Evidence-based practical guidelines of the International Society for Gynecologic Endoscopy (ISGE) for vaginal hysterectomy

Objective: The study was established by the International Society for Gynecologic Endoscopy (ISGE) to provide evidence-based recommendations in the steps that should be undertaken in successfully performing a vaginal hysterectomy for a non-prolapsed uterus. Material and methods: The ISGE Task Force for vaginal hysterectomy for the non-prolapsed uterus defined key clinical questions regarding the surgical technique, which led the Medline/PubMed and the Cochrane Database literature search. Identified pertinent articles, published in English from 1997 to 2019, were analysed. The available information was graded by the level of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Working Group approach. The recommendations were developed through multiple cycles of literature analysis and expert discussion. Results: Six recommendations were established: 1. A circular incision at the level of cervico-vaginal junction is recommended (grade IC). 2. The posterior peritoneum should be opened first (grade IC). 3. Clamping and cutting the uterosacral and cardinal ligaments before or after getting access into anterior peritoneum is recommended (grade IC). 4. Routine closure of the peritoneum during vaginal hysterectomy is not recommended (grade IB). 5. Vertical or horizontal closure of the vaginal vault following vaginal hysterectomy is recommended (grade IC). 6. To insert a vaginal plug following vaginal hysterectomy is not recommended (grade IB). Conclusion: Vaginal hysterectomy for a non-prolapsed uterus should be the preferential route for removing the uterus when hysterectomy is indicated. The ISGE provides evidence-based practical guidelines on how vaginal hysterectomy for non-prolapsed uterus should be undertaken. All efforts should be directed in teaching the surgical technique of vaginal hysterectomy during residency.