Vaginal hysterectomy: the original minimally invasive surgery

Hysterectomy is one of the most commonly performed procedures in the United States. It is a unique procedure with multiple routes of access and multiple operative techniques. While focus has shifted towards minimally invasive techniques, the vaginal hysterectomy should be ranked first in this category, as it represents an original natural orifice surgery. Vaginal hysterectomy offers the least invasive approach to hysterectomy, with the lowest associated risks and costs. Despite these benefits, vaginal hysterectomy has experienced a decline in the last two decades. This decline is likely due to both the prevalence of fibroid uterus as a major indication for hysterectomy, and the decline of vaginal surgical skills among gynecologic surgeon due to more recent focus on laparoscopic proficiency. While vaginal hysterectomy is not risk-free, and is not the best option for all diagnoses, it should be given first-line consideration when planning to perform a benign hysterectomy. The purpose of this review is to understand the origins and evolution of the vaginal hysterectomy, the evidence-based benefits of this route of surgery, and best practice methods to ensure that patients receive safe and effective surgical treatment.