue Extraction and Completion of Amputation
After transecting the uterine body, it must be extracted from the abdominal cavity. For this purpose, a morcellator (a special device for tissue fragmentation) is used, or extraction is performed through a created colpotomy opening.
If colpotomy was used, the vaginal wall around the opening is carefully sutured. This step can be performed either laparoscopically or directly through the vagina. If necessary, adnexa or fallopian tubes are removed using standard techniques.
The surgery concludes with mandatory sanitation of the abdominal cavity and additional bleeding control. The golden rule of this intervention: peritonization of the uterine stump is not performed.
Hysterectomy: Specifics of Cervical Management
The initial stage of hysterectomy (up to the point of transecting the uterine body from the vaginal fornices) is performed exactly the same as in supracervical amputation. However, this is followed by the most technically critical step — preparation for cervical transection.
To safely perform this step, the use of a Clermont uterine manipulator is mandatory. The probe is inserted into the uterine cavity strictly through the cervical canal. Tissue separation here is deeper: the urinary bladder and the posterior leaflet of the broad ligament are separated below the level of the uterine cervix.
The transection of the cervix itself from the vaginal fornices is performed with a monopolar coagulator, ensuring simultaneous hemostasis. Extraction of the completely transected uterus is carried out through the vagina.
Sealing, Hemostasis, and Vaginal Closure
To successfully complete the hysterectomy, sealing of the abdominal cavity is required. For this purpose, a sterile medical rubber glove containing a gauze sponge inside is inserted into the vagina.
Special attention is paid to meticulous hemostasis control:
- An isotonic sodium chloride solution is introduced into the lesser pelvis cavity.
- The fluid is aspirated, and the process is repeated until it is completely clear.
- The introduced liquid medium allows for clear visualization of even the smallest bleeding vessels.
- Identified sources of bleeding undergo targeted coagulation with dissector blades.
After final cessation of bleeding, vaginal closure is performed. The wall is sutured from the abdominal cavity side using an extracorporeal suture technique. The final step of the surgery is the mandatory suturing of the aponeurosis after morcellation, even if the opening size is only 15–20 mm.
Briefly: answers to topical questions
What are the main types of plastic surgeries on the vagina (colporrhaphy)?
The main types of plastic surgeries on the vagina include interventions on the anterior and posterior walls, as well as median techniques.
- Anterior colporrhaphy (colporrhaphia anterior) is a plastic surgery on the anterior vaginal wall.
- Colpoperineolevatoroplasty is the excision of excess tissue from the posterior vaginal wall and restoration of the muscular-fascial structure of the perineum.
- Median colporrhaphy of Le Fort-Neugebauer (Le Fort / Neugebauer) belongs to obliterative surgeries aimed at closing the vaginal lumen.
Which pelvic floor muscles are sutured during posterior colporrhaphy (colpoperineorrhaphy)?
During posterior vaginal wall and perineal repair (colpoperineolevatoroplasty), the muscles forming the pelvic floor are sutured.
- Levators (m. levator ani) are the muscles that elevate the anus. Their isolation and suturing together is a key step of the surgery aimed at strengthening the pelvic floor and restoring the muscular-fascial structure of the perineum.
What are the main indications for anterior colporrhaphy?
The main indications for anterior colporrhaphy are pathological conditions associated with anterior pelvic floor prolapse.
- Desensus of the anterior vaginal wall is the displacement of the vaginal tube tissues.
- Cystocele (cystocele) is a urinary bladder diverticulum accompanying vaginal wall prolapse.
The surgery is also indicated as part of comprehensive surgical treatment (e.g., in the Manchester procedure) for uterine prolapse and incomplete inversion.
Which blood vessels are ligated or coagulated during hysterectomy without adnexa?
During hysterectomy without adnexa, the main uterine blood vessels are ligated or coagulated.
- Uterine artery (a. uterina) is clamped and transected at the level of the internal os of the uterine cervix.
- Uterine veins (v. uterina) are veins accompanying the artery, which are grasped with heavy surgical clamps perpendicularly to the uterine margin along with it.
What is the difference between colporrhaphy and colpopexy/colpoclisis?
Colporrhaphy is a plastic surgery on the vaginal wall; anterior colporrhaphy is used for anterior vaginal wall prolapse and cystocele. Colpoclisis is an obliterative surgery aimed at closing the vaginal lumen; it is usually performed in elderly patients who are not sexually active.
The rule for visualizing vessels during hysterectomy: "Pour saline — aspirate until clear — target coagulate with dissector." The fluid acts as a contrasting background for the tiniest bleeding sources.
Class and exam questions
Is reperitonealization of the stump performed during supracervical amputation?
No, according to the surgical protocol, peritonization of the uterine stump is not performed at the final stage.
Which instrument is critical for amputating the cervix during a hysterectomy?
At this technically critical stage, it is necessary to use the Clermont uterine manipulator, inserting the probe through the cervical canal.
How is the vagina sutured following total hysterectomy?
Vaginal closure is performed from the abdominal cavity side using an extracorporeal suture technique.
Is it necessary to suture the aponeurosis if the morcellator incision is small?
Yes, suturing the aponeurosis is a mandatory concluding step even for small opening sizes (15–20 mm).
What else to study on this topic
- Technique of working with the Clermont uterine manipulator and Cohen probe.
- Features of using bipolar and monopolar coagulation on the ligamentous apparatus.
- Methodology of placing an extracorporeal suture during vaginal closure.
- Rules for performing morcellation and tissue extraction through a colpotomy opening.
- Algorithm for targeted vessel coagulation with dissector blades in a liquid medium.
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