Prepared by : Prof. Dr. Kh. Shahnewaj, FRCOG
Date: 4ᵗʰ October 2025
Institution: Department of Obstetrics & Gynaecology, Kumudini Women’s Medical College, Mirzapur
Adapted from: FOGSI, AAGL, SOGC, ACOG, and RCOG Guidelines
Version: 1.0

Purpose & Scope

• Establish a structured, evidence-based, standardized protocol for NDVH.
• Ensure patient safety and improve surgical outcomes by aligning practice with international recommendations.
• Serve as a reference for surgeons, trainees, and operating room personnel involved in hysterectomy procedures.

Indications (FOGSI and International Consensus)

• Symptomatic uterine fibroids (preferably ≤14–16 weeks in size)
• Abnormal uterine bleeding not responding to medical management
• Adenomyosis and small benign ovarian cysts (if accessible vaginally)
• Benign endometrial conditions following adequate evaluation
• NDVH should be prioritized as the preferred route for benign uterine disease whenever feasible.

Exclusion Criteria

• Clinical or radiological suspicion of malignancy (requires oncologic laparotomy)
• Extensive endometriosis or severe pelvic adhesions restricting uterine mobility
• Very large uterus (>16–18 weeks; relative contraindication)
• Adnexal pathology necessitating laparotomy
• As per FOGSI Guidelines: route should be individualized; unnecessary abdominal hysterectomy must be avoided

Preoperative Workup

• Clinical evaluation: Assess uterine size, mobility, descent, and adnexal status
• Imaging: Transvaginal sonography (TVS); CT/MRI if pelvic distortion or adnexal pathology suspected
• Endometrial assessment: Sampling recommended for abnormal uterine bleeding in women ≥40 years or with risk factors for malignancy
• Routine investigations: Baseline hematology and biochemistry, anaesthetic fitness assessment, blood cross-matching when indicated

Informed Consent

Counselling should include:

• Comparative risks and benefits of vaginal, abdominal, and laparoscopic approaches
• Possibility of intraoperative conversion if access or safety is inadequate
• Potential complications: hemorrhage, bladder/ureteric/bowel injury, infection, vault problems
• Advantages of vaginal route: shorter hospital stay, faster recovery, less postoperative pain, lower overall cost

Operative Protocol (Stepwise)

1. Position: Extended lithotomy; bladder catheterization; antiseptic prep and draping. Perform final bimanual exam to confirm feasibility.
2. Vaginal incision: Circumferential, anterior, or posterior colpotomy depending on accessibility
3. Entry: Open posterior pouch first, followed by anterior pouch
4. Sequential clamping and ligation:
   • Uterosacral ligaments
   • Cardinal ligaments
   • Uterine vessels
   • Utero-ovarian or infundibulopelvic ligaments (as required)
5. Debulking techniques for large/non-mobile uterus (FOGSI endorsed):
   • Bisection of uterus
   • Myomectomy (fibroid enucleation)
   • Morcellation (coring or wedge resection)
6. Vault closure: Secure closure with apical support (uterosacral ligaments, McCall’s or modified uterosacral suspension)

Conversion Criteria

Conversion from vaginal to abdominal/laparoscopic route is based on patient safety, not procedural failure. Indications:

• Uncontrolled intraoperative bleeding
• Inaccessible or pathologically altered adnexa
• Dense adhesions or distorted anatomy preventing safe dissection
• Intraoperative suspicion of malignancy

Postoperative Care

• Mobilization: Early ambulation; elastic stockings and pharmacologic prophylaxis if indicated
• Catheter & pack removal: Within 24 hours
• Analgesia: Multimodal pain control (Paracetamol + NSAID ± short opioid) for 3 days
• Antibiotic prophylaxis: Cefazolin 1–2 g IV within 30–60 mins pre-incision; continue up to 5 days if intraoperative contamination, prolonged surgery, or other infection risks
• Discharge: After 48–72 hrs if stable
• Follow-up: 2 weeks (wound/recovery review) and 6 weeks (final evaluation, return to normal activities)

Documentation & Audit

• Document indication and rationale for route selection
• Record intraoperative findings, surgical steps, estimated blood loss, complications
• If conversion occurs, specify indication and timing
• Maintain audit parameters:
  • Complication rates
  • Conversion rates
  • Average hospital stay
  • Re-admission and re-intervention rates

Continuous audit, feedback, and hands-on training are essential for maintaining surgical quality and improving outcomes

References

1. FOGSI Focus: Vaginal Surgeries (2015)
2. FOGSI Guidelines: Hysterectomy and Reporting Standards
3. SOGC Clinical Practice Guideline No. 377: Hysterectomy for Benign Gynaecologic Indications
4. ACOG Committee Opinion: Choosing the Route of Hysterectomy for Benign Disease
5. AAGL Position Statements and Teaching Modules on Vaginal Hysterectomy
6. RCOG – Relevant recommendations on route of hysterectomy

Compiled By

Prof. Dr. Kh. Shahnewaj

Contributors

1. Prof Fawzia Hossain
2. Dr Ummul Warda
3. Dr Amena Fardous
4. Dr Tanzia Akhter
5. Dr Maniza Khan
6. Dr Ananna Zakia
7. Dr Lutfa Amin
8. Dr Tasrina Akhter
9. Dr Amrita Saha
10. Dr Tasnuva Maliha