The Operative Technique of 
Vaginal Hysterectomy. 
BY 
Charles M. D., 
BRUSSELS, BELGIUM. 
REPRINTED FROM THE 
American Gynaecological and Obstetrical Journal 
for March, 1896. [Reprinted from the American Gynecological and Obstetrical Journal 
for March, 1896.] 
THE OPERATIVE TECHNIQUE OF VAGINAL 
HYSTERECTOMY.* 
By Charles Jacobs. M. D., Brussels, Belgium. 
At the last meeting of the American Gynaecological Society in 
Baltimore, I presented a large class of cases whose indications are dis- 
tinctly for vaginal hysterectomy.! I desire in this paper to describe in 
detail the manual technique of this operation, and we will consider all 
those modifications also which are properly applied to that form of 
the operation which may be called “ typical ”—modifications which 
have extended very greatly the field of its indications. 
The Typical Operation, 
A. Uterus of Normal Size, Non-adherent or Slightly Adherent. 
Instruments:—A perineal retractor, two lateral retractors, a pair 
of strong scissors, two traction forceps, six long forcipressure forceps, 
a thermocautery. 
The perineal retractor being in position upon the fourchette, the 
operator seizes both lips of the cervix in a traction forceps and drags 
down the uterus as far as possible ; then, holding the forceps vertically 
in his left hand, he draws the neck toward the pubis, in order to place 
the posterior cul-de-sac well upon the stretch ; the two lateral retrac- 
tors assist in exposing this region. With the thermocautery in his 
right hand, he makes a semicircular incision upon the posterior sur- 
face of the neck, after which the assistant on his left takes the traction 
* Expressly written for this Journal and translated literally from the original 
French. 
f Indications for Total Castration by the Vagina. American Gynecological and 
Obstetrical Journal, June, 1895. 
Copyright, 1896, by J. D. Emmet, M. D. 2 
Charles Jacobs, M. D. 
forceps in order to free the left hand of the operator. The latter then 
catches, with a long dissection forceps, the lower edge of the incision 
made by the thermocautery and continues the dissection into the 
deep tissues, still by means of the cautery, which he holds as close to 
the cervix as possible. The opening up of the posterior peritoneal 
cul-de-sac is rapidly done and is greatly assisted by the use of the 
fingers. 
The traction forceps are now drawn vertically toward the four- 
chette and a semicircular incision, the ends of which should unite 
with those of the first incision, is made upon the anterior surface of 
the neck with the thermocautery. The dissection of the cellular tissue 
is accomplished by means of the finger, which should separate the 
bladder and the ureters by a “ to-and-fro ” movement; the lower vag- 
inal portion of the cervix also being completely dissected from its 
attachment to the cellular tissue by the same means. The peritonaeum 
which appears at the bottom of the wound is caught up by the oper- 
ator and incised with scissors, the opening being further enlarged by 
the fingers. 
The index finger is now introduced through the open pouch of 
Douglas and examines the body of the uterus and the condition of the 
appendages. The separation of these organs from their adhesions to 
neighboring tissues is aided by the steady traction exerted by the 
other hand of the operator, which holds the forceps upon the uterine 
neck. The thumb and index finger of the left hand then grasp the 
entire thickness of the tissues which unite the neck laterally with the 
neighboring tissues and which always includes one or two vaginal ar- 
terioles. These tissues are firmly compressed by forcipressure forceps 
with a short bite, placed along each side of the cervix, and are then 
divided. After this proceeding, the uterus descends considerably. 
In order to extract this organ, it only remains to draw strongly 
upon the traction forceps, a finger being introduced at the same time 
into the anterior cul-de-sac to give the body of the uterus a swinging 
motion in an outward direction ; the appendages follow. A long pair 
of forceps are placed, on the outer side of the appendages, upon the 
broad ligament; if the uterus be large and the vascular system greatly 
developed, I do not hesitate to use two forceps, the lower one assur- 
ing haemostasis of the uterine and the upper of the ovarian artery. 
