Step-by-step colpotomy in total laparoscopic hysterectomy: a technique to avoid apical support damage to the upper vagina.

The purpose of this video article is to demonstrate our colpotomy technique that enables maximal protection of the cervical ring, helps to prevent the ureteral injury by distancing, and avoids shortening of the vagina at total laparoscopic hysterectomy. Step-by-step explanation of the colpotomy technique is presented using educational video setting in university-affiliated private hospital. After the uterine artery transection, a VECTEC surgical uterine manipulator (VECTEC, Hauterive, France) was inserted into the vagina in place of the sharp curette. The plastic rotating blade of uterine manipulator was strongly pushed forward into the anterior vaginal fornix. Colpotomy incision was started from the uppermost middle point of an anterior vagina, and extended to both sides with a monopolar L-hook electrocautery at 40 watts cutting mode. Then the manipulator’s blade was maneuvered into the right lateral fornix, and THUNDERBEAT platform (Olympus Medical Systems Corp, Tokyo, Japan) was chosen as the modality of energy for the transection of the rest of the vagina. At the posterior part of colpotomy, the vaginal wall was cut from the uppermost part of uterosacral ligaments, as well. Finally, the left lateral fornix was cut by the same principles, and colpotomy was completed circumferentially. In conclusion, maximal preservation of paracervical ligaments with this technique preserve the apical support of vagina, and avoids shortening of vaginal length. The technique also minimizes the ureteral injury by distancing.