ABSTRACT
The vaginal route is the preferred approach for benign hysterectomy. The main stumbling blocks for many surgeons in choosing the vaginal route include challenges with exposure, entry into the anterior cul-de-sac, hemostasis, avoidance of ureteral and bladder injury, and removal of the large uterus. In addition to these intrinsic challenges, a contributing factor to the declining rates of vaginal hysterectomies may be the rising adoption of laparoscopic and robotic approaches to hysterectomy. While minimally invasive approaches to hysterectomy have increased overall, rates of vaginal hysterectomy have remained stable or slightly decreased. With more stringent work-hour restrictions, exposure and training during residency are limited further. Moreover, training continues to decline with the gradual attrition of mentors with expertise in vaginal surgery. The chapter describes the fundamental steps used to perform vaginal hysterectomy, highlighting different techniques and instrumentation that can help overcome common technical challenges. The incorporation of advanced energy-based surgical devices can facilitate both vaginal hysterectomy and adnexectomy.
