The Technique of Vaginal Hysterectomy. 
BY 
GYNECOLOGIST TO ST. FRANCIS’ HOSPITAL, NEW YORK ; PROFESSOR OF DISEASES OF 
WOMEN AT THE NEW YORK POST-GRADUATE MEDICAL SCHOOL; CONSULTING 
GYNECOLOGIST TO ST. JOHN’S RIVERSIDE HOSPITAL, YONKERS, NEW YORK. 
GEORGE M. EDEBOHLS, A.M., M.D., 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
January, 1895. Extracted from The American Journal of the Medical Sciences, January, 1895. 
THE TECHNIQUE OF VAGINAL HYSTERECTOMY. 
GYNECOLOGIST TO ST. FRANCIS’ HOSPITAL, NEW YORK ; PROFESSOR OF DISEASES OF WOMEN AT 
THE NEW YORK POST-GRADUATE MEDICAL SCHOOL; CONSULTING GYNECOLOGIST TO 
ST. JOHN’S RIVERSIDE HOSPITAL, YONKERS, NEW YORK. 
George M. Edebohls, A.M., M.D., 
There is a growing tendency among gynecologists at the present time 
to attack by way of the vagina pathological conditions of the female 
pelvic organs formerly approached by coeliotomy. The chief arguments 
advanced in favor of the new departure are : the lesser shock of the 
vaginal operation, the absence of an abdominal cicatrix, and the avoid- 
ance of a possible hernia. The principal disadvantages of the vaginal 
operation lie in uncertainties of diagnosis previous to operation and in 
the greater difficulties of the operation itself. The uncertainties of 
diagnosis we can scarcely hope ever to entirely overcome. In many, 
though not in all, cases of uncertainty of diagnosis prior to operation, 
the diagnosis may be made after incision of the pouch of Douglas with 
practically equal facility as after opening the abdomen above the pubis. 
The technical difficulties of the vaginal operation will probably become 
less as the operation is more frequently practised and as we become more 
familiar with one or the other or all of the various techniques. 
Those who now perform coeliotomies for various purposes so succes- 
fully have attained their present expertness in the school of experience. 
Just so it is and will be with vaginal hysterectomy. By the vaginal 
operation, as the term is here used, is not meant simple incision or punc- 
ture, with or without drainage, or aspiration of pathological accumula- 
tions in the pelvis. The term is applied in bringing the vaginal opera- 
tion in competition with the suprapubic operation in the performance of 
oophorectomy, salpingectomy, and hysterectomy, singly or in any given 
combination. 
This paper deals with the technique of vaginal hysterectomy with 
and without added salpingectomy, oophorectomy, or salpingo-oophorec- 
tomy. Vaginal hysterectomy will first be considered by itself, to be 
followed by a few remarks upon the added procedures. 
The methods of vaginal hysterectomy are three in number: 
1. Serial ligation of the broad ligaments. 
2. The clamp operation. 
3. Enucleation, with ligation of bleeding vessels only. 
Each of the three methods may be performed with or without mor- 2 
EDEBOHLS: VAGINAL HYSTERECTOMY. 
cellement. The general rule should be to remove the uterus entire, 
whenever its size permits of its delivery as a whole, through the vagina. 
Morcellement under these circumstances, except in cases of malignnt 
disease of the cervix, is to be considered an inferior procedure ; it comes 
into play only in cases in which the uterus is too large to be delivered 
in one piece through the vagina. The writer has had occasion to re- 
move the uterus through the vagina for probably every indication on 
which the operation has been done, and has had personal experience 
with each of the various methods of vaginal hysterectomy. 
The following descriptions of the various methods is based upon this 
personal experience: Vaginal hysterectomy by whatever method, and 
for whatever purpose, is best practised with the patient in the lithotomy 
position. The vagina must, of course, first be cleansed and disinfected 
as thoroughly as possible. The writer employs for this purpose scrub- 
bing with mollin containing 10 per cent, of creolin, followed by subli- 
mate douches. A perineal retractor is next inserted. The writer makes 
use of the speculum bearing his name. The metal-weighted speculum 
of the French school and Simon’s speculum answer the purpose equally 
well. The latter has the disadvantage of requring an assistant to hold 
it. Lateral retractors are a necessity; the anterior retractor I have 
thus far always been able to dispense with. An electric forehead-light 
will be found very useful in illuminating the depths of the pelvis. Until 
the peritoneum is opened irrigation is used to remove blood and debris 
and keep clear the operative field. After the peritoneum is opened, 
mopping with sterilized gauze, either in the form of serviettes or sponges, 
is employed. If the cavity of the uterus is known or suspected to con- 
tain pathogenic germs the cervix is dilated and the uterine cavity thor- 
oughly washed with a strong (1: 2000) sublimate solution. It is then 
packed with antiseptic, iodoform or sublimate, gauze. 
