This is accomplished by using a wet laparotomy sponge placed inside a surgical glove. The laparotomy sponge is moistened to improve its malleability and to facilitate occlusion of the vagina. Once the pneumoperitoneum is re-established, extensive irrigation is used to demonstrate adequate hemostasis. 2-0 Monocryl provides sufficient strength and dissolution time to allow the vaginal apex to heal. An appropriately positioned KOH cervical cup minimizes the risk of bladder injury by clearly identifying the cervicovaginal reflection.
Many patients develop an enterocele after hysterectomy.
To avoid this, I place a high McCall suture, using 0-Ethibond through both uterosacral ligaments and the posterior vaginal apex. At this point, I have essentially completed the total laparoscopic hysterectomy. I irrigate the pelvis to remove residual blood clots and irrigation fluid. I inspect all pedicles for adequate hemostasis. I remove the trocar sleeves and release the pneumoperitoneum.