Morcellation-Assisted Vaginal Hysterectomy: A Practical Operative Guide

INTRODUCTION: Vaginal hysterectomy remains underutilized for the removal of enlarged uteri, despite being the preferred route for benign hysterectomy. While prior literature describes vaginal morcellation techniques in the context of laparoscopic or robotic hysterectomy, there is a paucity of guidance on morcellation-assisted vaginal hysterectomy. Reports of morcellation during vaginal hysterectomy focus on singular approaches and do not account for variation in morcellation strategy based on uterine anatomy. Furthermore, decision-support tools, shown to standardize medical care and improve outcomes, have not been widely applied to gynecologic surgery. OBJECTIVE: We propose a four-part operative guide to support safe and effective morcellation-assisted vaginal hysterectomy for enlarged uteri. METHODS: We conducted a structured review of existing literature describing morcellation-assisted vaginal hysterectomy and minimally invasive techniques for tissue extraction based on uterine size and fibroid location. This was supplemented by expert opinion based on institutional experience with morcellation-assisted vaginal hysterectomy to synthesize a reproducible, standardized workflow. The literature review and development process focused on patient selection, preoperative imaging and planning, intraoperative decision-making, and operative technique. Two deidentified cases were selected to illustrate the steps of the surgical workflow. RESULTS: Our operative guide introduces a novel decision-support tool to aid in selecting the optimal morcellation approach based on fibroid location and uterine size. A preoperative checklist is provided to standardize patient selection, ensure accurate preoperative imaging with fibroid mapping, and optimize operating room setup for safe vaginal access and morcellation. Our guide includes strategies for intramyometrial coring, wedge resection, and bivalving, tailored to different uterine anatomy. By offering an adaptable framework, our guide supports increased adoption of morcellation-assisted vaginal hysterectomy, even in cases involving significantly enlarged uteri, based on surgeon expertise and institutional resources. CONCLUSIONS: A structured, four-part operative guide for morcellation-assisted vaginal hysterectomy offers a practical, safe approach to managing enlarged uteri. Its use may facilitate a resurgence in vaginal hysterectomy as a patient-centered option, especially in resource-limited settings or among patients seeking to avoid abdominal surgery.