Cases of malignant disease of the cervix which have progressed to 
ulceration require circumcision and removal of the entire broken-down 
mass, after which the instruments thus far used are discarded. The 
vagina is again washed, disinfected, and the hysterectomy completed 
with safely sterilized instruments and redisinfected hands. After asepsis 
of the vagina and uterus have thus been secured, the first step in the 
operation, except in cases in which the uterus is removed for malignant 
disease, should consist of an exploratory incision of Douglas’ sac. This 
incision is made for the purpose of either establishing or confirming the 
diagnosis. It is only dispensed with in cases in which Douglas’ sac is so 
obliterated by adhesions that the latter cannot be safely separated in 
their entirety at this stage of the procedure. The next step of the 
operation, by whatever method attempted, is circumcision of the cervix. 
Except in cases of malignant disease this circumcision should be made 
as near as practicable to the lower end of the cervix. Hemorrhage from EDEBOHLS: VAGINAL HYSTERECTOMY. 
3 
the vaginal arteries is thus reduced to a minimum. The circumscrib- 
ing incision must be carried low enough, at least, to avoid the bladder 
anteriorly. Posteriorly it should be continuous with the incision into 
Douglas’ sac. The incision is carried clean through the mucous membrane 
into the submucous connective tissue. Up to this point the proced- 
ures already described are common to all the various methods of vaginal 
hysterectomy. From this stage on each method requires separate de- 
scription. 
1. Serial ligation of the broad ligaments. After separating the 
cervix from its surroundings for a short distance, so as to allow the 
tissues to retract somewhat, the bladder is dissected, bluntly or with 
scissors, from the anterior surface of the uterus until the vesico-uterine 
pouch is reached. In separating the bladder, always hug closely the 
anterior surface of the uterus. If it can be easily done at this stage the 
anterior peritoneal pouch is opened and the opening enlarged laterally 
by tearing. Ligation of the base of the broad ligaments, including the 
uterine arteries, is the next step. To insure inclusion of the entire 
arterial supply the armed ligature-carrier is best carried into Douglas’ 
pouch and made to pierce the broad ligament from behind forward, 
emerging in the anterior wound close to bladder. Care must, of course, 
be exercised not to include the ureters. After the ligature is tied on 
both sides the tissues between the ligatures and uterus are severed with 
the scissors, and the uterus is dragged farther down toward the vaginal 
outlet. The next section of the broad ligament is now tied in a similar 
manner on either side and cut with scissors between uterus and ligature. 
The third ligature generally reaches to the top of the broad ligament, 
including the tube and round ligament on either side. A clip of the 
scissors between the topmost ligature and the uterine cornu on either 
side will liberate the uterus, which is now removed. If it is desired to 
remove tubes and ovaries with the uterus, they are drawn down, either 
after removal of the uterus or with the latter, and the topmost ligature 
on either side is applied to the broad ligament outside of the tubal ostium. 
Tubes and ovaries are then cut out between the ligatures. 
2. The clamp operation differs in no wise from the method of serial liga- 
tion of the broad ligaments, except that haemostatic forceps of various 
shapes and sizes, according to the fancy of the operator, take the place 
of ligatures. The uterus, with or without the tubes and ovaries, is cut 
out between the clamps applied to control hemorrhage from the broad 
ligaments on either side. The handles of each pair of forceps are tied 
with silk to prevent their opening, and the clamps allowed to remain 
from twenty-four to forty-eight hours, their handles being wrapped in 
antiseptic gauze. 
3. Enucleation with individual ligation of bleeding vessels. After 
circumscribing the cervix by incision it is seized with strong volsella 4 
EDEBOHLS: VAGINAL HYSTERECTOMY. 
forceps and drawn well down; or a stout silk ligature may be passed 
through the cervix to act as a guy-rope in drawing it down. The uterus 
is freed from its surroundings by blunt dissection, aided, when neces- 
sary, by incisions with a hysterectomy knife or scissors. The author’s 
preference is for the scissors aided by a tenaculum. The tenaculum is 
hooked into and draws taut the tissues immediately adjacent to the 
uterus, while the scissors divides them as close as possible to that organ. 
