Video Clips on DVD
- 8-1
Uterine Morcellation Techniques
- 8-2
Difficult Anterior Entry
- 8-3
Difficult Posterior Entry
- 8-4
Uterovaginal Prolapse
Previous chapters have discussed the advantages of vaginal hysterectomy over other approaches and described its basic technique. There are few absolute contraindications to the vaginal approach for hysterectomy; however, there are a few factors that generally preclude this approach, including (1) the suspicion of malignancy; (2) the presence of known extrauterine disease or adnexal disease; (3) a narrow pubic arch (<90 degrees); (4) a narrow vagina (narrower than 2 fingerbreadths, especially at the apex); and (5) a fixed, immobile uterus. In the absence of all of these factors, vaginal hysterectomy should be the approach of choice whenever feasible given its well-documented advantages.
Some conditions and patient characteristics can make vaginal hysterectomy technically challenging. Many of these are easily identified preoperatively and can be anticipated. These conditions include the enlarged uterus, uterine prolapse, and the undescended uterus. This chapter discusses the surgical approaches to these difficult cases and describes techniques to facilitate their safe and successful completion. It also discusses techniques to manage surgical challenges that may not be anticipated and may be encountered even in cases initially thought to be simple and straightforward, such as difficult anterior or posterior entry into the peritoneal cavity and pelvic adhesive disease. By mastering the techniques described in this chapter, the gynecologic surgeon can increase the proportion of hysterectomies that can be successfully performed vaginally to the ultimate benefit of their patients.
Patient Selection and Preparation
Considerations for the selection of route of hysterectomy and a discussion of routine pre- and perioperative patient preparation can be found in Chapter 4 . Once it is determined that the patient is an appropriate candidate for hysterectomy, the choice of route of surgery is largely dependent upon the patient’s medical history, the findings during pelvic examination, and the surgeon’s experience and skill. The gynecologic surgeon must use his or her judgment to select the best approach for the individual patient. Suspected malignancy or the presence of an adnexal mass are contraindications to vaginal hysterectomy. However premalignant conditions such as cervical intraepithelial neoplasia (CIN) III or complex endometrial hyperplasia are often best performed via the vaginal route. Factors in the patient’s medical history that suggest the possibility of a difficult or technically challenging vaginal hysterectomy include uterine enlargement; a history of endometriosis, pelvic adhesive disease, or pelvic inflammatory disease; and a history of previous pelvic surgery. However, in appropriately selected patients the skilled vaginal surgeon can often successfully perform a hysterectomy via the vaginal approach in patients with these conditions. In patients with a history of endometriosis or previous pelvic surgery it is often useful to review the operative notes from previous surgeries to help determine the degree of pelvic adhesive disease when making the assessment of whether vaginal hysterectomy is appropriate. Additionally, patients with a history of or suspicion for extrauterine disease may benefit from preoperative imaging such as transvaginal ultrasonography or pelvic magnetic resonance imaging (MRI) in order to help determine the appropriateness of the vaginal approach. Nulliparity or history of cesarean section may increase the degree of difficulty of a vaginal hysterectomy, but should not be considered contraindications. Specific patient selection criteria for each of these conditions will be discussed in greater detail later in the chapter.
