**8.3 Opening the vesicouterine fold (anterior Colpoceliotomy)**

In our basic technique, opening the vesicouterine pouch becomes extremely simple after the disconnection of the inferior pedicle if the uterus is not enlarged or deformed. After sectioning the inferior pedicle, the uterus descends 3–4 cm, where the white-pearly transversal fold of the peritoneal vesicouterine fold can be

*Perspective Chapter: Total Vaginal Hysterectomy for Unprolapsed Uterus DOI: http://dx.doi.org/10.5772/intechopen.101383*

#### **Figure 9.**

*The incision of the anterior wall of the vagina 1.5–2 cm away from the external cervical orifice includes the entire thickness of the vaginal wall. Posteriorly, the incision is placed at the level of the first posterior rugae of the vaginal wall.*

#### **Figure 10.**

*To expose the cervico-vesical septum, the cervix is pulling down and the cutting edge of the vaginal wall in the opposite direction. The sectioning of the cervicovesical septum is done with scissors facing the mass of the cervix.*

observed. It is grasped with a clamp and cut where it enters the pelvis. The surgeon digitally explores the anterior side of the uterus and inserts a Briesky-Navratil retractor in this space, discharging the bladder upward (**Figure 12**).

### **8.4 Developing rectovaginal space and opening the pouch of Douglas (posterior Colpoceliotomy)**

Unlike with anterior colpoceliotomy, entering the rectovaginal cleavage space and opening the pouch of Douglas can be done at the same time. The level of

#### **Figure 11.**

*The anterior cleavage space is open. Bladder pillars delineate the spatial side of anterior cleavage space. The dissection of the vesicouterine space is done by the progression of the index on the median line.*

#### **Figure 12.**

*A. Identifying and opening the real vesicovaginal fold (white arrow). The black arrow marks the cervical insertion of the peritoneal fold (false fold). B. the vesicovaginal fold opens.*

posterior vaginal incision described above is significant to ensure a good entry into the rectovaginal space. The edge of the posterior vaginal wall incision is grasped with Allis clamps, and the rectovaginal space is entered by sharp or blunt dissection. After entering the rectovaginal space and pressing the rectum down, the peritoneal cul-de-sac may be observed swelling when the cervix is moved in or out. After opening the pouch of Douglas, the posterior side of the uterus, uterosacral ligaments, and the posterior leaf of the broad ligaments can be explored digitally (**Figures 13** and **14**).

In difficult cases, a particular variant can be used to avoid the creation of an excessively sizeable retroperitoneal space between the vagina and the rectum. (see Chapter 6).

*Perspective Chapter: Total Vaginal Hysterectomy for Unprolapsed Uterus DOI: http://dx.doi.org/10.5772/intechopen.101383*

#### **Figure 13.**

*Developing rectovaginal cleavage space. Allis clamps grasp the vaginal cutting edge, and the space is open by sharp dissection. The posterior aspect of the cervix is pulled upward, and the dissection is carried out using a Sims retractor.*

**Figure 14.** *The rectovaginal fold is open, and the posterior side of the uterus is visible. (arrow).*