The incision is made on the inner side of these forceps and the uterus 
is removed entire with the appendages. The patient has not lost five 
grammes of blood. The “typical” operation, performed by this 
method, takes from two to five minutes. The Operative Technique of Vaginal Hysterectomy. 
3 
B. Large, Adherent Uterus, without Attachments. 
The beginning of the operation is exactly similar to the preceding 
—that is to say, we detach the cervix from its insertion in the vagina 
by means of the thermocautery, we open up the anterior and poste- 
rior culs-de-sacs and place laterally on the neck two long forceps, which 
enable us to dissect it out without haemorrhage. 
We now divide the anterior lip of the cervix in the median line, 
and traction forceps are placed to the right and left of this com- 
missure. The left forceps is handed to an assistant, who draws 
forcibly upon it in a downward direction, while the operator holds the 
right forceps in his left hand and the scissors in his right. The cer- 
vix is divided at the median line as high up as possible and from be- 
fore backward. Two traction forceps are fastened upon the edges 
of the wound, one on the right and the other on the left, one branch 
of each being in the uterine cavity and the other fixed upon the an- 
terior surface of the cervix or uterus. Traction is maintained by con- 
tinuous action upon these forceps. Those adhesions holding the 
uterus in the pelvis, which are most accessible, are now divided and 
the median incision is continued. As a deeper portion of the anterior 
surface of the uterus appears, it is divided and two extra traction 
forceps are applied as high as possible upon the lips of the incision. 
When the fundus is reached the last adhesions are broken up by the 
finger and a swinging motion outward is given to the uterine body, in 
which manoeuvre a finger placed behind it is of marked assistance. 
When the uterus is delivered, the appendages come at once within 
reach and are seized and drawn down as far as possible. One or 
two forcipressure forceps are then applied to the broad ligament out- 
side the annexa and control the uterine and ovarian arteries. Here 
also the uterus is removed entire with its appendages. 
It often happens that, during the rocking motion given to the uter- 
ine body, the cervix, if large and somewhat elongated, tends to fall 
back into the cavity of the vagina. By drawing upon the first two 
traction forceps, which should always be left in place, the whole organ 
can easily be drawn down. 
It is an essential point in placing the forcipressure forceps always 
to protect the bite of these instruments upon the index finger passed 
in front and the thumb passed behind the ligament, that we may be 
certain not to injure any organ, whether intestine or omentum. In 
the same way section with the scissors should always be carried out 
with the greatest care. 4 
Charles Jacobs, M. D. 
The cases of uterine prolapse which occur in this category often 
present great difficulties on account of the thickness of the vaginal 
mucosa, the great vascularity, the elongation of the cervix and the 
formless condition of the portio vaginalis. Here also one must be 
very careful not to wound either the rectum or the bladder. I have 
always found in cases of prolapse that the operation is longer and 
more difficult than in other cases. 
C. Pelvic Suppuration j Pelvi-peritonitis ; Old Adhesions. 
If the uterus is voluminous with thick friable walls and held down 
in the pelvis by numerous adhesions, and if the pelvic cavity is filled 
by large, attached tumors adherent to all the neighboring organs, the 
following is the operative technique : 
Traction forceps having been placed upon the cervix, its condi- 
tion of fixity in the pelvis is determined by a few vigorous pulls. The 
inferior retractor is now inserted, and the neck is raised by holding 
the traction forceps against the pubis with the left hand. We then 
make a semicircular incision upon the posterior surface of the neck 
with the thermocautery. 
The assistant holds the traction forceps without changing their 
position, and the dissection of the posterior cul-de-sac is continued 
by the thermocautery, which is kept as near as possible to the 
uterine tissue. While in cases of movable uterus the peritoneal cul-de- 
sac is easily opened by the thermocautery, in these cases we can 
rarely succeed in this way. Raising the posterior retractor, we con- 
tinue the dissection by means of the finger until the peritonseum is 
reached. The finger, by a lateral to-and-fro movement, breaks up 
all the adhesions, opens the peritoneal cavity and frees the posterior 
surface of the uterus. It often happens at this time that a gush of 
serous, sero-sanguineous, or purulent fluid occurs, the finger having 
opened adhesion sacs behind the uterus ; though inflammatory sacs 
of the annexa are rarely opened in this way. Considerable prac- 
tice in these operations imparts to the finger such tactile sensibility 
that these inflammatory pockets of the annexa can easily be distin- 
guished from those which are peri-uterine or from intestinal, omental 
or other adhesions. We thus free the whole posterior surface of the 
uterus and are enabled to explore the whole of the lower pelvis. 