On preoperative physical examination, the surgeon should make careful note of the following factors in order to assess the degree of difficulty of performing a vaginal hysterectomy: (1) size and shape of the bony pelvis with particular note of the angle of the pubic arch; (2) the vaginal caliber, particularly at the apex; (3) the mobility of the uterus in all dimensions; and (4) the size and shape of the uterus. A pubic arch angle of less than 90 degrees generally precludes vaginal hysterectomy, and a wide pubic arch angle will facilitate the vaginal approach. In addition to the pubic arch angle, advocate assessing the slant the vulva makes with the body axis (vulvar slant) as a way of assessing the adequacy of the bony pelvis for vaginal surgery ( Fig. 8-1 ). They noted that the gynecoid pelvis, which has the most room for vaginal surgery, has a vulvar slant of about 45 degrees with the horizontal, but the android and anthropoid pelvis is often contracted and associated with a vulvar slant that is about 90 degrees or perpendicular with the horizontal. The platypelloid pelvis, which may also be constricted, has a vulvar slant of approximately 30 degrees. During bimanual examination, the surgeon should carefully assess the uterine mobility in all directions. Adequate mobility in the lateral and anteroposterior (AP) directions is a prerequisite for vaginal hysterectomy. Although lack of uterine descent is often discussed as a contraindication to vaginal hysterectomy, the descent of the cervix and uterus noted on preoperative examination is less important than mobility in the lateral and AP directions for predicting successful vaginal hysterectomy. As will be discussed later in the chapter, vaginal hysterectomy can often be successfully completed in women without uterine descent noted on preoperative examination, presuming adequate vaginal caliber and uterine mobility in the other planes. Moreover, uterine descent often improves significantly after the patient is placed under anesthesia and the pelvic floor muscles are relaxed. Some surgeons advocate assessing uterine descent preoperatively by performing a “traction test” whereby the cervix is grasped with a single-tooth tenaculum and traction is applied on the uterus. We generally do not advocate the use of the traction test as it can be painful to the patient and is not necessarily predictive of the degree of descent that will be present when the patient is under anesthesia or the likelihood of success of vaginal hysterectomy. The surgeon should also assess the vaginal caliber during preoperative examination, paying particular attention to the caliber of the upper vagina. If the width of the vagina at the apex is less than 2 fingerbreadths, then it is unlikely that a vaginal hysterectomy can be accomplished safely and the laparoscopic or abdominal approach is more appropriate. Conversely, a wide vaginal caliber will increase the likelihood of successful vaginal hysterectomy and is particularly desirable in the face of other factors that might make the vaginal hysterectomy more challenging, such as an enlarged uterus and poor uterine descent. During preoperative physical examination, the surgeon should also assess the uterine size and shape. With the skilled use of morcellation and other uterine size reducing techniques there is no upper limit of uterine size that necessarily precludes the vaginal approach; however, we generally do not advocate vaginal hysterectomy for uterus greater than 16 weeks in size. Details of the appropriate selection of vaginal hysterectomy for patients with the enlarged uterus are discussed in detail later in the chapter.
While all patients undergoing vaginal hysterectomy should be counseled that a laparotomy or laparoscopy may be necessary to complete the hysterectomy if vaginal removal is not possible, this is particularly true for the patient whose hysterectomy is expected to be difficult. In these patients, it is often useful to inform the operating room staff to have the equipment for a laparoscopy or laparotomy readily available in case conversion is necessary. As with all hysterectomies, the standard perioperative intravenous antibiotics and antiembolic prophylaxis are routinely given prior to surgery. Factors that will increase the likelihood of successful and safe completion of a vaginal hysterectomy that is anticipated to be difficult include proper patient positioning, a careful examination under anesthesia, adequate lighting and instrumentation, and good surgical assistance. Although vaginal hysterectomy can be performed using either Allen or candy-cane stirrups, the candy-cane stirrups are particularly helpful in cases that are expected to be difficult. Compared with Allen stirrups and other similar boot stirrups, the candy-cane stirrups provide increased exposure to the deep pelvis and adequate room for two operative assistants. (See Chapter 7 for a discussion of appropriate patient positioning using candy-cane stirrups.) After proper patient positioning, an examination under anesthesia (EUA) should be performed to confirm the preoperative assessment and more carefully evaluate the uterine size, degree of uterine mobility, the width of the vaginal canal, and the presence or absence of pelvic disease. A rectovaginal examination should be performed to assess the freedom of the posterior cul-de-sac. The EUA provides the surgeon with the best assessment of whether or not the hysterectomy can be performed successfully and safely via the vaginal route and it is at this point that the final decision about whether or not to proceed with the vaginal approach should be made.
Good visualization is important for any surgery but especially for the difficult vaginal hysterectomy. To maximize visualization, it is valuable to have two surgical assistants, ideally with at least one of them also a skilled vaginal surgeon. Good operative lighting is essential. In some instances, the use of a headlamp or lighted retractor or suction device can be valuable. A number of instruments can be useful for difficult vaginal surgery beyond those found in the typical vaginal hysterectomy set including a long needle drivers; long heavy Mayo scissors; a weighted speculum with an extra-long blade (Steiner-Auvard speculum); long Allis clamps; a number of different tenacula including the single-tooth, Jacobson, and Leahy varieties; Briesky-Navratil vaginal retractors; long and short right-angle retractors (Heaney retractors); a flexible uterine sound; a Bovie extender; and a scalpel with a long handle ( Fig. 8-2 ). A cystoscope should also be available to evaluate the integrity of the bladder and ureters during or at the end of surgery. In cases in which blood loss may be increased such as the large fibroid uterus, the use of a surgical blood salvage/autotransfusion system (CellSaver®, Haemonetics Corp., Braintree, MA) can be considered.
