After cesarean section, hysterectomy is the second most commonly performed surgical procedure in the United States (US) and Canada. Despite the availability of conservative alternatives, hysterectomy rates and indications have not changed significantly over the past few years. A hysterectomy rate of approximately 5 per 1,000 US patients has stayed the same since 1995. In Canada, rates vary from province to province, with the highest rates (around 5 per 1,000) in Prince Edward Island and the lowest rates (around 2 per 1,000) in Nunavut.

Uterine fibroids provide the most common indication for hysterectomy, followed by menstrual disturbances, prolapse, and endometriosis. Other benign indications include dysmenorrhea and adenomyosis, cervical dysplasia, endometrial hyperplasia, and pelvic inflammatory disease. Vaginal hysterectomy only accounts for approximately 20% of all hysterectomies in the US, as laparotomy is by far the most common route for hysterectomy. This is different from some European countries where one out of two hysterectomies is performed transvaginally.

The vaginal route is associated with decreased postoperative febrile morbidity, a shorter duration of hospital stay, and a speedier patient return to normal activities when compared to the abdominal route for hysterectomy. Intraoperative complications arise with similar or lesser frequency during vaginal when compared to abdominal hysterectomies via laparotomy or laparoscopy. Whenever possible, vaginal hysterectomy should be the preferred route. Bilateral salpingo-oophorectomy is also feasible vaginally in most cases and should not be considered a contraindication to performing a hysterectomy via the vaginal route.

Patients should be counseled regarding alternatives to hysterectomy, such as uterine artery embolization for fibroids, hormonal treatments or endometrial ablation for menstrual disturbances, vaginal pessaries for prolapse, gonadotropin-releasing hormone (GnRH) analogue or pain management for endometriosis, and progestins for endometrial hyperplasia. Completion of childbearing and the use of a reliable method of contraception until surgery should be confirmed with the patient. A history of cervical cytology should be carefully reviewed and abnormal results should be clarified. Symptomatic pelvic organ prolapse and stress urinary incontinence should be carefully assessed before surgery, so that the merits of concurrent surgical management at the time of hysterectomy can be discussed with the patient. Hysterectomy alone is not adequate surgical treatment of pelvic organ prolapse. If physical examination is inconclusive at determining the size and shape of the uterus or is indicative of additional gynecologic pathology such as an adnexal mass, a pelvic ultrasound should be obtained prior to determination of surgical approach. If menstrual bleeding is irregular or excessive, an endometrial biopsy should be obtained, especially in women over 35. An endometrial biopsy should also be obtained with postmenopausal bleeding.

Typically, a vaginal hysterectomy is feasible if the uterine size does not exceed the size of a 12-week gravid uterus. Consideration should be given to the use of a GnRH analogue preoperatively if the uterine size can be reduced enough to make the vaginal approach feasible. A very narrow (less than 90°) pubic arch can make a vaginal approach challenging. The shape of the uterus should also be assessed. If the uterus is enlarged due to the presence of a pedunculated subserosal fibroid floating above it, a vaginal hysterectomy may be feasible. Conversely, if the fibroids are mainly intramural and give the uterus a cannonball shape or extend too far laterally or into the cervix, a vaginal approach may be extremely challenging. The vaginal surgeon can rely on a variety of techniques for uterine debulking intraoperatively (such as bivalving, coring, and sequential myomectomy); however, these only become available once the uterine artery pedicles have been divided. Consequently, the cardinal ligaments need to be sufficiently low and accessible for clamping vaginally to improve feasibility of vaginal hysterectomy for an enlarged uterus.

Patients should also be counseled regarding salpingectomy and oophorectomy at the time of vaginal hysterectomy. There is some evidence to suggest salpingectomy may decrease the lifetime incidence of ovarian cancer as some of these cancers may originate in the Fallopian tubes. Currently, one out of two US women undergoing hysterectomy for benign disease also receives prophylactic oophorectomy. Prophylactic bilateral oophorectomy seems to be harmful prior to age 55, as there is an 8.6% excess mortality by age 80. There is decreasing benefit of ovarian conservation until the age of 75, when excess mortality for oophorectomy is less than 1%.