The result of this exploration will show us what our course should be. 
If the condition of the patient be very serious and her weakness 
will not permit a long operation, I am satisfied to look for the en- 
cysted purulent pockets, to open them with finger or forceps and The Operative Technique of Vaginal Hysterectomy. 
5 
evacuate their contents. Moreover, this operation is without danger 
on account of the numerous adhesions which close the lower pelvis 
above the uterus. The radical operation may be taken up later when 
the condition of the patient permits. 
If the exploration indicates immediate operation, we continue 
as follows : The neck is drawn toward the fourchette and the vaginal 
mucous membrane of the anterior cul-de-sac is incised by the thermo- 
cautery. The incision is opened out deeply, the bladder is freed by 
the finger and the peritonaeum is opened either by this means or by 
the scissors. This anterior dissection is always easier than that of the 
posterior surface where the adhesions are usually found. Two shorter 
forceps are placed upon the lower part of the ligament, the cervix is 
completely separated by the scissors and is then incised along the 
anterior median line. This incision is continued upon the anterior 
surface of the uterus as far as the adhesions will permit. Two trac- 
tion forceps are placed on each lip of the incision, and the operator 
draws them strongly toward him. The incision is prolonged upward 
upon the part which presents and is thus continued to the fundus of 
the organ, which is often adherent to the intestine or omentum. The 
dissection of the fundus of the uterus may be made in full view. I 
have often seen, while detaching intestinal adhesions with the thermo- 
cautery, the uterus at the vulva—the cervix at the fourchette and the 
fundus at the superior commissure. The last adhesions having been 
separated, the uterus is held by traction forceps placed at the middle 
of the upper posterior surface; this allows the removal of the traction 
forceps previously attached. 
If examination of the annexa shows them to be very large, I am 
accustomed to place two long forceps upon the sides of the uterus 
and to remove the latter, in order to give more room for the ablation 
of the annexa. If, however, these are neither very adherent nor large, 
they may be removed with the uterus en masse, as in the preceding cases. 
All adhesions about the tubes and ovaries should be broken up 
carefully by the index finger and these organs drawn gradually down 
to the vulva. If the tubal and ovarian pockets are too large they 
may be punctured and their extraction thus rendered easier. When 
we have succeeded in bringing the tubes and ovaries outside, it will 
be sufficient to place one or two forcipressure forceps with a short 
bite upon the broad ligament and to cut them off. 
A douche with sterilized water is often necessary after ablation, 
especially if the escape of pus has been abundant. If the tumors or 
annexial pockets are very large we should begin by puncturing them. 6 
Charles Jacobs, M. D. 
I am accustomed to evacuate the contents of these pockets by the 
bistoury or scissors at the most accessible point. Generally it is easy, 
after a partial or complete evacuation, or even during it, to draw the 
pockets down to the vulva either by means of the traction forceps 
attached to their walls or by using simply the fingers to separate ad- 
hesions and drag them outside. It is very rarely that I am obliged to 
leave portions of these pockets in the pelvis, and I have often been 
able to demonstrate the facility which the vaginal route offers for at- 
tacking all adhesions, whether intestinal or omental. I have many 
times been able to draw the walls of these pockets and the intestines 
which adhere to them down to the vulva and to dissect off these ad- 
hesions by the thermocautery under the eyes of the spectators. When 
the walls of a tubal pocket are thick and cheesy, as is usually the case 
in enormous tumors, we should never hesitate to drag them down 
outside by means of traction forceps, one blade of the forceps being 
introduced into the pocket. 
