Abstract
Vaginal hysterectomy is the surgical removal of the uterus through the vagina. The first reported vaginal hysterectomy, performed by Themison of Athens, dates back to 50 BC, and the procedure is also known to have been performed by Soranus of Greece in AD 120 [1]. There are also sporadic reports dating to the sixteenth century but with questionable outcomes. In 1670, Percival Willoughby, a male midwife, reported a case of a 46-year-old peasant, Faith Haworth, who was carrying a heavy load when her uterus prolapsed completely and, agitated by this, she pulled it out as far as possible and cut it off using a knife. The bleeding apparently settled soon after and she lived to old age albeit with a fistula [2]. The first detailed reports of planned vaginal hysterectomy were for carcinoma, performed by Langenbeck in 1813. After reporting the operation, he was disbelieved by his peers, and it was only when the patient died of old age 26 years later that she was subjected to a post-mortem, and it was confirmed that the uterus had been removed in its entirety. Sauter described a vaginal hysterectomy for cervical cancer in 1822. This is detailed in a commentary on the history of the procedure by Senn [3]. The early mortality from the procedure was very high, with a figure of 75% quoted by Senn. With developments in anaesthesia, instrumentation and antisepsis, this gradually decreased from 15% in 1886 to 2.5% in 1910 [2], and numbers were significantly lower than the figures for abdominal hysterectomy. In 1934, Noble Sproat Heaney of Chicago reported 627 vaginal hysterectomies resulting in only three deaths [4].
15.1 Introduction
Vaginal hysterectomy is the surgical removal of the uterus through the vagina. The first reported vaginal hysterectomy, performed by Themison of Athens, dates back to 50 BC, and the procedure is also known to have been performed by Soranus of Greece in AD 120 [1]. There are also sporadic reports dating to the sixteenth century but with questionable outcomes. In 1670, Percival Willoughby, a male midwife, reported a case of a 46-year-old peasant, Faith Haworth, who was carrying a heavy load when her uterus prolapsed completely and, agitated by this, she pulled it out as far as possible and cut it off using a knife. The bleeding apparently settled soon after and she lived to old age albeit with a fistula [2]. The first detailed reports of planned vaginal hysterectomy were for carcinoma, performed by Langenbeck in 1813. After reporting the operation, he was disbelieved by his peers, and it was only when the patient died of old age 26 years later that she was subjected to a post-mortem, and it was confirmed that the uterus had been removed in its entirety. Sauter described a vaginal hysterectomy for cervical cancer in 1822. This is detailed in a commentary on the history of the procedure by Senn [3]. The early mortality from the procedure was very high, with a figure of 75% quoted by Senn. With developments in anaesthesia, instrumentation and antisepsis, this gradually decreased from 15% in 1886 to 2.5% in 1910 [2], and numbers were significantly lower than the figures for abdominal hysterectomy. In 1934, Noble Sproat Heaney of Chicago reported 627 vaginal hysterectomies resulting in only three deaths [4].
In current practice, the vaginal route is the preferred route of hysterectomy and has several advantages. The Cochrane review comparing routes of hysterectomy for benign gynaecological conditions [5] found that vaginal hysterectomy was superior to abdominal and laparoscopic hysterectomy, with a faster return to normal activities and fewer febrile episodes postoperatively. Where a vaginal hysterectomy is not feasible, other routes are recommended, with the laparoscopic route having advantages over the abdominal, but this is somewhat offset by longer operating time. There are, however, no advantages of the laparoscopic route to the vaginal route.
15.2 Indications
The vaginal hysterectomy is usually performed for benign conditions and is almost never performed in an emergency. It is usually carried out when conservative options have failed, depending on the underlying indication for the procedure. Common indications are similar to those for hysterectomy by other routes with the exception of pelvic organ prolapse and include:
Pelvic organ prolapse: Pelvic organ prolapse is caused by stretching and weakening of the ligamentous supports of the pelvic organs. This can affect the different compartments of the vagina involving the bladder, rectum or uterus. When the apical compartment is prolapsed, a vaginal hysterectomy remains the procedure of choice amongst most urogynaecologists, with 75% performing a vaginal hysterectomy and repair for a uterine prolapse [6].
