Facilitating Vaginal Surgery for Residents and Veterans

With the increasing use of operative laparoscopy in gynecologic surgery, there is a rising concern that the use of the vaginal approach is decreasing and emerging gynecologic surgeons have reduced vaginal skills. Often the laparoscopic approach is initially used during a hysterectomy for purposes of oophorectomy or evaluation of pelvic pain and endometriosis. Elevation of the anterior abdominal wall and insertion of a laparoscope often allow initiation and completion of a hysterectomy totally by the vaginal approach. Avoidance of a pneumoperitoneum allows laparoscopic visualization of the entire procedure as well as the option of a regional anesthetic. The backlighting afforded by the laparoscope greatly enhances the vaginal view, and a concurrent laparoscopic view improves placement of clamps as well as upper pelvic dissection. This technique improves the safety and efficacy of the vaginal steps. Use of this technique can improve resident teaching as well as facilitate difficult vaginal dissections.