When the adhesions present a very large surface, it is possible, 
though with difficulty, to separate them by partial morcellation of the 
walls. When the firmness of the intestinal adhesions causes danger 
of perforation to the latter by too strong traction, it is better to leave 
the upper part of the pockets in the pelvis. They will contract and 
disappear rapidly, owing to the drainage which will be established 
after the operation. 
Uterine Cancer. 
Cancer of the Cervix. 
After having freed the cervix from all friable tissue by the sharp 
curette I increase the traction forceps over its entire circumference ; 
that is to say, in order to draw down the uterus I use four, six, eight, 
or ten traction forceps—a method which prevents any of the forceps 
from slipping and tearing the tissues. 
With the thermocautery I then incise widely the vaginal mucosa 
all around the neck, for a good centimetre in length of the diseased 
tissues, as far as the cellular tissue. The freeing of the bladder and 
of the rectum is accomplished by the finger. If, unfortunately, the 
bladder be torn at the time of operation, the wound should be closed 
immediately with interrupted sutures. I open the anterior and pos- 
terior culs-de-sac with scissors, the finger being used to protect the 
broad ligament. After this, the openings in the peritonaeum are en- 
larged by the fingers and the uterus is drawn down to the vulva by 
traction forceps. Two small forceps are then placed on each side The Operative Tech7iique of Vaginal Hysterectomy. 
7 
of the lower vaginal portion of the cervix. Great care must be taken 
before closing the forceps that the integrity of the tissues is assured; 
the cervix is now entirely freed by the scissors. I am accustomed 
next to give a swinging motion to the uterine body, anteriorly or pos- 
teriorly, according to the greater facility given by its position and 
•size. Two forceps placed outside the annexa, which follow the ex- 
traction of the uterus, assist very greatly in rapid total extirpation 
and, in a measure, obviate the fear of infecting the pelvic perito- 
naeum. 
In commencing cancer of the body, the method is the same. If it 
has lasted several months, the uterus has increased in size and be- 
come very friable, and extirpation may be very difficult. After open- 
ing the peritoneal culs-de-sac and completely freeing the cervix up to 
the level of the internal os, I perform median section, either anteriorly 
or posteriorly, according to the case; the danger to be avoided is the 
slipping of the traction forceps. This may easily be obviated by em- 
ploying very small forceps and many of them, since with the cervix 
the multiplication of points of traction assists the operator very 
greatly and is an assurance that he will not see his instruments sud- 
denly slip out of hand and the uterus rise in the pelvis. 
By means of this method pursued carefully as far as the fundus 
(which should always be protected by the finger), we reach a point 
when the uterus may be drawn down to the vagina and the operation 
completed by forcipressure of the broad ligament. 
Uterine Fibroma. 
The operative methods differ according to the case. The separa- 
tion of the cervix and the opening of the peritoneal cul-de-sac is carried 
out according to the rules which I have already given. If either cul- 
de-sac, on account of its retracted position, can not easily be reached, 
we should not waste too much time with it but open it during the 
course of the operation. The cervix is drawn down and divided at 
the anterior median line. Two traction forceps are immediately 
placed at the upper ends of the incision, and by their means a con- 
siderable portion of the uterus is dragged down into the pelvic strait 
and the traction continued. 
During this traction either by the operator or his assistants, all 
the retractors are inseued and the operator proceeds with the index 
finger to free the bladder as high as possible. The anterior retractor 
is replaced, which draws the bladder aside and also frees a greater-or 
less extent of surface on the anterior uterine wall. 8 
Charles Jacobs, M. D. 
The median incision is prolonged either by continuing it in its- 
original course when the fibroma is not too large, or by bifurcating it 
in a Y shape or according to this figure'k. Two traction forceps are 
now placed lengthwise on the tissues thus separated and are drawn 
down as much as possible. If the freedom of motion thus obtained 
is not marked, all that portion of the anterior surface of the uterus- 
comprised within the branches of the V should be immediately cut 
with scissors or with a bistoury. If two traction forceps be placed 
on the upper portion, a considerable freedom of motion forward will 
be obtained, and always in direct relation to the size of the V or of 
the y/. If the peritoneal cul-de-sac now comes into view, I hasten to 
open it widely. The anterior retractor will draw aside completely 
the bladder and the ureters and thus obviate any further danger of 
wounding them. 
