310 Obstetrics and Gynecology Board Review •••
❍ What is an intrafascial TAH, and what are the advantages of this technique?
An intrafascial hysterectomy is one in which the cervix is removed by placing the cardinal ligament clamps inside
the pubovesicocervical fascia. This is done by making a V-shaped incision in the pubovesicocervical fascia anterior
to the cervix just below the internal os. The fascia can then be reflected laterally. This is a safer technique since it
avoids most bladder and ureteral injuries. It is appropriate only with benign disease.
❍ What is the purpose of suspending the vaginal cuff after removing the uterus?
To avoid vaginal vault prolapse and enterocele formation later on.
❍ How is the vaginal cuff suspended after TAH?
The posterior vaginal cuff is sutured to the uterosacral ligaments. In a patient with a deep cul-de-sac, a posterior
cul-de-sac obliteration may also be performed using the Moschcowitz or Halban technique.
❍ At what point in abdominal hysterectomy do the most urinary tract injuries take place?
During removal of the cervix.
❍ In addition to careful surgical technique, what can be done to reduce the risk of undiagnosed urinary tract
injuries at the time of hysterectomy?
Intraoperative cystourethroscopy is a low-risk, simple procedure that can identify undiagnosed injury to the
urinary tract. Routine use of cystourethroscopy at the time of pelvic surgery is controversial, but should be
considered for procedures in which the risk of urinary tract injury is 1% to 2% or greater.
❍ When performing a supracervical hysterectomy, at what point is the uterus amputated from the cervix?
After ligation of the uterine vessels, the uterus is amputated just below the internal os.
❍ How is the cervical stump closed?
A V- or conical-shaped portion of the cervical stroma is removed to facilitate closure. The remaining endocervix
may be cored out or cauterized. Then the cervical stump is closed and suspended using the round ligaments.
The cervix may be cauterized transvaginally at the end of the case.
❍ What factors influence route and method of hysterectomy?
Vaginal/uterine size and shape, extent of extrauterine disease, need for concurrent procedures, hospital technology,
and an informed patients preference.
❍ What factors are important for a successful vaginal hysterectomy?
Adequate introitus, pubic arch > 90 °, uterine mobility (previous vaginal delivery or prolapse), and uterine size
≤ 12 weeks (280 g).
❍ What are relative contraindications for vaginal hysterectomy?
Prior cesarean delivery, nulliparity, and adnexal mass.
❍ What are absolute contraindications for vaginal hysterectomy?
Lack of descensus, extensive adhesions, and contracted pelvis.