A complete physical examination should be performed preoperatively and blood work, a chest X-ray and electrocardiogram, as well as other investigations should be ordered depending on patient-specific health concerns. The patient should be assessed for preoperative anemia, especially if the reason for hysterectomy is abnormal uterine bleeding. If anemia is present, iron supplements or GnRH analogue are helpful to correct anemia prior to surgery. In cases of severe anemia, preoperative blood transfusion should be considered. If intraoperative blood loss is expected to be significant, such as in the case of large fibroids, cross-matched packed red blood cells should be available for intraoperative transfusion. In any case, a preoperative Type and Screen is prudent. Drugs and supplements that increase the risk of surgical bleeding should be discontinued prior to surgery. Patients taking oral contraceptives for abnormal uterine bleeding may not be able to discontinue them prior to surgery. In these patients, there is a moderate risk of venous thromboembolism based on this risk factor alone, so careful prophylaxis against deep vein thrombosis should be administered. Preoperative bowel preparation is not necessary for vaginal hysterectomy.

Prophylactic antibiotics should be administered prior to incision. A first-generation cephalosporin should be the first choice, but clindamycin, erythromycin, or metronidazole are also acceptable choices for those allergic to penicillin or cephalosporins. An assessment of risk for deep venous thromboembolism is indicated, and given the lithotomy position and length of case, some prophylactic measure, whether pharmaceutical or mechanical, is usually appropriate. We use sequential compression devices applied prior to surgery and maintained intraoperatively and postoperatively until the patient is fully ambulatory. Consideration should be given to simultaneous postoperative anticoagulation with heparin or low molecular weight heparin in patients at moderate risk for deep vein thrombosis. Heparin or low molecular weight heparin should be given to patients at high risk for deep vein thrombosis. Following is a brief description of the surgical procedure used (see also video: Total Vaginal Hysterectomy).

In preparation for vaginal hysterectomy, the patient is placed in comfortable dorsal lithotomy position, with the edge of her hips just over the edge of the operating table. Hip hyperflexion and excessive external rotation are avoided to prevent injury to the femoral and sciatic nerves. The patient’s lower legs are elevated to allow enough space for surgeon and assistants to operate comfortably. A metallic shelf or Mayo tray can be used to hold instruments close to the surgical field, as space is lacking for the scrub nurse to pass required instruments back and forth easily (as during abdominal cases). The patient’s skin is prepared with a scrub solution from lower abdomen to upper medial thighs bilaterally; an internal vaginal scrub is also required. Surgical lights are directed onto the surgical field although a head lamp may be utilized for optimal visualization.

A pelvic examination under anesthesia is performed to assess the size and shape of the uterus and any pelvic pathology including pelvic organ prolapse. The bladder is emptied. Some surgeons prefer to leave a Foley catheter in place for intraoperative bladder drainage, while others prefer to perform the surgery with a full bladder, which facilitates recognition of inadvertent cystotomy.
A weighted speculum or a Jackson retractor is placed in the posterior vagina and lateral vaginal retractors such as curved Deavers are used to facilitate exposure.

The cervix is visualized and grasped with a Lahey thyroid clamp. Alternatively, two tenaculums, one on the anterior and one on the posterior cervical lip, can be used for downward traction on the cervix. The cervical clamp as well as Deaver retractors can be moved around during the operation to provide optimum exposure. The proper use of these instruments for traction and countertraction is essential for the correct performance of the operation. Pulling the cervix upward and out assists in identification of the uterosacral ligaments at the back of the uterus. Their three-dimensional orientation is 45° downward, posteriorly and lateral to the cervix. Downward traction on the cervix also protects the ureters during placement of clamps on the pedicles.

Next, the cervicovaginal junction is infiltrated with saline or a vasoconstrictive agent circumferentially. (Figure 3.1) This facilitates dissection in the proper plane and also acts as an internal tourniquet, decreasing blood loss. The cervicovaginal junction is then incised with scalpel or cautery circumferentially (Figure 3.2

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