**9. Disconnection of superior connective-vascular pedicle**

For vaginally delivering the uterus, securing the superior connective vascular pedicle is the most important and sometimes the most difficult step of vaginal hysterectomy.

In most cases, the superior pedicle can be brought into the surgical field by tilting the uterus. The uterus can be tilted anteriorly (Doderlain-Kronig maneuver) or posteriorly (Heaney maneuver).

When the uterus is highly mobile and small, its release from the pelvis can also be done without tilting.

For the uterus weighing up to 200–280 g, access to the superior pedicle is done by tilting, a maneuver that brings the superior pedicle into the surgical field, which consists in anatomical order of the round ligament, fallopian tube, and homologous utero-ovarian ligament. This pedicle includes the anastomotic branch of the uterine artery and the tubo-ovarian vascular arch.

#### *Hysterectomy - Past, Present and Future*

The main disadvantage of the tilting maneuvers is that it forces the vaginal opening through which the uterus is pulled, which can lead to the slipping of ligatures placed on the anteriorly cut and ligated connective vascular pedicles (**Figures 18**–**20**).
