Uterine Procedures

John O. Schorge and David M. Boruta II

ABDOMINAL HYSTERECTOMY

Procedure Overview

Approximately 600,000 hysterectomies are performed annually—second only to cesarean delivery as the most frequently performed major surgical procedure for women of reproductive age in the United States. An estimated 20 million US women have had a hysterectomy, more than one-third of them by age 60. Approximately half will undergo concomitant bilateral oophorectomy.¹

The 5 classes (or types) of hysterectomy were originally defined by Piver et al² to more accurately describe the technical features involved when tailoring surgical treatment of women with cervical cancer. Type I hysterectomy, also known as extrafascial or simple hysterectomy, removes the uterus and cervix, but does not require excision of the parametrium or paracolpium. Within gynecologic oncology, a simple hysterectomy is usually performed for benign conditions, preinvasive cervical disease, stage IA1 cervical cancer, and most instances of endometrial or ovarian cancer. Occasionally, a planned simple hysterectomy must be adapted to a type II or III procedure based on intraoperative findings.

Abdominal hysterectomy was the foundation of gynecologic surgery for the latter half of the 20th century. However, several recent developments have resulted in fewer of these procedures being performed each year, a trend that is expected to continue into the future. Nonoperative techniques, such as office endometrial ablation, insertion of levonorgestrel-releasing intrauterine devices, and outpatient uterine artery embolization, have enabled many women to avoid hysterectomy. Additionally, the rapid introduction of minimally invasive surgery over the past decade has decreased the number of abdominal hysterectomies being performed. In many training programs, abdominal cases are now often mainly performed in extreme circumstances, such as a frozen pelvis or massively enlarged uteri. As a result, residents currently graduating may have more experience using a laparoscopic approach. Since trainees in obstetrics and gynecology are increasingly confronted with a wider range of techniques that must be mastered, and fewer hysterectomies are being performed each year, the need for improved surgical education to achieve competency is increasingly recognized.³

Despite the recent paradigm shift to minimally invasive surgery, approximately two-thirds of uteri in the United States are still removed through an abdominal incision. As high-volume surgeons, the majority of gynecologic oncologists have increasingly incorporated laparoscopic and robotic techniques into their practice.⁴ However, one-quarter of hysterectomies are performed by gynecologic surgeons who perform fewer than 10 per year. Such lower volume surgeons continue to perform the vast majority of their hysterectomies abdominally.⁵

Abdominal hysterectomy allows the greatest ability to manipulate pelvic organs and thus is often preferred to a minimally invasive approach if large pelvic organs or extensive adhesions are anticipated. Moreover, abdominal hysterectomy typically requires less operating time than laparoscopic or robotic hysterectomy, and no advanced instrumentation or expertise is needed. However, the duration of inpatient hospital stay is longer, and postoperative complications are more prevalent.

Preoperative Preparation

A spectrum of tests may be required to reach the preoperative diagnosis. These tests vary depending on the clinical setting and are discussed within the respective chapters covering those etiologies. Review of all pertinent information and office pelvic examination are crucial to form the best possible surgical plan.

After deciding to perform a hysterectomy, the next decision is to confirm that laparotomy is the best option based on patient circumstances. Abdominal surgery can result in major short- and long-term morbidity, generally exceeding a minimally invasive or vaginal approach. The other major decision in surgical planning is whether a vertical or transverse incision is best. When there is a pre-existing abdominal incision, it may or may not be appropriate for the planned operation. Morbidly obese patients should be examined supine in the office to map out and show where the intended incision will be located. Thereafter, the surgeon can effectively counsel the patient about abdominal hysterectomy via the intended incision. The consent should reflect the thought process behind the approach, as well as all related factors specific to the diagnosis. Concurrent illnesses, prior abdominal surgery, and a poor performance status are potential mitigating circumstances that should be taken into consideration during the consenting process.

Frequently, intra-abdominal findings of gynecologic oncology patients cannot be reliably predicted based on examination or imaging tests. In general, intraoperative bladder injuries are more likely with a history of cesarean section or a large uterus, whereas bowel injuries are more commonly associated with adhesiolysis.⁶ Patients should be fully informed that such gastrointestinal or genitourinary injuries are possible, as are unexpected bleeding and the need for transfusion. Postoperative wound dehiscence, infection, or other unanticipated sequelae are important to discuss.