Case 1: Menometrorrhagia, Dysmenorrhea, and Uterine Fibroids
L.D. is a 42-year-old gravida 2, para 2 female who presents with painful, irregular, heavy menses. She reports a 3-year history of painful menses that are partially relieved with nonsteroidal anti-inflammatory drugs (NSAIDs). She states that her menses occur every 2 to 4 weeks and last 8 to 9 days with a heavy flow that includes blood clots. She uses approximately 10 to 12 pads per day to manage this bleeding. Previous treatments have included oral contraceptives and depot-medroxyprogesterone acetate, which did not relieve her symptoms. Her past surgical history is significant only for a previous postpartum tubal ligation. Bimanual examination reveals an irregularly shaped 12-week-size uterus that is freely mobile in all directions. Several fibroids appear to be located in the uterine fundus but the lower uterine segment and cervix are normal size. Her pubic arch angle is approximately 120 degrees and her vaginal caliber is approximately 3 fingerbreadths in width. Office hysteroscopy reveals a distorted uterine cavity but no intramural fibroids or polyps. An endometrial biopsy performed 2 months previously reveals proliferative endometrium. Her laboratory values reveal a hematocrit of 30.0%. The options of further medical management, uterine fibroid embolization, myomectomy, and hysterectomy were discussed and she prefers a vaginal hysterectomy if possible.
Discussion of Case
Uterine fibroids are a common cause of excessive and irregular menstrual bleeding and dysmenorrhea. Other symptoms that can be attributable to uterine fibroids include pelvic pain and bulk symptoms such as urinary frequency and urgency, rectal pressure, pelvic pressure, and increasing abdominal girth. Hysterectomy can be considered in a woman with symptomatic uterine fibroids who no longer desires fertility, particularly if the severity of symptoms is such that they interfere with her daily life. Given the severity of this patient’s symptoms, the lack of response to medical management, and resulting anemia, it is reasonable to consider hysterectomy in this case. Myomectomy by either laparoscopy or laparotomy and uterine fibroid embolization are also options, but hysterectomy remains the most effective and definitive method for relieving this patient’s symptoms. As was noted in Chapter 3 , uterine fibroids and menstrual irregularities are the most common indications for hysterectomy in reproductive age women. Uterine fibroids are the most common reason for uterine enlargement, but adenomyosis and malignancy are other potential sources that should be considered. When the uterus is enlarged, bimanual examination is usually adequate to make a diagnosis of uterine fibroids, particularly when intramural and subserosal fibroids are present, because they often result in a characteristic irregularity of the uterine contour as in this patient. Although the vaginal, laparoscopic, or abdominal approach to hysterectomy might be reasonable in this patient, the vaginal approach offers several distinct advantages. When vaginal access is adequate and the uterus is enlarged, vaginal hysterectomy can often be accomplished safely using uterine size reduction techniques such as wedge morcellation, uterine bisection, and intramyometrial coring. A randomized trial comparing the vaginal to the abdominal route for women with enlarged uteri (200 to 1300 g) demonstrated decreased operating time, febrile morbidity, postoperative narcotic use, and hospital stay for those who received vaginal hysterectomy (with or without morcellation) compared to total abdominal hysterectomy ( ). Similarly, several clinical trials have demonstrated advantages of vaginal hysterectomy over laparoscopically assisted vaginal hysterectomy (LAVH) in women with enlarged uteri including decreased hospital stay, less operating room time, quicker discharge, and less blood loss ( ; ). One trial suggested that vaginal hysterectomy also had a lower complication rate than LAVH in women with enlarged fibroid uteri ( ). There are currently no randomized comparisons of total laparoscopic hysterectomy and vaginal hysterectomy performed exclusively for enlarged uteri, but generally the laparoscopic approach is associated with greater operating time and cost ( ). This patient has a number of characteristics that make her ideal for the vaginal approach including adequate vaginal caliber and pubic arch angle, a mobile uterus with a surgically accessible lower uterine segment, and fibroids confined to the uterine fundus.
