A technique to positively identify the vaginal fornices during complicated postpartum hysterectomy

The frequency of cesarean hysterectomy is increasing, predominantly driven by an increased incidence of morbidly adherent placenta associated with previous cesarean delivery with or without placenta previa. Most cases of morbidly adherent placenta are located anteriorly with involvement of the bladder. The lower uterine segment in increta and percreta cases frequently is thinned and deformed, with extensive vascular supply to the bulging placenta. This deformation of the lower segment makes identification of the cervicovaginal interface and vaginal fornices difficult. This may result in either removal of excess vaginal tissue with unnecessary vaginal shortening, or alternatively, a supra- or transcervical hysterectomy that may include placental tissue within the pedicle and increase blood loss. We have developed a technique, repurposing a reusable and cost-effective device designed to help in bowel anastomosis (end-to-end anastomosis sizer), that improves identification of the vaginal fornices, helps to secure the vaginal angles, and improves the ability to perform a total hysterectomy.