When performing a hysterectomy abdominally, or by any other route, a blood sample should be typed and crossed for potential transfusion. Pneumatic compression devices, subcutaneous heparin, or both are particularly important due to the anticipated length of the operation and longer duration of postoperative recovery. Bowel preparation with a polyethylene glycol–electrolyte solution (GoLYTELY) is no longer commonly used. Inadvertent bowel injury should be rare unless extenuating circumstances are identified such as previous bowel surgery, known adhesions, or prior pelvic infections. Similarly, the addition of ureteral stenting varies widely, based on surgeon experience and patient circumstances.

A single dose of perioperative antibiotic prophylaxis with a third-generation cephalosporin such as cefoxitin is ordered to be given prior to incision. This is sufficient to prevent most postoperative surgical site infections, but the dose may need to be repeated if the operation continues beyond 4 hours or excessive bleeding is encountered.

Fortunately, abdominal hysterectomy is largely not dependent on specific instrumentation. In general, a self-retaining retractor, such as the Balfour or Bookwalter, is required. However, the surgeon may have particular requests, such as the Bookwalter extender with deep blades for an obese patient, certain coagulation sealing devices, or other relevant items required for an individual case.

Operative Procedure

Anesthesia and Patient Positioning

Lower extremity compression devices are placed on the patient for venous thrombosis prophylaxis. General endotracheal or regional anesthesia is administered. Many gynecologic oncologists routinely position all abdominal surgery patients in dorsal lithotomy rather than supine position, mainly in the event that access to the perineum for intravaginal manipulation or transrectal placement of stapling devices is required. Frequently, the extent of pelvic disease cannot be anticipated with certainty based on examination findings and preoperative imaging. When positioning in dorsal lithotomy, the patient’s legs are placed in Allen stirrups, the buttocks brought down to the table break, and arms secured laterally. Bimanual rectovaginal examination should always be performed to familiarize oneself with the anatomy and to make a final decision on the type of incision.

The abdomen and vagina are surgically prepared, and a Foley catheter is placed. When there is any perceived possibility of bladder injury, a 3-way Foley provides additional access to easily backfill with methylene blue–colored saline, and the integrity of the bladder should be confirmed before abdominal closure.

Abdominal Entry

Abdominal hysterectomy may be safely performed through a midline vertical, Pfannenstiel, Maylard, or Cherney incision. Many factors go into determining which is most appropriate for the particular patient, but adequate exposure is absolutely critical to prepare for unanticipated findings, excessive adhesive disease, or the unexpected need for cancer staging.

Once the fascia has been incised and the abdominal cavity entered, the undersurface of the abdominal wall is palpated to search for omental or intestinal adhesions. To maximize exposure, the peritoneal incision is sharply dissected as cephalad and caudad as possible within the limits of the skin incision. Peritoneal washings, if appropriate, are collected, and a comprehensive abdominal exploration is performed. Occasionally, the incision will be perceived as inadequate and may need to be further extended before proceeding. Bowel adhesions may need to be dissected away from the pelvic organs.

Next, the surgeon’s preferred self-retaining retractor is assembled. Meticulous care of blade placement and bowel packing is critical to provide excellent visualization, decrease the likelihood of femoral nerve palsy, and allow for surgical efficiency in performing the subsequent surgical steps.

Retroperitoneal Dissection

Curved Kelly clamps are placed bilaterally at the uterine cornua, incorporating the round ligament. An Allis clamp is used to grasp the round ligament, and a single 0-vicryl is tied and held on a clamp laterally. Tagging the round ligament is particularly helpful whenever pelvic lymphadenectomy is to be later performed. The uterus is held medially to put the round ligament on stretch so that it can be divided with cautery. A right angle clamp is used to guide further cautery dissection of the anterior and posterior leaves of the broad ligament. Occasionally, the round ligament cannot be clearly identified due to pelvic disease or anatomical distortion. In this circumstance, the Allis clamp is used to grasp a section of peritoneum laterally on the pelvic sidewall, cautery is used to incise a small opening, the posterior broad ligament is opened, and the round ligament can be identified later in the dissection.

