and Jyothi G Seshadri2
Vaginal hysterectomy should be the hysterectomy of choice in patients who have a certain degree of uterovaginal descent provided there is no adnexal mass/suspicious mass/no cervical or broad ligament leiomyoma or suspected sarcoma [1, 2].
Vaginal hysterectomy may also be the hysterectomy of choice in women who are very obese and in whom laparoscopy and laparotomy are going to be very difficult and are associated with high incidence of wound infection and gape, burst abdomen, and incisional hernia. Depending on the skills of the gynecologist, vaginal hysterectomy along with the removal of fallopian tubes and ovaries can be accomplished in women with an undescended uterus (non-descent vaginal hysterectomy) and also in women with the history of one or more caesarean delivery. The size of the uterus per se should not be a contraindication [1, 2]. Presence of the conditions already mentioned, namely presence of adnexal mass, broad ligament leiomyoma, cervical leiomyoma, and possibility of the leiomyoma being a sarcoma, should be a contraindication for vaginal hysterectomy. Laparoscopy should be the surgery of choice in such situations. However, one must keep in mind that even during laparoscopy and laparotomy, one should desist from using a myoma screw or morcellating the uterus, and must avoid intraoperative spillage of the tumor contents in order to avoid upstaging of a possible malignant condition. However, this rule does not apply to advanced carcinoma of the ovary with metastatic deposits, since the question of upstaging due to intraoperative spillage does not arise. The condition is already advanced.
While doing vaginal hysterectomy in a patient with uterovaginal descent, one must begin by sounding the bladder after emptying it in order to determine the extent of bladder. Bigger the prolapse, lower one can expect the bladder to be (large cystocele). In procidentia, one can expect the bladder to be present just above the cervix. Determining the extent of bladder by using tactile sensation of the gloved finger or by visual assessment of what appears to be the lower limit of the bladder is subjective. Sometimes in cases of very large procidentia, the entire bladder and even the parts of the ureters just above the trigone can be in the prolapsed mass (when the cervix is held with a vulsellum and pulled with moderate traction). It is always better to sound the uterus and determine the extent of the bladder and then take the incision a few millimeters below it in order to avoid bladder injury. One must remember that if the bladder injury is on the posterior wall involving the trigone, one cannot just suture the bladder rent vaginally. The ureteric orifices can get kinked and end up very close to each other, causing narrowing of the ureteric orifices, and sometimes the ureteric orifice(s) may also get included in the sutures! Injuries of this kind will require a urologist, and the repair will have to be accomplished by placing a stent in the ureter brought out per urethra. In short it will require an extensive repair [3].
For the same reasons, if hysterectomy is planned following conization of the cervix, it is better to do a laparoscopic or an open hysterectomy. The extent of bladder may be just above the stump of the cervix.
After infiltrating the mucosa over the cervix with saline, take a circumferential incision over the cervix. Adrenaline can also be added to the saline infiltration, since adrenaline causes vasoconstriction and helps reduce the intraoperative bleeding. But bleeding can take place much later when the effect of adrenaline has worn off. It need not be apparent during the surgery. Adrenaline should be used cautiously in cardiac patients, and the anesthetist should be informed prior to infiltration.
The successful opening of the anterior and posterior pouches is the first major step that needs to be accomplished while doing a vaginal hysterectomy. Once the specimen is delivered out after the pouches are opened, the possibility of ureteric injury is negligible since the ureters are retroperitoneal structures, and cannot possibly be outside along the specimen. So the opening of the pouches has to be done early in the course of the surgery.
One can use dry gauze and do blunt dissection, but if the posterior pouch is adherent due to previous colpotomy or infection, or if the anterior pouch is adherent due to previous caesarean delivery, then it is better to do sharp dissection. The assistant should pull the specimen with moderate traction, while the operating gynecologist holds the vaginal mucosa held with Allis forceps with one hand and does the sharp dissection with the other. After the posterior pouch is opened, excise the posterior peritoneum along the posterior uterine wall. This facilitates descent in a case of non-descent vaginal hysterectomy. It is easier to open the posterior pouch first, and after it has been opened, the operating gynecologist can insert his nondominant hand into the pouch of Douglas and hook the uterine fundus with fingers and separate the uterovesical fold over the prominence of his fingers. The assistant gives moderate traction to the specimen if required. However, it is not possible to hook one’s fingers over the fundus after opening the posterior pouch in cases of undescended uteri especially when the specimen is very big. In such cases one has to open the anterior pouch either by blunt dissection- if the planes are well made out, or by sharp dissection- if the planes are not well made out. If there has been a previous caesarean delivery, one is justified in fearing that the bladder may be fused to the isthmus and is more likely to get injured. One can in such situations proceed with sharp dissection, pausing at every step to drain the urine and check if the urine is blood stained or not. If the urine is clear then one can be sure that the bladder has not been injured (yet!). Another tip for opening the anterior pouch in cases of previous caesarean delivery is that one can start the dissection a bit laterally, on either side of the cervix. This is a point where the incision of LSCS may not have been taken and the bladder may not be adherent at this point. If a lot of bleeding is encountered, one can safely cauterize the bleeding vessels on the surface of the specimen, but for bleeding vessels on the base of bladder, one has to be very careful. The bleeding vessel must be caught with a fine tip forceps and gently lifted off the bladder wall before cauterizing it, as a quick “tough and go.” One must make sure that the cautery settings are appropriate before starting the surgery. A cautery burn on the bladder wall should be avoided. If there is a lot of bleeding, apply pressure and think Am I in the right plane? Or am I going into the substance of the cervix? Why should there be so much bleeding if one is in the right plane?