Abnormal uterine bleeding: Menorrhagia, i.e. heavy uterine bleeding, is a common cause for a hysterectomy.
Fibroids: The symptoms caused by fibroids have been discussed in other chapters of this book. When conservative treatments fail, a woman may opt for a hysterectomy, and where appropriate, and depending on the size and location of the fibroids as well as uterine mobility, this can be done vaginally.
Cervical abnormalities: Pre-cancer abnormalities of the cervix that fail to resolve or recur after treatment can be an indication for a vaginal hysterectomy.
Endometrial hyperplasia: Endometrial hyperplasia is a precursor of endometrial cancer, and if it fails to respond to more conservative treatments, then it can be treated by a vaginal hysterectomy provided invasive cancer can be ruled out.
Chronic pelvic pain: When pain is due to adenomyosis, a vaginal hysterectomy may be indicated.
15.3 Preoperative Assessment
The indication for the hysterectomy should be evaluated preoperatively to determine if a vaginal hysterectomy is the best approach. Preoperatively, an assessment of the patient should take place to assess the menopausal status, size of the uterus, degree of mobility, adnexal pathology, obesity and degree of prolapse if this is present. Other factors such as the patient’s cardiac status and the ability to tolerate anaesthesia must be taken into consideration.
A discussion regarding the pros and cons of removal of the tubes and ovaries should also take place. It is not routine practice to remove the ovaries during a vaginal hysterectomy, and elective removal is associated with pros and cons [7]. Alternatively, the tubes can be removed with conservation of the ovaries.
The presence of fibroids is not an automatic exclusion for a vaginal hysterectomy, and in the presence of prolapse this would still be the preferred route as better vaginal support can be achieved. Most clinicians would use a uterine size equivalent to a 16-week gravid uterus as the upper limit for attempting a vaginal hysterectomy, and beyond this size would revert to an abdominal approach. The location of the fibroids is an important determinant of whether the procedure will be feasible vaginally. A cervical fibroid can make a colpotomy difficult, and likewise large lateral fibroids can obstruct access to the uterine cornua and hamper the ability to safely secure the uterine vasculature.
An important assessment to be made prior to a vaginal hysterectomy, therefore, is the degree of pelvic support and uterine mobility. A vaginal approach is feasible if the uterus is mobile, and this can be assessed in the office setting with a Valsalva manoeuvre. In the presence of prolapse, a formal classification of the prolapse using the POP-Q [8] or its alternatives should be undertaken.
Vaginal access should be assessed based on the angle of the pubic arch. An assessment of the bony pelvis provides a guide to the degree of technical difficulty of the procedure. A gynaecoid pelvis usually has an adequate vaginal canal and a deep and wide posterior fornix, which improves surgical access to the uterus and placement of instruments, facilitating the vaginal approach.
Lastly, the breadth of the vaginal apex identifies if there is adequate access for a vaginal hysterectomy. If the apex is greater than 3 cm, access is usually adequate. This assessment is made by performing a bimanual examination and placing two fingers in the posterior fornix. A wider apex provides sufficient space for anterior and posterior entry and allows visualization of the vasculature.
Laboratory tests including haemoglobin, pregnancy test in the premenopausal patient and urinalysis to rule out underlying urinary tract infection should be undertaken. Previous smears should have been negative. Further tests may be required depending on underlying comorbidities. In patients with a large prolapse, an intravenous pyelogram is helpful to rule out hydronephrosis and assess ureteral function [9, 10] but does not change management.
15.4 Procedure
When a vaginal hysterectomy is performed, either there can be a coincidental finding of fibroids during surgery for prolapse or this may be known in advance due to prior investigations such as ultrasound scan. Irrespective of this, the technique of vaginal hysterectomy remains broadly the same as it would in the absence of fibroids. When fibroids are present, special manoeuvres may be required to facilitate removal. If it is known in advance that fibroids are present and these are likely to obstruct surgery, it is sensible to reduce their size either with the use of GnRH analogues or with medications such as ulipristal acetate. GnRH analogues can reduce the size of the uterus by 25–50%. In addition, fibroids can make patients anaemic, so it is beneficial to shrink the fibroids to improve haemoglobin levels before surgery. If there is a coincidental finding of fibroids during surgery and the uterus is too big, it may not be possible to remove it vaginally and an abdominal route will be required.