After a fair and patient trial of the hysterectomy dissector, the writer 
has been unable to accustom himself to its skilful use. Blunt dissec- 
tion, aided, when necessary, by an occasional clip of the scissors, is thus 
proceeded with until the origin of the tube from the uterine cornu is 
reached on both sides, the peritoneum having, as already stated, been 
freely opened anteriorly and posteriorly. 
Fig. 1. 
Cole’s hysterectomy dissector. 
Two cardinal principles are involved in the successful performance 
of vaginal enucleation of the uterus. The first is to carry the dissection 
as close to the uterus as possible. Hemorrhage is thus reduced to a 
minimum. The uterine arteries as they approach the uterus divide 
rapidly into smaller and smaller tortuous branches—the curling arteries 
of the uterus—which finally penetrate the uterus as arterioles of the 
smallest calibre. By dissecting very close to the uterus, we divide only 
these arterioles or capillaries, and the slight oozing from them almost 
immediately ceases spontaneously. In working further away from the 
uterus, larger vessels, requiring ligation, are divided. 
The second cardinal principle involved is always to keep your imme- 
diate work well in view in the centre of the field of operation; to seize 
with forceps any spurting vessel that may happen to be divided and to 
immediately secure it with a slender catgut ligature. It will not do, how- 
ever, to tie the ligature around the artery in the usual way. The danger 
of retraction of the artery and slipping off of the ligature is too great, 
and when the artery has once retracted outward into the folds of the 
broad ligament, it may become a serious and difficult task to again secure 
it. To' be on the safe side, the transfixion ligature (Umstechungligatur) 
must be employed. The bleeding mouth of the artery is seized with 
forceps and slight traction made upon the vessel. This puts the tissues 
about the artery upon the stretch, and a needle carrying the ligature is 
passed underneath the artery, piercing in a part of its course the con- 
nective tissue surrounding the vessel. The ligature is then tied upon EDEBOHLS: VAGINAL HYSTERECTOMY. 
5 
the side of the artery opposite to that on which the connective tissue 
has been pierced. A ligature thus tied cannot slip off. 
The ovarian, uterine, and vaginal arteries (Hyetl) : a, ovarian artery ; a' and b', branches 
to tube; b, branch to round ligament; c, uterine artery; c', branches to ovary ;g, vaginal 
artery ; h, azygos artery of vagina. 
If it is desired to ablate the tubes and ovaries, the same blunt dissec- 
tion, aided when necessary by the scissors, is carried close to the tubes 
and ovaries until the infundibulo-pelvic ligaments are reached. Divided 6 
EDEBOHLS: VAGINAL HYSTERECTOMY. 
bleeding vessels are separately secured by fine catgut ligatures. In all 
clean cases closure of the peritoneum is the next step of the operation, 
except in the clamp operation, in which an efficient closure is impracti- 
cable. In cases in which the peritoneum has been necessarily or acci- 
dentally defiled iodoform gauze tamponade of the lower pelvic cavity is 
practised. 
Fig. 3. 
Ligation with transfixion. 
The peritoneum is closed by a running Lembert suture of cat- 
gut. This is an easy matter when the uterus alone has been removed. 
When the tubes and ovaries have been ablated closure of the perito- 
neum becomes a more difficult undertaking ; it is best accomplished by 
beginning at the infundibulo-pelvic ligament on either side and working 
downward toward the median line, where the two sutures meet and are 
tied to each other. A strip of iodoform gauze is loosely placed in the 
raw space between the vagina and the closed peritoneum. A little more of 
the same gauze is placed in the vagina, and the operation is completed. 
Having finished the description of the routine operation according to 
each of the three methods, a few general considerations relating to the 
modifications of technique, to meet complications and the exigencies pre- 
sented by the various indications upon which the operation is performed, 
are in order. 
A narrow vagina need not necessarily contraindicate vaginal hysterec- 
tomy. The required room can be obtained by incision of the vagina on 
both sides, along its whole length if necessary. These incisions are best 
made in the postero-lateral direction. After completion of the operation 
the vaginal incisions are closed by suture. 
In cases in which the uterine cavity contains infectious material the 
cervix may be closed by suture as a precaution additional to the subli- 
mate irrigation and gauze tamponade of the uterus, prior to proceeding 
with the operation. EDEBOHLS: VAGINAL HYSTERECTOMY. 