Loose areolar retroperitoneal connective tissue is bluntly dissected until the external iliac artery is palpated just medial to the psoas muscle. The index and middle fingers then are placed on either side of the artery, and the areolar connective tissue is dissected bluntly by a “walking” motion toward the patient’s head (Figure 25-1). The medial peritoneal leaf of the broad ligament is elevated and placed on traction to permit direct identification of the common iliac bifurcation and origins of the external and internal iliac arteries. Blunt dissection with a finger or suction tip is used in a sweeping motion from top to bottom along the medial peritoneal leaf to identify and sufficiently mobilize the ureter crossing at the bifurcation. As a general rule, it is inadequate to just palpate the ureter or assume its location without directly visualizing unequivocal peristalsis. When the peritoneum is held on traction, and the tubular structure presumed to be the ureter is not seen to undergo peristalsis, the surgeon may need to further mobilize it by blunt dissection along its course and relax the peritoneum until its identity is confirmed.

FIGURE 25-1. Finding the ureter. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)

Consistently performing a comprehensive retroperitoneal dissection has a number of potential advantages, including immediate ability to perform hypogastric artery ligation in case of hemorrhage and defining the anatomy when the pelvis is distorted by endometriosis, malignancy, or adhesions. Small vessel bleeding during this dissection can be quickly controlled with directed cautery, or a small sponge can be firmly placed into the space to tamponade general oozing, while switching to work on the contralateral side of the pelvis.

In the presence of diffuse fibrosis or other extenuating circumstances, it may be advisable to tag the ureter for visualization throughout the abdominal hysterectomy procedure. When the ureter is sufficiently mobilized off the medial peritoneal leaf, a right-angle clamp is used to “pop” through the underlying avascular space. Typically, the clamp is placed in a lateral to medial direction to avoid inadvertent injury to the sidewall vasculature. If the ureteral location does not easily allow this, a Babcock clamp can be used to grasp the ureter gently without crush injury and facilitate clamp placement underneath. Next, a ¼-in-wide Penrose drain is guided by a forceps to the right angle tip and slid back underneath the ureter, and the 2 ends are held on a clamp laterally. It is critical to directly observe unequivocal peristalsis before moving on to the subsequent surgical steps.

Utero-Ovarian Ligament Transection

The next part of the operation depends on whether the adnexa are to be concurrently removed or not. Once the ureter has been identified, the infundibulopelvic (IP) ligament may be divided and peritoneal attachments dissected, as described in Chapter 24. When the adnexa are to be temporarily or permanently left in situ, division of the utero-ovarian ligament is performed.

Development of the retroperitoneal spaces and tran-section of the round ligament should enable the surgeon to wrap a finger around the utero-ovarian ligament and identify an avascular space underneath. Cautery is used to open the space sufficiently to place a curved Heaney clamp laterally. The clamp should be placed with tips pointed toward the uterus in order to best secure the lateral vascular pedicle. Usually, the Kelly clamp originally placed on the uterine cornua can simply be repositioned into the opened space to prevent back-bleeding (Figure 25-2). The intervening tissue is divided, followed by a 0-vicryl free tie to crush the vessels while the Heaney clamp is “flashed” (opened and closed), and then a second 0-vicryl transfixion stitch is placed on the lateral pedicle. A segment of adjacent peritoneum may also be sharply dissected so that the adnexa can be packed away from the operative field. The identical procedures are repeated on the contralateral side.

FIGURE 25-2. Transection of the utero-ovarian ligament. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)

Bladder Flap

The uterus is pulled upward and cephalad in the mid-line position to best visualize the vesicouterine fold. The peritoneum that connects the superior edge of the bladder to the uterine isthmus should have been cut when the anterior leaf of the broad ligament was opened. Only loose areolar connective tissue joins the posterior surface of the bladder and anterior surface of the uterine isthmus and cervix. Many gynecologists will bluntly dissect the bladder distally, using either a thumb or sponge stick. However, the complicated circumstances wherein a gynecologic oncologist is performing an abdominal hysterectomy frequently dictate the necessity of careful sharp dissection instead. Tumor infiltration, tissue induration, and postsurgical fibrosis all increase the likelihood of bladder injury or deserosalization with blunt dissection.