The decision to perform a vaginal hysterectomy when fibroids are present is usually because there is an element of prolapse and better support of the vaginal vault can be achieved vaginally than abdominally to prevent prolapse recurrence immediately after surgery, which is the main concern if an abdominal approach is used.
Increased uterine size per se is not a contraindication for performing a vaginal hysterectomy [11]. However, as they tend to be technically more difficult, surgeons undertaking these procedures should be adequately trained. There are several case series reported of vaginal hysterectomy in the presence of fibroids which show good outcomes [11–13].
The following steps describe the author’s technique of performing a vaginal hysterectomy:
1. Once anaesthetized and in the dorsal lithotomy position, the patient is prepared and draped. An examination is performed to assess the degree of prolapse and defects of other compartments, the size of the uterus and its mobility, and whether or not the procedure is feasible vaginally or better performed abdominally. Most clinicians would use a 16-week-sized uterus as a cut-off for vaginal removal.
2. The cervix is grasped on both the anterior and posterior lip, using a vulsellum forceps. By gentle traction and massaging the uterosacrals, the descent of the uterus can be maximized.
3. Paracervical injection of 20 mL of Marcaine (0.5%) is useful for delineating the surgical planes, and reducing postoperative pain. The author’s preference is to inject exclusively paracervically, but it is routine to inject around the uterosacrals, cardinal ligaments and the bladder pillars. Using infiltration with 1:200,000 adrenaline has the advantage of reduced blood loss during surgery but the disadvantage is that the spasm of the vessels caused by vasoconstrictors may mask bleeding from small vessels until the medication wears off and presents as postoperative haemorrhage.
4. With traction on the cervical lips, a circumferential incision is made extending this posteriorly to reach the pouch of Douglas (PoD). The author’s preference is to use diathermy for this but a knife can be used. Anteriorly at the cervicovaginal junction, the full thickness of the mucosa is opened and posteriorly vaginal mucosa opened to reach the PoD. Counter-traction provided by the assistant using a lateral vaginal wall retractor is helpful in this dissection. It is important to avoid dissection too low on the cervix or too deep into the cervix anteriorly and posteriorly as this can cause more bleeding and make dissection difficult.
5. Once the circumferential incision is made, sharp dissection is used to dissect the underlying tissue to reach the cul-de-sac anteriorly and posteriorly.
6. The posterior peritoneum is identified and is held with forceps, and the PoD is opened by sharp dissection using scissors, ensuring there are no loops of bowel in it. A speculum can be inserted into the opened posterior cul-de-sac.
7. It is the author’s preference to open the anterior cul-de-sac before application of clamps on the uterosacral. This ensures that the ureters are moved out of the operative field by dissecting the bladder up. Access to the peritoneal reflection may require blunt dissection to move the bladder out of the way. Through use of a retractor, the bladder is pushed upwards to identify the peritoneal reflection, and this is then opened to enter the vesicovaginal space. Opening the vesicovaginal fold of peritoneum requires sharp dissection using a scissors with the tips pointing towards the uterus. The peritoneal contents are identified and a retractor is left in place anteriorly once the fold of peritoneum is opened to avoid damage to the bladder till the anterior repair is scheduled to be performed or, when this is not planned, till the vault is due to be closed.
Where access is not possible due to a failure to identify the peritoneal reflection, entry is delayed till the uterosacral has been clamped, cut and ligated.
8. Once both cul-de-sacs are opened, and whilst applying traction on the cervix, the clamps (the author’s preferred is Zeppelins) are placed on the uterosacral, perpendicular to the uterine axis. The pedicle is cut and ligated. During ligation, this pedicle is transfixed to avoid slippage when applying traction for vault support at the end of the procedure. Once tied, the two ends of the ligature on the uterosacral are left long enough to attach to the vaginal mucosa and across the midline at the end of the operation. This reduces the incidence of vaginal vault prolapse [14].