At this point of the operation fibroid nodules of different sizes are 
often seen cropping out at various places from the uterine muscle. I 
immediately enlarge the opening at the site of these tumors, seize them 
with the traction forceps and extirpate them either by tortion or by 
morcellaticn with the scissors or bistoury. When the principal tumor 
projects into the uterine cavity it also is excised either en bloc or by 
morcellation if its size be too great. I was able to demonstrate this 
last June at the Rush Medical College in Chicago, extirpating by this 
method a large interstitial fibroma without forcipressure and without 
haemorrhage. A finger carried into the uterine cavity and into the 
spaces left by the fibromata enables us to ascertain if any portions 
of them remain ; in which case we should find and extirpate them,, 
following the steps already described. Little by little, with the enu- 
cleation of the interstitial fibromata, the traction exerted upon the two 
forceps which are attached to the extremities of the median incision 
will suffice to work the uterus outside. Often it is merely necessary 
at this point to extend somewhat this first incision, when we will see 
the whole uterine mass suddenly slip down to the vulva. The poste- 
rior peritoneal cul-de-sac may now be easily opened. 
With the uterus at the vulva, total extirpation is completed by 
placing two long forceps with a short bite upon the broad ligament on 
each side. 
If the uterus be surrounded by subperitoneal fibroid nodules, it 
frequently happens that their extirpation must precede that of the 
uterus, because of the latter’s exit through the small vagino-perineal 
opening ; if too large, morcellation may be practiced, since of course 
there is no longer any fear of hsemorrhage. The Operative Technique of Vaginal Hysterectomy. 
9 
The essential point in this morcellation of the fibromata is to be- 
gin this or to attack the tumors without waiting for the methodic ex- 
tirpation of the uterus. Moreover, this operation requires a certain 
amount of experience, although this is quickly acquired. While the 
uterus, which is studded with fibrous nodules, is being worked down, 
the sense of touch will enable the surgeon to know which of these it 
is which offers resistance to extraction—that is the one he must at- 
tack. If the nodules are situated in the posterior wall, he will look 
for them after cutting through the uterine mucosa. When the prin- 
cipal fibroma is situated in the lower part of the posterior wall and 
has pushed the cervix very high up, why waste time in attempting to 
open the anterior cul-de-sac which is absolutely inaccessible ? The 
posterior vaginal cul-de-sac should be opened, where the fibroma may 
be directly attacked with ease if the tumor be situated low down ; if it 
be high it may be necessary, in order to reach it, to perform a median 
section or one in the shape of a V upon the posterior wall. When ac- 
cess to the anterior cul-de-sac is possible, the typical operation should 
be undertaken. When the fibroma has developed in the broad liga- 
ment we should perform morcellation before attempting hysterectomy. 
Evidently I can not give here, in detail, the course to be pursued 
in each case. Two fibromata which are exactly the same are rarely 
met with, and the operation must thus be varied in detail according 
to the case. Latitude must be given to the operator, who alone can 
judge whether this or that method is applicable or favorable to the 
speedy termination of the operation. 
When absolutely necessary, fibrous tumors may, with the exercise 
of patience, be operated upon which extend to the umbilicus and 
even beyond, but I fear that the length of the operation and the many 
manipulations necessary are scarcely favorable to the patient. I have 
seen French surgeons attempt operations of this sort lasting from two 
to three hours ! I have long given up this practice. I do not oper- 
ate upon fibromata through the vagina if they extend beyond the um- 
bilicus. When they reach that point and beyond it I perform total 
abdominal extirpation. 
Such, briefly, is the operative technique of vaginal hysterectomy as 
I perform it to-day and as I have had the honor of demonstrating it 
during my visit to America. I hope at a future time to return to this 
very practical subject, in this Journal, and to describe the operative 
sequelae and the complications consequent upon total vaginal cas- 
tration.