Mastering Anterior Entry: A Three-Step Approach to Vaginal Hysterectomy Using Anatomic Landmarks

INTRODUCTION: Vaginal hysterectomy is the recommended approach for benign gynecologic disease; however, the proportion of hysterectomies performed vaginally continues to decline, leading to inadequate surgical training and difficulty maintaining surgical skills. A key dissection point during a vaginal hysterectomy is the separation of the bladder from the uterocervical junction to complete anterior peritoneal entry, which may be considered the most difficult step of vaginal hysterectomy. Errors made during this dissection can result in inadvertent cystotomy. Anatomical challenges, such as history of cesarean birth, enlarged uteri, cervical elongation, and lack of vaginal parity, can limit visualization and further complicate anterior entry. OBJECTIVE: The objectives of this video are to 1) review important anatomic landmarks visualized during the dissection to complete anterior entry, 2) demonstrate a three-step surgical approach to anterior entry, and 3) apply this method to cases of challenging anatomy. METHODS: This surgical technique video outlines a three-step method for anterior peritoneal entry in vaginal hysterectomy. It emphasizes identifying anatomical landmarks and performing precise sharp dissection of tissue planes and spaces to ensure safe anterior entry. The first step provides exposure by creating a small incision at the anterior vaginal wall and releasing the vesicouterine ligaments. The second step safely elevates the bladder ventrally by incising the supravaginal septum, the connective tissue fibers from the bladder to the cervicovaginal junction. Additionally, the vesicocervical space is dissected to reveal the vesicouterine peritoneal reflection. Finally, in step three, the peritoneal fold is identified, elevated, and anterior entry is secured. This approach is applied to other challenging cases, such as prior cesarean birth, elongated cervix, and uterine procidentia. RESULTS: This video outlines the anatomical landmarks involved in the anterior entry dissection and provides a three-step surgical strategy to safely complete entry. The primary benefit of this technique is the consistent identification of landmarks that guide the dissection to safely enter the peritoneal cavity. Direct visualization combined with the knowledge of apical pelvic anatomy are key factors to reliably avoid iatrogenic bladder injury and complete vaginal hysterectomy. CONCLUSIONS: Anterior peritoneal entry is a critical component of completion of vaginal hysterectomy. Standardized surgical dissections that rely upon anatomical structures can be beneficial for decreasing surgical error and increasing surgeon confidence. This three-step approach consistently achieves safe anterior peritoneal entry during vaginal hysterectomy by direct visualization and sharp dissection even in challenging anatomy. This surgical technique may further advance the evidence-based utilization of vaginal hysterectomy.