A vaginal fornices delineator was introduced in the mid-90s by a gynecologic surgeon named Charles Koh as a device that would facilitate total laparoscopic hysterectomy. It is also used in robot-assisted and traditional laparoscopic hysterectomies. The delineator delineates the vaginal fornices and provides improved visualization of vital structures during a hysterectomy. The determination of the anatomic level of the cervix is vital in the identification of the inferior borders of a total hysterectomy and to avoid injury to the ureters and uterine vessels. As such, we describe 3 gynecologic surgeries in which the identification of this level was suboptimal. Our solution was to utilize a vaginal fornices delineator as the cervical “guide” to enhance this visualization and to allow for a complete and safe surgical outcome. The following surgical scenarios and the surgical facilitation provided by the vaginal fornices delineator will be presented: (1) a postpartum cesarean hysterectomy complicated by a large lower uterine fibroid tumor that distorts the cervix, (2) a robotic-assisted placement of an abdominal cerclage in a first-trimester pregnancy, (3) abdominal hysterectomy complicated by a necrotizing uterine infection and the associated difficulty in the identification of the cervicouterine junction.
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Problem: postpartum cesarean hysterectomy, robotic-assisted abdominal cerclage, and abdominal hysterectomy
A cesarean delivery was complicated by a 10-cm lower uterine fibroid tumor and postpartum hemorrhage that necessitated a hysterectomy. The cervix was closed, uneffaced, and in the mid position. A KOH Cup (KC; Cooper Surgical, Inc, Trumbull, CT) was placed intravaginally, and cephalad traction was applied. As the case progressed, the KC was easily palpable and aided in the identification of the vaginal fornices. At this level, the peritoneum was dissected laterally. This aided in the lateralization of the ureters and in the identification of the uterine vessels. The uterine specimen was then removed in its entirety.
A 31-year-old G 6 P 1 woman at 12 +3 weeks of gestation underwent placement of a robot-assisted abdominal cerclage for cervical insufficiency. A KC was used vaginally to delineate the vaginal fornix and to identify the uterine vessels. The peritoneum overlying the KC was dissected; uterine vessels were identified, and a cerclage was placed successfully. The patient delivered at term.
A 19-year-old G 4 P 3104 woman underwent a cesarean delivery at 32 weeks of gestation for preterm labor and category III fetal tracing. Within 3 days, fascial dehiscence, purulence from the vagina and abdominal incision, and uterine necrosis developed. Exploratory laparotomy showed copious intraabdominal purulence that necessitated an abdominal hysterectomy. A KC was utilized to identify the vaginal fornix during hysterectomy, and the necrotic uterus was entirely extirpated.
Our solution
In our institute, the KC is readily available for gynecologic procedures. The KC is made of Ultem plastic (Sabic Americas, Houston, TX; Figure 1 ) and is available in 4 sizes: 2.5-, 3-, 3.5-, and 4-cm cups. The correct size allows the rim of the cup to be well applied against the vaginal fornices while covering the entire cervix.
Once adequate anesthesia is achieved, we use a vaginal speculum or sidewall retractors to visualize the cervix and select the proper-sized KC. Two ring forceps are then clamped along the posterior rim of the KC ( Figures 1 and 2 ), particularly with robot-assisted cerclage placement in pregnant patients and with challenging abdominal hysterectomies that preclude normal identification of the vaginal fornices and cervix. Once set up, the ring forceps and KC are lubricated and gently advanced intravaginally. We place the KC under steady cephalad traction to ensure constant vaginal stretch and distance ureters from the planned colpotomy as described in the literature. The KC serves as a palpable landmark at the level of the cervix that aids in the identification of uterine vessels and displacement of the ureters away from the dissection plane as the broad ligament is dissected during hysterectomy (Video).