Vaginal Hysterectomy for the Enlarged Uterus
Patient Selection
As noted earlier, during the preoperative bimanual examination a careful assessment of uterine shape is essential, as it is often more important than actual size for identifying the appropriate patient for vaginal hysterectomy in the face of uterine fibroids. Before beginning any uterine size reduction or morcellation procedure, the uterine vessels must be ligated bilaterally and the peritoneal cavity should be entered both anteriorly and posteriorly. If the cervix or lower uterine segment is enlarged or contains fibroids that prevent uterine artery ligation or entry into the peritoneal cavity then the procedure should not be performed vaginally, regardless of size. In contrast, if the lower uterine segment is accessible surgically and the uterine fundus is mobile, then even very large uteri (up to 20-week size) can be removed transvaginally by an appropriately skilled surgeon. The presence of lateral or anterior fibroids tend to make transvaginal removal more difficult. In contrast, posterior fundal myomas are often easily removed transvaginally.
With increasing skill the gynecologic surgeon can become adept at removing large uteri transvaginally. For most gynecologic surgeons, it is probably reasonable to attempt transvaginal hysterectomy in patients with up to 12- to 14-week-size uteri (or 300 cm 2 ). Although the upper limit of uterine size for which a vaginal hysterectomy should be done has not been established, many skilled vaginal surgeons would consider 16- to 18-week size as a reasonable and practical upper limit. In our experience, removing uteri larger than this, although often technically feasible, can be a significant struggle associated with long operating times and increased blood loss.
In women with uterine fibroids and anemia, gonadotropin-releasing hormone (GnRH) agonists preoperatively should be considered. A common regimen is leuprolide acetate 3.75 mg given intramuscularly at monthly intervals for 3 months preoperatively. A meta-analysis of 26 randomized trials comparing preoperative GnRH agonists to no treatment or placebo found that those who received preoperative GnRH agonists increased their hematocrit an average of 3%, decreased their uterine volume an average of two gestational sizes (i.e., from 14 weeks to 12 weeks), and decreased intraoperative blood loss an average of 58 mL ( ). Additionally, because of the decrease in uterine volume, women who received preoperative GnRH agonists were more likely to receive a vaginal hysterectomy than those who did not.
Surgical Techniques (Video 8-1 
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Transvaginal removal of an enlarged uterus begins similar to that of a routine vaginal hysterectomy. A careful EUA should be performed to confirm the size, shape, and mobility of the uterus as well as the adequacy of vaginal access. The hysterectomy proceeds in the standard fashion until the uterine arteries are ligated bilaterally. After entry into the anterior and posterior cul-de-sacs, it is helpful to digitally palpate the uterus to confirm the location and size of the uterine fibroids. When the uterus is enlarged from uterine fibroids or adenomyosis, uterine debulking techniques such as uterine bivalving, intramyometrial coring, wedge morcellation, and myomectomy are often necessary to successfully complete the hysterectomy vaginally. The employment of uterine debulking techniques becomes necessary when all accessible pedicles have been cut and ligated and no further uterine descent is possible for the delivery of the fundus through the anterior or posterior cul-de-sac. Each of these uterine debulking techniques may be used alone but often are used in combination with each other, so the surgeon should be familiar with each technique. noted that the versatility in the application of the various morcellation techniques is a key factor to successful transvaginal removal of the enlarged uterus.
Prior to proceeding with uterine morcellation the following criteria should be met regardless of technique planned:
- 1.
The uterine arteries should be ligated bilaterally. If an additional pedicle on the broad ligament beyond the uterine artery can be ligated prior to beginning morcellation, this is desirable.
- 2.
The anterior and posterior cul-de-sacs should be entered. There are circumstances where the surgeon may consider proceeding with morcellation without having entered the anterior or posterior cul-de-sacs but these are uncommon and should be approached with caution. (See section on difficult anterior and posterior entry later in the chapter.)
- 3.
Long retractors should be placed anteriorly and posteriorly to protect the bladder and rectum respectively. We prefer to use a long weighted speculum such as the Steiner-Auvard speculum posteriorly and a long right-angle Heaney retractor anteriorly.
- 4.