Superficial cautery is the most hemostatic method of identifying the right plane between the posterior surface of the bladder and the anterior uterine surface. Bending the cautery tip often facilitates the correct angle of dissection, especially when operating deep in the pelvis (Figure 25-3). Short horizontal bursts of cautery along the cervix, followed by gentle distal mobilization of the fibrous attachments with the cautery tip, should provide a good result. Ideally, the bladder is dissected onto the anterior vaginal fornix before moving to the next steps of the operation. Occasionally, the bladder dome is fused to the anterior uterine corpus with no discernable plane. In this instance, it may be possible to bluntly develop a retroperitoneal space from the left or right lateral location, on top of the anterior cervix distal to the area of dense bladder attachment. Wrapping an index finger around the dense adhesion in this fashion will greatly facilitate sharp dissection and decrease the likelihood of bladder injury. Alternatively, sharp dissection is performed in the imagined plane between the bladder and uterus, with frequent attempts to identify a plane distally. Almost invariably, once the uppermost fibrotic attachments are dissected, the correct plane is encountered at some point thereafter, greatly facilitating distal mobilization of the bladder.

FIGURE 25-3. Dissecting the bladder flap. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)

Uterine Artery Ligation

The uterus is again held on medial traction to skeletonize the uterine vessels in order to further drop the ureter laterally and allow an isolated vascular pedicle to be secured. Peritoneal attachments and excess connective tissue are gently retracted laterally with fine, smooth forceps and cauterized in a direction perpendicular toward the vessels. The uterine artery and vein are then visualized along the lateral aspect of the uterus at the level of the isthmus. In extenuating circumstances, a uterine vessel may be lacerated in the course of skeletonizing and lead to brisk bleeding. However, because the bladder flap has been taken down in advance, the vessel can be quickly secured by prompt clamp placement.

A curved Heaney clamp is opened, placed across the uterine vessels inferiorly to the planned site of tran-section, and purposefully slides off the lateral cervix as it is closed. The clamp tip must be placed as close to the cervix as possible to secure the entire lumen of both artery and vein. Additionally, the clamp should be placed as perpendicular as possible across the vertical axis of the uterine vessels (Figure 25-4). A Kocher or other straight clamp is placed to control back-bleeding above the planned uterine vessel transection so that its tip abuts the tip of the Heaney clamp and crosses the vessels at an approximate 45-degree angle. The uterine vessels are then sharply transected with curved Mayo scissors with blades pointed up, sliding along the Heaney clamp until reaching the distal tip, when the scissors are turned around to gently divide the last remaining tissue and fully isolate the uterine pedicle. The scalpel may be used in place of scissors but may be an inferior choice in some instances. When visualization is limited by obesity, a bulky uterus, or other mitigating circumstances, the uterine vessels may still be divided safely by the surgeon’s “feel” of the Mayo scissors along the Heaney clamp to reach its tip, whereas the scalpel is a less-controlled approach.

FIGURE 25-4. Clamping the uterine vessels.

A simple stitch of 0-gauge delayed-absorbable suture is placed below the tip of the Heaney clamp, with the needle directed posteriorly away from the bladder. The suture ends are wrapped to the heel of the clamp and tied directly against the back of the Heaney clamp with release upon cinching the knot. Next, the uterus is again pulled upward, and a straight Heaney or Zeppelin clamp is placed medially, inside the uterine pedicle, vertically and directly adjacent to the cervix. Upon closing the clamp onto the paracervical tissue, the handle is gently directed laterally to further press the tip against the cervix and laterally displace the uterine pedicle. The pedicle is similarly cut and ligated, before repeating these steps on the contralateral side.

Supracervical Hysterectomy

The surgeon may choose to amputate the uterus from the midcervix at this point in the operation due to benign disease and patient preference, limited visibility from a bulky uterus, or dense adhesions making cervix removal too risky to proceed. Regardless of the indication, the cautery tip is bent at an angle, its energy source turned up, and suction brought into the field to remove the smoke plume. Often it is advisable to place a hand-held retractor posteriorly to prevent inadvertent cautery injury to the rectum. The uterine fundus is detached and handed off the field.

If the cervix is to remain in situ, the upper endocervix may be further resected or cauterized to prevent cyclic bleeding, which may otherwise be observed postoperatively in premenopausal women. Interrupted 0-gauge delayed-absorbable suture may be placed to achieve hemostasis, but otherwise is not required.