9. The next pedicle is the uterine. Where the vesicouterine fold of peritoneum has not already been opened, it should be done at this point and prior to clamping of the uterine vessels.
Contralateral and downward traction is applied on the cervix, and, by incorporating the anterior and posterior reflections of the peritoneum, the clamp is applied over the uterine vessels. These are then cut and ligated. It is not usual to transfix this as it is a vascular pedicle. It is the author’s practice to tie the uterine pedicle incorporating the uterosacral pedicle to secure any bleeders between the two pedicles, and also to ensure that the uterine does not slip.
10. The next pedicle in a normal-sized uterus is the tubo-ovarian pedicle. When the uterus is big, particularly with fibroids, it may be necessary to take one to two more pedicles before the tubo-ovarian can be clamped. If additional pedicles are required, they are clamped cut and ligated in the usual way until the tubo-ovarian pedicle can be reached. The tubo-ovarian pedicle is then clamped cut and ligated. This will usually include the round ligaments as well. It is the author’s practice to transfix and double ligate this pedicle as it is usually quite big.
The ovaries and tubes are inspected to rule out adnexal pathology at this point.
11. In the presence of fibroids and where access to the tubo-ovarian pedicles is obstructed by fibroids, it may be possible to shell these out at this point to reduce the size of the uterus. This may be required for multiple fibroids to allow access. Where it is not possible to shell them out but access to the tubo-ovarian pedicle is restricted, the alternative is to bisect the uterus (Figure 15.1).
When the fibroids are fundal, enucleation is usually not required but the uterus may need more than the usual three pedicles for removal.
12. Once the uterus has been detached from all its attachments, it can be removed either by delivering the cervix first or by delivering the fundus posteriorly.
13. If adnexal removal is planned as part of the surgery, the round ligaments will need to be clamped cut and ligated separately. The peritoneum between the round ligament and the fallopian tube is excised, and by applying traction on the tubo-ovarian pedicle and drawing it into the operative field using atraumatic forceps, this manoeuvre will allow the infundibulopelvic ligament to be clamped, cut and tied, followed by delivery of the adnexa.
14. Closure of the vault can be achieved in several ways. Some surgeons prefer to peritonize the anterior and posterior layers, incorporating the posterior layer as high as possible to close the enterocele sac. This is followed by separate closure of the vaginal mucosa either vertically or horizontally.
15. The author’s preference is to start closure posteriorly in the midline at the 6 o’clock position, incorporating both the vaginal mucosa and peritoneum, with closure of the transverse opening of the vaginal vault vertically using a continuous locking stitch. This closes the enterocele sac while closing the posterior cul-de-sac. The last stitch at the 3 and 9 o’clock positions is used to incorporate the uterosacrals on both sides, thereby accomplishing a McCall’s culdoplasty for further vault support.
16. Where there has been difficulty with access and bleeding in excess of the usual, as well as in premenopausal women or women with fibroids, the author inserts a drain (using either a large-bore Foley catheter or a Robinson drain for this purpose) into the vaginal vault. The use of drains in routine vaginal hysterectomy has failed to show a benefit [15], but in well-selected cases this reduces postoperative pyrexia and vaginal vault haematoma formation.
17. When a vaginal wall repair is required for concurrent cystocele, this is completed before closure of the anterior vaginal wall.
18. The author’s preference is to insert a pack in the vagina overnight and to leave the catheter in overnight when only a hysterectomy is done, but it may be required for longer when an anterior repair has also been done.
19. Postoperative analgesia and fluid management is necessary. Even with minimal bowel manipulation, the bowel tends to be sluggish and there can be nausea and loss of appetite. Early commencement of oral fluids and diet when the patient is able to tolerate this allows for intravenous fluid administration to be limited to the first operative day.
It is unusual to require a patient-controlled analgesia pump (PCA) following a vaginal hysterectomy and usually oral analgesia is sufficient.
