Bladder fully reflected from the front of the uterus. Note the colour of the vaginal wall demonstrating the underlying massive vascularity.
Once adequate bladder reflection is achieved, the vaginal ‘swab on stick’ will guide the surgeon to the appropriate point to begin the colpotomy.
* This can be an extremely risky part of the hysterectomy as the cervix and/or vagina may have huge varicosities resulting in rapid, significant blood loss at colpotomy. Therefore the haemodynamic stability of the woman must be taken into consideration and all possible attempts made to stabilise her before the colpotomy is undertaken.
With the SAC Technique we try to take a very brief break in the surgery at this point to ensure the anaesthetic team has the woman as stable as possible before we risk rapid blood loss.
In low body weight women or those who have already lost a significant amount of blood, we often process all of the cell salvage blood and give it back to the woman before proceeding.
The handheld monopolar device can be used to open the vagina and perform the anterior portion.
Then switching to the Ligasure device (Medtronic, UK) to continue the colpotomy laterally and posteriorly – either preserving, dividing or taking the uterosacral ligaments as indicated by the pathology.
In cases of excessive vascularity we use Zeppelin clamps for extra haemostasis and blood loss control.