Techniques for completing Colpotomy without Uterine Manipulator in a Total Laparoscopic Hysterectomy

Approach for Anterior Colpotomy

This approach can be used when the vaginal manipulator cannot be applied in cases such as the narrow vagina, cervical stenosis, or even in virgin women. Often in these situations, vaginal access is still possible using simple narrow instruments only, such as sponge forceps.

The surgeon can delineate the anterior fornix by applying a “swab on a stick,” i.e., a sponge forceps with a 4 × 4 gauze held folded at its tip, in the anterior vaginal fornix, and pushing the fornix cephalad and ventrally. This maneuver makes the apex of the anterior vaginal wall bulge out and can be seen clearly (Fig. 1A). This step can also be used to dissect the bladder against the anterior vaginal wall and separate the cervix anteriorly from the vagina by using the monopolar hook (Fig. 1B).

Approach for Posterior Colpotomy

Posterior colpotomy appears a good option to start with when separating the cervix from the vaginal wall. Some centers recommend it as the better method of starting colpotomy. But, after opening the posterior fornix, it is difficult to grasp the cervix and pull it outside the incision. The insertion of the uterosacral ligament at the posterolateral aspect of the cervix prevents its eversion backward. Thus, if the surgeon had decided to start with posterior colpotomy, he should divide the uterosacral ligament bilaterally before attempting to open the posterior fornix. This will help in everting the posterior lip of the cervix outside the posterior colpotomy incision easily. The posterior fornix can again be delineated using sponge forceps and 4 × 4 cm gauze (swab on stick), as described in the anterior colpotomy approach (Fig. 2).

Left Uterosacral Approach

This approach has advantages over the other suggested approaches for many reasons. The uterosacral ligament is a clear anatomical landmark. It is a taut structure and does not need vaginal aid for identification. The ureters are relatively far from the incision site, especially while considering lateral thermal damage. We suggest the left side uterosacral ligament because the surgeon usually stands on the left side, which makes it more ergonomical and easily accessible. In addition, the rectum physiologically deviates slightly to the right side.

To identify the uterosacral ligament clearly, the surgeon can push the cervix anteriorly (ventrally) by pushing the posterior aspect of the isthmus forward. This step will open up the pouch of Douglas and facilitate the division of the left uterosacral ligament. Then, the ligament is electrocoagulated with an energy device, at its insertion to the uterus and cut. Continuing to cut in the same plane toward the vagina will open the vaginal wall at the level of the cervicovaginal junction. Then, the incision is extended posteriorly and anteriorly. The cervix can then be grasped and pulled upward (cephalad) using a single tooth forceps so that the surgeon can coagulate and cut along the cervical edge to complete the colpotomy (Fig. 3).

Cardinal Ligament Approach

Opening the lateral fornix after cutting the cardinal ligament is considered a feasible approach and can be performed without a vaginal assistant. However, the surgeon must keep in mind the proximity of the ureter and the risk to it of both a direct injury and a thermal damage. Thus, the surgeon must identify the ureter’s course before coagulating and cutting the cardinal ligament. The division of the cardinal ligament should be as perpendicular as possible to its insertion to the cervix, keeping in mind that the bladder has already been dissected and pushed below the cutting level. After dividing the ligament, the vaginal wall is opened by cutting at the insertion of the cardinal ligament obliquely. Then, the colpotomy is extended, and the vaginal wall is cut at the level of the cervicovaginal junction.