Removal of the Cervix

If the uterus has not been amputated from the cervix, then lateral straight clamp placement and pedicle ligation continue as before. Otherwise, single-toothed Kocher clamps are placed on the anterior and posterior walls of the remaining cervix for upward traction. The bladder flap is further advanced, if needed, by sharp dissection. The cardinal ligaments are successively clamped, cut, and ligated to reach the lateral aspect of the upper vaginal vault. The cervical distance to the vaginal fornix should be checked intermittently by placing a gloved hand into the pelvis, directly grasping the cervix in the palm, and palpating the cervical portio between the thumb and index finger. Otherwise, it is possible to inadvertently perform an upper vaginectomy or prematurely cut into the cervix before reaching the vagina. Further sharp dissection is performed anteriorly to be confident the bladder is sufficiently mobilized distally.

Once the lateral vaginal vault has been reached, upward and lateral traction is again exerted by the Kelly clamps holding the uterine cornua. A curved Heaney clamp is placed in front of the lateral tip of the cervix and swung posteriorly to incorporate the uterosacral ligament. A second Heaney clamp is similarly placed on the contralateral vaginal angle. The lateral vaginal fornices and intervening anterior and posterior vaginal attachments can be divided under direct visualization using a knife (Figure 25-5) or sharply curved scissors. The clamped pedicles are each secured with a transfixing 0-gauge delayed-absorbable stitch. The remainder of the upper vagina can then be closed by either interrupted or continuous running, 0-gauge delayed-absorbable suture.

FIGURE 25-5. Detaching the uterus and cervix from the upper vagina. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)

On occasion, a bulky cervix, lateral tissue induration, or a cervix flush with the vaginal apex will dictate the need for a different approach. With the bladder flap dissected distally onto the anterior vaginal fornix, a Kocher clamp is placed anteriorly in the midline beyond the cervical portio. A second, more proximal Kocher clamp is similarly placed and cautery used in between to enter the vaginal vault (Figure 25-6). A right-angle clamp is inserted into the opening (colpotomy) and used to facilitate bilateral cautery dissection. The proximal Kocher is repositioned to grasp the anterior lip of the cervix, reflecting it upward, where cautery or scissors can be used to detach it laterally and posteriorly. The vaginal cuff is grasped with Kocher or Allis clamps and closed, as described earlier.

FIGURE 25-6. Entering the anterior vaginal fornix.

Final Steps

Once the abdominal hysterectomy has been performed, strict hemostasis should be achieved. The course of both ureters and all pedicle sites are re-inspected. Further abdominal exploration may be performed, as needed. Intraoperative drain placement is at the discretion of the surgeon, depending on concurrent ancillary procedures, the amount of blood loss, and other specific concerns. Copious irrigation of warmed saline is advisable, followed by careful attention to closure of the abdominal incision.

Postoperative Care

Abdominal hysterectomy is generally associated with longer patient recovery and hospital stays, increased incisional pain, and a greater risk of postoperative febrile morbidity and wound infection compared to other approaches.⁷ However, sometimes it is the best, or possibly the only, option for effective surgical management of the patient. Only extenuating circumstances, such as intraoperative hemorrhage, multiple concurrent procedures, or severe medical comorbidi-ties, should prompt the surgeon to request specialized services within the intensive care unit for the immediate postoperative recovery.

All patients should be examined by a member of the health care team within several hours, with visualization of the dressing. Most dressings can be safely removed on postoperative day 1. In patients with vertical incisions above the umbilicus, it is often advisable to wait an additional day to remove the dressing as long as it remains dry. Thereafter, the incision site is checked frequently looking for signs of infection.

Typically, Foley catheter drainage may be discontinued on the first postoperative day. However, many gynecologic oncology patients may need to have catheter removal postponed due to difficulty with ambulation, fluid shifts resulting in borderline urine output, or related issues. When an intraoperative bladder injury has been repaired, the catheter should remain in place to keep the bladder decompressed from several days to 2 weeks, depending on the size of the injury. Although meticulous ureteral dissection should reduce the risk, the majority of ureteral injuries will be recognized postoperatively. Thus, symptoms of urinary incontinence or vaginal fluid leakage should alert the surgeon to this possibility.

