**9.1** *Anterior tilting* **(Doderlain-Kronig maneuver)**

*Anterior tilting* (Doderlain-Kronig maneuver) is recommended in the case of a small uterus with a short superior pedicle or for a prolapsed uterus. The most common examples are those selected for vaginal subtotal hysterectomy. Anterior tilting is the quickest route to access the pedicle, but it cannot be used successfully with a large uterus (**Figure 21**).

The cervix is forcefully pulled caudally to expose as much as possible the anterior side of the uterus. Using a Pozzi clamp, the mass of the uterine body is clamped on the median line as high up as possible. It is gradually pulled, without sudden moves that lead to the rupture of the myometrium. At the same time, the cervix is left free without traction or pushed cranially and posteriorly with the Pozzi clamp. Along with the uterus's progress into the surgical field, using another Pozzi clamp, the mass of the uterine tissue is escalated as high up as possible until the uterine fundus and one or two superior pedicles appear in the surgical field. At this time, the cervix is pulled cranially to place the pedicle under tension. The index finger of the surgeon's left hand cranially and caudally loads the superior uterine pedicle, while the right-hand loads the pedicle into the arms of the Wertheim clamp.

After clamping and cutting, the pedicle is ligated, and the ends of the threads are kept as benchmarks. For the contralateral side, the maneuver for clamping the pedicle simplifies because, by pulling onto the cervix, the pedicle will be well exposed. Cutting and ligating the pedicles gives rise to the extraction of the uterus.

**Figure 18.** *Disconnection of upper pedicle by posterior tilting (Heaney maneuver).*

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

#### **Figure 19.**

*Disconnection of the superior pedicle. In this case, the uterus is hemisected previously. The pedicle is hooked by the index finger and then clamped.*

#### **Figure 20.**

*Clamped left upper pedicle. We can see what it is made of 1 = round ligament, 2 = utero-ovarian ligament, 3 = tube.*

The pedicle can be completely clamped or the round ligament isolated when one aims to perform the adnexectomy.

#### **9.2 Posterior tilting (Heaney maneuver)**

Posterior tilting (Heaney maneuver) is the most frequently used maneuver to access the superior pedicle for non-prolapsed uteruses weighing more than 180 g.

#### **Figure 21.**

*Anterior tilting (Doderlain-Kronig maneuver). After anterior colpoceliotomy, the anterior side of the uterus is evident. Using Pozzi forceps, the uterine fundus is extracted, and the superior pedicle can be clamped and cut.*

Posterior tilting has the main advantage of being able to rotate the uterus in a much larger space, represented by the sacral concavity.

The cervix is forcefully pulled cranially while the assistant depresses the rectum using a Sims retractor to reveal as much as possible of the posterior side of the uterus. The surgeon places a Pozzi clamp on the dorsal middle bottom of the uterus, as close as possible to the uterine pouch. Relaxing the tension exerted on the cervix, it is pulled progressively by the clamp while the assistant tries to extract the uterus using the posterior retractor. When uterus progression is observed, the position of the uterus pulling clamp is changed to become as cranial as possible, and the releasing maneuvers are continued until the uterine fundus appears in the surgical field (**Figures 22** and **23**).

Unlike anterior tilting, the superior pedicle does not become visible. To be able to identify it, the surgeon places a Briesky retractor in the area between the lateral wall of the vagina and the uterine horn, usually on the left side, where access is more accessible. As an aiding maneuver, the clamp anchoring the uterine fundus is repositioned as close as possible to the externalized uterine horn. Thus, by simultaneously pulling the cervix and uterine fundus and maneuvering the Briesky-Navratil retractor laterally, the superior pedicle is revealed at its insertion into the uterus. With the medius of the left hand, the surgeon loads the pedicle in a cranial position to clamp the pedicle in a caudal place with the right hand using a Wertheim clamp.

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

#### **Figure 22.**

*Posterior tilting (Heaney maneuver). Clamping the left superior pedicle. The cervix is pulled cranially at the same time that the uterine fundus is pulled hard caudally.*

**Figure 23.** *The Heaney maneuver. The right pedicle is clamped ˝a la Vue easily. ˝.*
