PRE-OPRATIVE PREPARATION

1. Patient clerkship and physical examination.
2. Informed consent from patient.
3. Check if any extra medical considerations regarding patient’s anamnesis are required
4. Surgical safety checklist 
 
INTRAOPERATIVELY

1.  Prophylactic antibiotics on induction
2. General anaesthesia
3. Patient in Trendelenburg position
4. Abdominal shaving
5.  Speculum exam
6. Physical examination if not performed earlier
7. Monitors in position 15 to surgeon’s eye axis surgeon on left assistant on the right
8. Second assistant between the legs,
9. Ensure all cables in order
 
PNEUMOPERITONEUM

1. Entry technique as preferred by surgeon and clinical history of patient
2.  Ports placement: laparoscope is ideally at umbilicus, accessory ports are placed at least 7.5 cm from central trocar lateral to umbilicus. Trocar size 5 mm
3. Eye instrument axis must be maintained. the target is the vaginal vault

 
TASK ANALYSIS

1. General endotracheal anesthesia has already been induced.
2. Abdomen has already been insufflated with CO2 (see previous section)
3. Careful pelvic and upper and lower abdomen exam is performed
4. Patient should be placed in Trendelenburg position
5. Bowel is swept out of the pelvis if needed
6. Using a rectal sizer placed in the vaginal vault, the vault is inverted
7. Peritoneal lining should be identified overlying the pubocervical and rectovaginal fascias
8. Uterosacral ligaments should be indentified as well as their topographic relation to the urethers (the latter run anterolateral to the ligaments) in order to avoid lesions at this level)
9. Follow the uterosacral ligaments as they enter the sacrum
10. Tag with suture the unbroken uterosacral ligament bilaterally
11. Open the peritoneum overlying the pubocervical and rectovaginal fasciae
12. By sharp dissection, identify ventrally the pubocervical fascia that lies between the vagina and the bladder
13. Identify posteriorly the rectovaginal fascia
14. Excise redundant peritoneum and excess vagina as needed
15. Take stitches at the corners on each side in a way they will approximate the edges of the pubocervical to the rectovaginal fascia overlying the vaginal mucosa
16. The corner stitch on each side is then incorporated into the ipsilateral uterosacral ligament which had been already tagged
17. The now reapproximated fasciae along with the vaginal apex are now incorporated to the uterosacral ligaments as the enter the sacrum on both sides
18. The pubocervical and rectovaginal fascia are hence sutured to the unbroken uterosacral ligaments
19. The pubocervical fascia is approximated to the rectovaginal fascia acrros the center of the vaginal vault with interrupted sutures
20. Reinforcing sutures from the uterosacral ligaments to the posterior rectovaginal fascia are then placed bilaterally, taken into the account not to cross the midline but rather reinforce the attachment of the corner of the vaginal vault to the ipsilateral uterosacral complex
21. Cystoscopy should be ideally performed to rule out kinking of the urethers during the suspension of the uterosacral ligaments to the vaginal vault
22. Hemostasia is confirmed
23. Ports are withdrawn under direct visualization, optical port is withdrawn and closed
24. Deinsufflation of abdomen is done
25. Skin incisions are sutured