Once both the pouches are opened and the color of the urine is clear, one can safely clamp, cut, and transfix the uterosacral ligaments and then clamp, cut, and ligate the uterine arteries. The cardinal rule in hysterectomy abdominal or vaginal, is that subsequent clamps must always be applied medial to the preceding clamp. Thus, the uterine clamp should be applied medial to the uterosacral pedicle and the cornual clamp is applied medial to the uterine pedicle. In an abdominal hysterectomy, the sequence is the other way—uterine clamp is always applied medial to the cornual pedicle, and the uterosacral clamp is always applied medial to the uterine pedicle.
But what does one do when it is not possible to open the anterior pouch? In such situations, one can apply clamps on the either side of the cervix, making sure that only a small length of tissue is included. The bladder can be sounded again to check if it is really high up before proceeding to cut and transfix. Releasing the uterosacral ligaments on either side will facilitate some descent.
Fothergill’s surgery, also known as Manchester repair, is a procedure indicated for uterovaginal prolapse where there is an elongation of cervix and preservation menstrual function is desired. This surgery involves amputation of the cervix followed by plication of the uterosacral ligaments in front of the cervix. Therefore, one can clamp, cut, and transfix the uterosacrals even if it is not possible to open the pouches. But in order to proceed with vaginal hysterectomy further, that is, ligation of the uterine arteries, the pouches have to be opened.
Once the uterine arteries are ligated on both sides, the vascular supply to the uterus is cut off and one can bisect or morcellate, or core out the uterus. Bisection, morcellation, or coring out of the uterus reduces the bulk of the uterine fundus and helps by facilitating descent. It also provides more space for applying clamps in case of nondescent vaginal hysterectomy. But one has to remember that the uterus also gets its blood supply from the uterine branch of ovarian arteries, and the specimen can in some cases still be vascular. There can be a lot of bleeding during bisection/coring/morcellation of the uterus if the uterine branch of ovarian artery is very big. If the uterus is very fleshy, bulky, and vascular for a postmenopausal woman, think of the possibility of sarcoma and avoid morcellation to avoid intraoperative spillage of a possible malignant condition. It is advisable to convert the surgery to a staging laparotomy. For the same reason, it is better to do a staging laparoscopy or a laparotomy and avoid using a myoma screw in those women who have a sudden increase in the size of a leiomyoma or appearance of a new leiomyoma after menopause [4].
Another special situation is atypical complex hyperplasia of the endometrium. This condition is associated with foci of carcinoma endometrium which may have been missed during endometrial sampling or D&C. Therefore, one must remove the uterus without morcellation and must cut it open after it has been removed to look for any endometrial growth and gross signs of myometrial invasion. This holds true even when the hysterectomy is being done laparoscopically or by laparotomy for complex atypical hyperplasia; one must avoid any kind of morcellation or splitting open of the uterine cavity in situ. It will result in upstaging of an early stage carcinoma endometrium. The patient and her relatives should be told about the need for restaging and completion of surgery should the histopathology report show malignancy [5].
To facilitate further descent, one can divide the round ligament and apply a stay suture on the lateral cut end. This stay suture will be of immense help should the clamps slip and the pedicle gets retracted upward and starts bleeding. By pulling the stay suture on the round ligament gently, one can hope to catch the bleeding pedicle.
Also, by splitting the round ligament a bit laterally, one can gain access to the infundibulopelvic ligament if the removal of the ipsilateral fallopian tube and ovary is desired. One can deliver the specimen out of the vagina and gently hold the ovaries and fallopian tubes with a Babcock forceps, and then clamp, cut, and transfix the infundibulopelvic ligaments. Salpingo-oophorectomy can also be done vaginally in this way.
But if it is just not possible to gain access to the infundibulopelvic ligament vaginally even after morcellating the uterus and dividing the round ligament, what can possibly be done?
No attempt must be made to pull hard, in order to bring the specimen down to clamp the infundibulopelvic ligaments. The specimen could be friable or the clamps may slip leading to profuse hemorrhage necessitating a laparotomy. One must remember that the ovarian artery is a direct branch of the descending aorta, and bleeding from a torn infundibulopelvic ligament which contains the ovarian vessels can be torrential. One option is to clamp the cornua on the ipsilateral side and remove the specimen. The salpingo-oophorectomy can be done once the uterus is out of the way. The stay suture on the round ligament can be lowered a little, and using a Babcock forceps, the fallopian tube can be held. Using a long curved clamp, one can try and hold the infundibulopelvic ligament.
Drain the bladder at intervals. This serves two purposes. First, finding clear urine assures that there has so far been no bladder or ureteric injury, and second, draining the bladder facilitates descent and makes the surgery easier. In other words, a full bladder prevents descent.
Let us now study some photographs taken during live vaginal hysterectomy. Vaginal hysterectomy for uterovaginal prolapse where the specimen is present outside the introitus, and vaginal hysterectomy of a bulky undescended uterus both can be equally challenging.
Taking an Incision Over the Cervix (Fig. 9.1a–c)
Fig. 9.1a
The cervix is being held with a vulsellum and is being pulled with moderate traction (Fig. 9.1a). Bladder has been emptied. The white arrow is showing the metal catheter which is being used to determine the extent of the bladder. The prominence formed by the tip of the metal catheter in the lower part of the prolapse, as shown by the black arrow, is the extent of the bladder. In case of a large prolapse, or procidentia, the extent of bladder could be just above the cervix, and if the extent is not well noted before taking the incision, the bladder injury is certain.
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