Abdominal hysterectomy will result in a delay of return to normal bowel function for an unknown duration. In the absence of extensive concurrent surgery, a nasogastric tube is not necessary. The timing of when to advance diet past nothing by mouth (NPO) depends on numerous factors, including the individual surgeon’s experience and specific preferences. Patients with a high vertical incision will be at higher risk of ileus and should be advanced more slowly. In uncomplicated circumstances, sips of clear liquids may be initiated on postoperative day 1 if the patient’s examination is appropriate. Beyond that, advancing the diet is a day-to-day decision until flatus is passed, when a full diet may be allowed. Any signs of abdominal distention, nausea, or emesis should be taken into consideration throughout the hospital stay, with the patient potentially made NPO again if necessary.

Early ambulation is among the most critical interventions to facilitate rapid recovery. Discharge planning should be discussed early, especially when postdischarge rehabilitation is anticipated.

VAGINAL HYSTERECTOMY

Procedure Overview

Vaginal hysterectomy offers a number of potential advantages over abdominal or laparoscopic surgery, especially when pelvic organs are small, some degree of uterine descensus is present, and access to the upper abdomen is not required.⁸ Operating time is reduced, regional anesthesia may be an option, inpatient hospitalization is brief, major morbidity is less, and a shorter postoperative recovery may be anticipated, especially when the procedure is performed by high-volume vaginal surgeons.^9,10 Moreover, because no abdominal incisions are required, vaginal hysterectomy could rightly be considered more of a minimally invasive operation than laparoscopy or robotic surgery.

In a previous era when the rate of cesarean delivery was very low and the number of births per woman was higher, the prevalence of pelvic organ prolapse made vaginal hysterectomy a popular technique. Currently, less than one-quarter of hysterectomies are performed vaginally in the United States. There are numerous additional reasons why it is not currently used more often, including lack of expertise of the gynecologic surgeon, anticipated pelvic adhesive disease, presence of a contracted pelvis, or other problematic factors. Within gynecologic oncology, even fewer patients are treated by this approach, mainly because the indications for hysterectomy often require intra-abdominal evaluation with or without staging. For the gynecologic oncologist, preinvasive cervical disease is one of the more common indications, as well as the occasional elderly or excessively obese woman with complex atypical hyperplasia or grade 1 endometrial cancer.¹¹ Conceptually, the operational steps are in reverse order compared to abdominal hysterectomy.

Preoperative Preparation

The preoperative evaluation for vaginal hysterectomy largely mirrors that of the abdominal approach. Preoperative pelvic examination is especially important. With careful assessment, the potential for needing laparoscopic assistance or likelihood of converting to a laparotomy should be low. However, intraoperative findings often cannot be reliably predicted based on examination or imaging tests. As when performing other types of hysterectomy, patients should be fully informed that gastrointestinal or genitourinary injuries are possible, as is unexpected bleeding.

Vaginal hysterectomy is not dependent on specific instrumentation. However, sidewall retractors, such as the Breisky, are often helpful. Curved-tip needle drivers may also facilitate suture ligation of pedicles. The individual surgeon may have specific requests, such as certain coagulation sealing devices, to maximize efficiency. Frequently, a dilute saline solution containing vasopressin (20 units diluted in 20 mL of saline) is used to reduce blood loss.¹² Alternatively, some surgeons prefer using just saline due to concerns that intracervical vasoconstrictor usage may increase the risk of postoperative infection.

Operative Procedure

Anesthesia and Patient Positioning

One of the important advantages of vaginal hysterectomy is that it can be comfortably performed under regional anesthesia in patients who have a heightened surgical risk. Once regional or general anesthesia has been administered, positioning is particularly important. Access to the perineum is limited, and visualization is critically important. The patient is placed in dorsal lithotomy position with her feet comfortably positioned in stirrups. Candy-cane stirrups are preferred in order to provide maximal exposure to the operative field and allow room for 1 or 2 assistants. Extra care, including alternative stirrups (such as Allen), is sometimes necessary but may result in imperfect exposure. Next, the patient’s hips are brought over the edge of the operating room table, and leg positioning is reassessed to confirm appropriate padding. Improper positioning can lead to sciatic, peroneal, and/or femoral nerve palsies.

Bimanual rectovaginal examination is performed before prepping to familiarize oneself with the anatomy. The vagina is surgically prepared, and a Foley catheter is placed. When there is any perceived possibility of bladder injury, a 3-way Foley may be indicated. It is often good practice to prep the abdomen as well, in case circumstances dictate the need to look laparoscopically or convert to an abdominal approach.

