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Comment and Controversy

Tip for difficult colpotomy at vaginal hysterectomy

December 2006 · Vol. 18, No. 12
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“Vaginal hysterectomy: 6 challenges, an arsenal of solutions,” by Barbara S. Levy, MD

Dr. Levy’s enjoyable article inspired me to offer this solution to another common challenge. Vaginal hysterectomy traditionally begins with an anterior colpotomy followed by a posterior one. When the latter is difficult, I instill 200 to 300 mL of sterile normal saline through the opening of the anterior colpotomy, which causes the posterior cul-de-sac to bulge. This swelling of Douglas’ cul-de-sac facilitates entry into the cavity, as the incision initiates the escape of instilled saline.

The technique is also useful for anterior and posterior colpotomies during laparoscopically assisted vaginal hysterectomy.

Reza Mohajer, MD
Los Angeles

Dr. Levy responds: I prefer to start with posterior colpotomy

I appreciate Dr. Mohajer’s technical trick! I’m sure some readers will find it useful.

In my procedures, I routinely start with the posterior colpotomy. I find that postponing the anterior colpotomy until the peritoneal fold is clearly visible helps me to perform vaginal hysterectomy safely for women with large myomas, especially in women with previous cesarean sections.

There is little doubt that each anatomical situation is unique and that Dr. Mohajer’s approach will be useful at times.

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