Checklist for Vaginal Hysterectomy

The pdf form of this Checklist for Vaginal Hysterectomy may not contain the latest changes below.

Preoperative Checklist
(Please indicate   - Done,   X - Not done,   NA – Not applicable)


 * 1) ___ Screen and treat patients  for BV (prevent vaginal cuff infection)
 * 2) ___ Make sure uterus is mobile (prevent abdominal route conversion)
 * 3) ___ Check bituberous distance to be >10 cm (prevent abdominal route conversion)
 * 4) ___ Check infrapubic arch to be >75 deg (prevent abdominal route conversion)
 * 5) ___ Check uterine size to be < 12 weeks gestational size (or your preference) (prevent abdominal route conversion)
 * 6) ___ Sign consent for possible complications: bleeding, bladder injury, ureteral injury, bowel injury, infection, pelvic abscess, burn injury, nerve injury, conversion to abdominal procedure, and postoperative vault prolapse.
 * 7) ___ Be familiar with coring, bivalving and other morcellation techniques to reduce uterine mass (prevent abdominal route conversion)
 * 8) ___ Be familiar with inverting the uterus to gain exposure (prevent abdominal route conversion)
 * 9) ___ Order prophylactic antibiotics, at least 30 minutes before incision and consider repeating antibiotics (up to three doses) for high risk patients (prevent cuff abscess)
 * 10) ___ Discontinue ASA, Plavix and other anti-clotting meds prior to surgery

Intraoperative Checklist

 * 1) ___ Use Allen’s (Yellow fin) stirrups (prevent nerve injury)
 * 2) ___ During EUA, check for cul-de-sac endometriosis ensuring that posterior cuff is free (prevent bowel injury)
 * 3) ___ Inject pitressin/saline solution (10-20 units/100cc)at junction of vagina and cervix to hydrodissect along the pubovesicocervical fascia (prevent bladder/bowel injury) (decrease blood loss)
 * 4) ___ Avoid injecting epinephrine because of higher incidence of necrosis (Pitressin preferable)(prevent cuff infection).
 * 5) ___ Avoid use of cautery to incise vaginal mucosa/muscularis around cervix  (prevent cuff infection)
 * 6) ___ Avoid accidental electrocauterization of weighted speculum, retractors or hemostats(prevent burn injury)
 * 7) ___ In posterior dissection, avoid being too posterior to vaginal reflection off of cervix and  angle Mayo scissors parallel to the cervix (prevent bowel injury)
 * 8) ___ Use Trendelenberg position (prevent bowel injury)
 * 9) ___ Check for adhesions of bowel to fundus upon entering cul de sac (prevent bowel injury)
 * 10) ___ Use minilap packs to pack away small bowel (can tie sutures to blue tag to aid in placing entire pack in pelvis) (prevent bowel injury)
 * 11) ___ Tie square knots and avoid unnecessary tension on the first throw of a suture (prevent post operative bleeding)
 * 12) ___ Run and lock posterior cuff with absorbable suture after cul de sac entry and ligature of the  uterosacral   ligaments  (prevent excessive blood loss and prevent suture erosion)
 * 13) ___ Keep field clean to aid in clearly identifying pubovesical fascia when making anterior incision (prevent bladder injury)
 * 14) ___ After sharp incision of mucosa/muscularis to identify pubovesicocervical fascia, dissect bladder from cervix along the pubovesical fascia plane with blunt (not sharp) dissection (prevent bladder injury)
 * 15) ___ Dissect far enough up the cervix to likely bladder reflection (prevent bladder injury)
 * 16) ___ Incise peritoneum below anterior retractor and the forceps that tents the peritoneum anteriorly, with scissors tip pointed toward the cervix away from the bladder (prevent bladder injury)
 * 17) ___ Leave urine in bladder to identify any bladder damage (recognize bladder damage)
 * 18) ___ Maintain downward traction of cervix throughout procedure until uterus is removed (prevent ureter injury)
 * 19) ___ Roll clamps off of the cervix and uterine corpus (prevent ureter injury)
 * 20) ___ Double-ligate ovarian vessels if removing ovaries, with the first tie being a suture anchor stitch, then a second tie being a free tie (prevent post op bleeding)
 * 21) ___ Identify uterosacral ligaments as attached firmly to sacrums and incorporate the uterosacral ligaments into the vaginal cuff (uterosacral vault suspension, modified McCall’s culdoplasty, using Ethibond  or other permanent suture) (prevent future vaginal vault prolapse)
 * 22) ___ Identify any continuing bleeding before cuff closure (prevent postoperative bleeding)
 * 23) ___ Keep vaginal cuff hemostatic sutures as superficial as possible (prevent ureter injury)
 * 24) ___ Run anterior and posterior cuff closure with absorbable suture (as opposed to interrupted sutures) (prevent post operative bleeding and avoid stitch erosion)

Signature: _________________________ Attending:_____________________ Date:______

Global Evaluation: |Initial learning|       |Needs work|       |Progressing|      |Good for level|        |OK on own|