Vaginal Wall Incision

The operating table is raised to the appropriate height for the surgical team. A weighted vaginal speculum is placed posteriorly, and a right-angle or other suitable retractor is placed along the anterior vaginal wall to be held by the surgical assistant. A Lahey thyroid clamp is used to grasp both the anterior and posterior cervical lips, and the cervix is placed on downward and outward traction. The margin of the bladder can be identified as a crease in the overlying vaginal epithelium and accentuated by in-and-out movement of the cervix. Between 10 and 15 mL of diluted vasopressin solution is injected circumferentially beneath the mucosa at a level above the cervicovaginal junction, but below the inferior margin of the bladder to aid in defining tissue planes.

The location of the vaginal wall incision is crucial to facilitate the subsequent steps of the operation. If the incision is made too close to the cervical os, it results in unnecessary difficulty in entering the peritoneal cavity. Alternatively, an incision too far away from the os can lead to inadvertent bladder or rectal injury. Bending the cautery tip 45 degrees and using it on “cut” mode will facilitate dissection into the appropriate tissue planes. With the cervix pulled forward, the incision is started at the point of the posterior fornix attachment to the cervix. The anterior retractor is rotated to provide exposure so that the circular (or diamond-shaped) incision can be performed circumferentially.

Entering Posteriorly

Frequently, the peritoneal cavity is first entered posteriorly because it is easiest. Although it is tempting to bluntly dissect posteriorly after the vaginal incision has been made, that maneuver pushes the peritoneum farther away, making it much harder to enter the cul-de-sac. Instead, the cervix is pulled anteriorly to expose the posterior vaginal vault, and an Allis clamp is placed on the incised edge of the posterior vaginal wall. The Allis clamp is pulled downward to create tension across the exposed posterior peritoneum, and the posterior vaginal vault is boldly cut with curved Mayo scissors, with tips pointed up (Figure 25-7). If the peritoneal cavity is not entered with a single stroke, then the Allis clamp can be used to regrasp the posterior vaginal wall and the process repeated. If there is any concern for proximity to the rectum, a rectal examination can be performed to help guide the dissection. Inordinate difficulty in entering the peritoneal cavity posteriorly is unusual and may indicate an unanticipated obliteration of the cul-de-sac.

FIGURE 25-7. Entering the posterior cul-de-sac.

Upon entering the peritoneal cavity, the opening is expanded laterally by placing the Mayo scissors within the defect and opening widely. An index finger should be inserted to confirm position within the peritoneal cavity and gently palpate for adhesive disease or other pathology. The midportion of the posterior peritoneum is sutured to the posterior vaginal wall incision with a single 0-gauge delayed-absorbable suture and held on a straight snap. The weighted speculum is removed and ideally replaced by one with a longer blade (such as the “duckbill”), which is inserted through the opening into the cul-de-sac. The tie is maneuvered underneath the speculum to be used later during closure of the peritoneum at the procedure’s end.

Entering Anteriorly

The cervix is again held downward, and the bladder is mobilized anteriorly with the right-angle retractor. Brief horizontally directed strokes of cautery with intermittent upward mobilization using the tip should allow the tissue to fall away and facilitates identification of the correct plane of dissection. When the cautery dissection is too vigorous, the cervical stroma may be entered. To re-establish the correct plane, meticulous fine dissection is required above and distal to the inadvertent stromal entry. The anterior vaginal wall is next grasped and elevated with an Allis clamp. This traction will reveal fibrous bands still connecting the bladder and cervix. Typically, the cautery is exchanged for Metzenbaum scissors at this point to allow more precise dissection of these fibers (Figure 25-8). Blunt dissection with a finger or surgical gauze should be limited, if performed at all, to avoid pushing the anterior peritoneum farther away and making it harder to reach. Additionally, when the fibrous bands are thick and the fascial plane is hard to visualize, it is possible to create a cystotomy with blunt dissection that is more difficult to repair than when a small entry is made with sharp scissor dissection.

FIGURE 25-8. Sharp dissection between bladder and cervix. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)

If a cystotomy is made, it will often allow the correct tissue plane to be more easily identified inferiorly. Once the hysterectomy is completed, cystoscopy can be performed to assess the injury’s proximity to the trigone, and then typically it can be easily repaired vaginally. Injuries near the trigone may require ureteral stent placement.

