(6) The vaginal incision is carried around the cervix; the posterior wall flaps
are grasped with Allis forceps. The cul-de-sac peritoneum is opened with a knife. A
suction set and small laparotomy packs may be used. The peritoneal edges are
sutured to the posterior wall with silk or chromic traction sutures swaged to 1/2- circle,
taper-point needles secured on Crile-Wood needle holders.
(7) The uterosacral ligaments containing blood vessels are doubly clamped,
ligated, and cut. The ends of the ligatures are left long and tagged with a clamp.
(8) The uterus is drawn downward and the bladder held away with retractors
and moist small laparotomy packs.
(9) If the bladder is entered, the opening is closed with two layers of
interrupted chromic gut number 4-0 sutures swaged to 1/2- circle, taper-point needles
secured to long needle holders. The vesicouterine reflection is sutured to the anterior
vaginal wall by means of traction sutures and free ends held in a clamp.
(10) The cardinal ligament on each side is doubly clamped, cut, and doubly
ligated. The uterine arteries are doubly clamped, cut, and ligated.
(11) The fundus is delivered through the anterior route with the aid of a
(12) When the ovaries are to be left, a Kocher clamp is placed from below
and two from above to grasp the pedicles, which are then cut and doubly ligated on both
sides; the uterus is removed.
(13) The peritoneum between the rectum and vagina is approximated with a
continuous suture of chromic gut number 2-0. The retroperitoneal obliteration of the
cul-de-sac is done by sutures that pass from the vaginal wall through the
infundibulopelvic ligament and round ligament, through the cardinal ligament, and out
through the vaginal wall. The suture is tied on the vaginal aspect of the new vault. The
uterosacral ligament on each side is sutured in the midline. The round, cardinal, and
ureterosacral ligaments may be individually approximated for additional support.
(14) An existing rectocele and the perineum are repaired, as described for
vaginal plastic repair. In the presence of prolapse, reconstruction of the pelvic floor is
(15) An indwelling system of urinary drainage is established; the vagina may
be packed; and a perineal pad is applied.