The cervix is now dragged backward and a transverse incision is made across the anterior vaginal fornix.
The bladder is carefully dissected from the anterior face of the cervix with the knife, scissors, and finger, and the utero-vesical fold of peritoneum is opened. The peritoneum and the anterior vaginal wall may here also be united by suture.
Fig. 221.—Vaginal hysterectomy with clamps: third and final step (Baldy).
An incision may then be made through the vaginal mucous membrane of the lateral fornices, uniting the anterior and posterior incisions.
With a finger in Douglas’s pouch as a guide, the broad ligaments are then secured in successive portions by ligature or by strong clamp forceps, and the uterus is cut away with the scissors as the ligatures or clamps are placed.
As the upper portion of the broad ligaments is reached the procedure may be facilitated by retroverting or anteverting the uterus, the fundus being dragged through the posterior or the anterior incisions in the vaginal vault.
The tubes and ovaries should be removed when possible, especially in the case of malignant disease.
After the uterus has been removed the vagina may be packed with a gauze drain that reaches upward between the stumps of the uterine arteries; or, if ligatures have been used, the vaginal vault may be closed. The former procedure is the safer. When the gauze drain is used, it is advisable to leave the ends of the ligatures on the uterine arteries long and protruding into the vagina. The ligatures usually become infected, and their removal is facilitated by this procedure. If clamps are used, they should be removed in forty-eight hours.
The treatment after vaginal hysterectomy is the same as that already described after celiotomy.