The bladder should drained either continuously or at frequent intervals throughout the case.
Because the uterine vessels have been ligated and steady traction is applied to the uterus throughout the procedure compressing collateral vessels, the amount of bleeding from any of the uterine debulking techniques is limited. Prior to beginning any of the uterine debulking procedures, it is useful to place Heaney clamps or single-tooth tenacula bilaterally on the uterine fundus just above the highest ligated pedicle. This ensures that the pedicles will not be lost, maintains uterine orientation, and provides useful lateral landmarks for morcellation. Careful observation for nearby intestines or intestinal adhesions should be made throughout in order to prevent accidental bowel injury. It may be desirable to use the Trendelenburg position and pack the bowel out of the pelvis using long laparotomy sponges.
Bivalving or Hemisection (See Fig. 8-3 and Video 8-1 
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Uterine bivalving or hemisection is performed by splitting the uterus in the midline into halves before removal. This allows one half of the uterus to be temporarily displaced into the pelvis, providing greater mobility and visualization for surgical removal of the other half of the uterus. Bivalving is best performed on mildly enlarged uteri that are symmetrical. Bivalving is begun by grasping the uterine cervix at 3 o’clock and 9 o’clock with tenacula. Using a scalpel or heavy scissors the uterus is divided longitudinally in the midline ( Fig. 8-3B ). Continuous traction should be placed on both tenacula throughout the procedure. Once the uterine fundus is accessible, a finger or vaginal retractor is placed behind the uterus to protect the pelvic viscera and the fundus is completely divided. If the uterine fundus is not accessible, then morcellation or myomectomies should be performed, as needed ( Fig. 8-3C ), until delivery of the fundus occurs and the upper pedicles can be ligated.
Intramyometrial Coring (See Fig. 8-4 and Video 8-1 
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Intramyometrial coring was first introduced by Lash in 1941. This technique facilitates removal of the enlarged uterus through decreasing the uterine width by increasing its length. Coring is most easily performed on moderately sized symmetrically enlarged uteri without multiple fibroids. It is a particularly useful technique when the vaginal canal and pubic arch are somewhat narrow. While applying firm traction to the cervix, the myometrium is incised circumferentially using a scalpel or heavy scissors parallel to the long axis of the uterine cavity at the level of the uterocervical junction below ( Fig. 8-4C ). The incision is continued circumferentially parallel to the uterine serosa maintaining a thin shell of myometrium superficially to avoid perforation into the serosa. Care should be taken to avoid creating multiple planes. As the cervix is pulled, the myometrium is “cored out” so that the endometrial cavity and a layer of myometrium are pulled toward the surgeon, collapsing the bulky uterus and allowing access to the upper pedicles (see Fig. 8-4D ). As the uterine fundus enlarges, the plane of dissection should stay close to the uterine serosa in order to ensure that the removed core is large enough to reduce uterine volume sufficiently to allow delivery of the fundus. Because the coring technique is intraserosal, it is a particularly useful technique when uterine adhesions are present, as will be discussed later in the chapter.
Wedge Morcellation (See Fig. 8-5 and Video 8-1 
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Wedge morcellation is the most versatile uterine debulking technique and is the procedure of choice when other techniques fail. Wedge morcellation begins by amputating the cervix with a wedge-shaped incision into the uterine corpus. Alternatively, the surgeon can begin wedge morcellation after bivalving the cervix. The surgeon maintains orientation of the uterus and continuous traction by placing Heaney clamps or single-tooth tenacula bilaterally on the uterine fundus just distal to the highest ligated pedicle. It is generally recommended that these clamps not be moved or removed until the uterine fundus has been debulked enough to be delivered. V -shaped pieces of tissue are removed piecemeal from the anterior and posterior uterine walls in order to centrally debulk the uterus. (See Fig. 8-5 and Video 8-1 for two variations in the technique. 
) A tenaculum is applied to the tissue that is to be excised and traction applied. Excision is performed with a long-handled scalpel or heavy Mayo scissors. Several different kinds of uterine tenacula including single-tooth, double-tooth (Jacobson), and Leahey tenacula should be available to assist with the morcellation process. Uterine myomas are removed as encountered. Morcellation is continued until the round ligament, utero-ovarian ligament, and fallopian tube are accessible and can be clamped, cut, and ligated.