7 
Should the bladder happen to be wounded, the injury is immediately 
repaired by suture. A running suture of fine chromicized catgut in two 
tiers, the deep tier extending down to but not penetrating the mucous 
membrane of the bladder, will answer the purpose. Frequent catheter- 
ization, or a permanent catheter, should form a feature of the after-treat- 
ment in cases of wounded bladder. 
Adhesions do not contraindicate vaginal hysterectomy; they merely 
render it somewhat more difficult of performance. Separation of adhe- 
sions is effected in the same manner and on the same principles that 
obtain in coeliotomy. 
The intestines are best kept out of the way during operation by ele- 
vation of the pelvis, when they gravitate toward the diaphragm in the 
same manner as obtains in coeliotomy in the Trendelenburg posture. 
The writer’s operating tables, both stationary and portable, have proved 
very serviceable in this direction. 
The operation may frequently be facilitated by inverting the fundus of 
the uterus into the vagina either through the anterior or the posterior 
opening in the peritoneum. When this course is considered desirable, and 
the uterus cannot be readily turned down by the fingers, our object may 
be accomplished by “ climbing ” up the anterior or posterior surface of 
the uterus with the aid of two tenacula forceps. The uterus is grasped at 
an accessible part of its anterior or posterior surface by the first forceps. 
Traction upon these brings into view a higher part of the uterus which 
is grasped by forceps No. 2. This releases forceps No. 1, which in turn 
grasps a higher part, and so on until the fundus appears and is pulled 
down into the vagina. 
The one great disadvantage of the vaginal operation lies in the 
fact that it is sometimes very difficult to remove the tubes and ovaries 
when such removal is indicated. This difficulty and indication obtain 
chiefly when the diseased adnexa are adherent high up in the pelvis. 
The atrophy and shrinking of the tubal and ovarian attachments fol- 
lowing the menopause may also render it difficult to bring these organs 
down into the field of operation for removal; their removal under this 
circumstance is, however, fortunately but rarely called for. 
The after-treatment of vaginal hysterectomy with closure of the peri- 
toneum is a very simple matter. The urine is drawn until the fourth 
day, when the gauze is removed from the vagina. After that the patient 
uses the bed-pan in emptying her bladder, receiving a vaginal douche 
of 1: 3000 sublimate immediately after each urination. When the peri- 
toneum has been left open and tamponaded with iodoform gauze, this 
gauze is removed on the fourth day, and a small quantity of fresh iodo- 
form gauze introduced. This is removed on the seventh day, after which 
the vagina is douched after urination, as in the cases with closure of the 
peritoneum. Patients may sit up from the ninth or tenth day on, and 8 
EDEBOHLS: VAGINAL HYSTERECTOMY. 
generally leave the hospital at or before the end of three weeks after 
operation. 
The three methods of vaginal hysterectomy above described may be 
properly designated as the German, the French, and the American. The 
Germans, almost to a man, practise serial ligation of the broad liga- 
ments. The prominent exponents of the French school, following the 
lead of Pean, swear by the clamp. Enucleation with simple ligation of 
bleeding vessels, although probably practised in isolated instances else- 
where, first became established as a routine procedure in our own country, 
where it is rapidly gaining adherents. To Pratt, of Chicago, belongs 
the credit of having by his practice demonstrated the practicability and 
value, and by his teaching and writings disseminated a knowledge, of 
the method which justly bears his name. As already stated, the writer 
has practised each of the three methods. The clamp operation he soon 
abandoned, as to his mind eminently unsurgical. He has no further 
use for it, and will not again leave a clamp in the body except in the 
dire necessity of being unable to secure a bleeding point by ligature or 
torsion. Serial ligation of the broad ligaments presents the serious ob- 
jection of unnecessary constriction of vital tissues richly supplied with 
nerves, bloodvessels, and lymphatics. Ligation is required merely to 
check hemorrhage, and this object can be accomplished by simply tying 
the bleeding vessels ; all constriction or crushing of tissues beyond this 
is uncalled for, harmful and illegitimate. Vaginal hysterectomy by 
serial ligation of the broad ligaments is indicated only in cases of malig- 
nant disease in which we wish to give the uterus as wide a berth as pos- 
sible. Enucleation of the uterus, with ligation of bleeding vessels only, 
appeals to my mind as a surgically ideal method of hysterectomy, supra- 
pubic and vaginal. All my cases operated upon after this method, one 
abdominal and nine vaginal hysterectomies, have made good recoveries. 
The first vaginal hysterectomy bears date of May 18, 1894. 
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