The bladder dissection is continued until the vesicouterine fold is reached. Usually, it can be identified as a transverse white line across the anterior cervix. Palpation reveals 2 thin smooth layers of peritoneum slipping against one another. The vesicouterine fold is grasped and elevated to place this peritoneal layer on tension. If there is any concern for the tissue fold representing bladder mucosa, the bladder can be backfilled and the presumed vesicouterine fold re-examined. The peritoneum then is incised (Figure 25-9).

The surgeon’s index finger next explores the opening to confirm peritoneal entry and to palpate for any unanticipated pathology. The anterior retractor is then repositioned with its distal blade entering the peritoneal cavity, thereby elevating the bladder.

FIGURE 25-9. Vesicouterine fold incision. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)

Dividing the Lateral Ligaments and Vessels

Once the peritoneum has been safely entered anteriorly and posteriorly, the hardest part of the operation is over. Firm lateral traction on the Lahey thyroid clamp both pulls the supporting uterine ligaments into view and prevents ureteral injury. Especially in obese patients, the Breisky sidewall retractor is often helpful at this point in the operation to facilitate visualization of the lateral pedicles. The uterosacral ligament is identified, clamped using a curved Heaney with tips pressed against the cervix, transected, and suture ligated with a transfixing stitch. The suture is tagged with a curved Kelly clamp, and the procedure is repeated on the contralateral side. Tissue sealing and cutting devices may be used instead of clamping and suturing to perform the steps more quickly, but the ligaments cannot be tied together later to provide vault support.

Next, the cardinal ligaments are similarly clamped, cut, and suture ligated (Figure 25-10). When feasible, the anterior jaw of the Heaney clamp should be positioned around the cardinal ligaments, incorporating the anterior peritoneal edge into the pedicle. The cardinal ligaments are held with curved hemostats to distinguish them later from the uterosacral pedicles. Frequently, the supportive ligaments are not easy to distinguish individually, and more than 2 clamp placements are required bilaterally to divide all of the connective tissue.

FIGURE 25-10. Cardinal ligament transaction. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)

The uterine vessel pedicle, which contains the uterine artery and vein and the broad ligament peritoneum anterior and posterior to these vessels, is clamped with a single curved Heaney clamp, cut, and ligated with a single ligature. A transfixion suture should not be used on this vascular pedicle because of the possibility of injuring a vessel and causing a broad ligament hematoma. When the uterus is larger, it may be beneficial after securing the uterine vessels to deliver the uterine corpus posteriorly in order to expose the round and utero-ovarian ligaments (Figure 25-11). To accomplish this, tenaculum clamps can be used in tandem to pull the fundus into the vagina.

FIGURE 25-11. Delivery of the uterine corpus posteriorly. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)

If the uterus is small and descensus adequate, 2 curved Heaney clamps are placed in tandem across the utero-ovarian and round ligaments, as close to the uterine fundus as possible. Often the surgeon’s index finger can be looped around the pedicle to help guide the final clamps safely in place, avoiding omentum or loops of bowel. When visibility is limited, clamps may be placed bilaterally with removal of the uterus and cervix before securing the pedicles. A free tie is used first to ligate the lateral pedicle and occlude all vessels. Next, a transfixion suture ligature is placed with removal of the medial clamp (the one closest to the uterus). The ties are again held laterally with matching clamps to help identify them later.

Oophorectomy

If removal of the ovaries is desired, the adnexa is grasped with a Babcock clamp and gently pulled toward the incision. An index finger is wrapped around the IP ligament to isolate it from surrounding structures. The IP ligament is clamped and ligated similarly to the utero-ovarian pedicle (Figure 25-12). The ends of the transfixing suture may be held by matching hemostats.

FIGURE 25-12. Salpingo-oophorectomy. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)

Vaginal Cuff Closure

The surgical pedicles should be inspected for bleeding and resecured if necessary with additional free ties or suture ligature. If hemostasis is adequate, then the utero-ovarian (or IP) ligament ties are cut. The peritoneum may be closed in a purse-string manner using 2-0 delayed-absorbable suture in order to extraperitonealize the pedicles. However, this is not a required step, and it can certainly be skipped when visualization is limited.

The easiest and quickest way to provide apical support is to tie both cardinal ligaments together in the midline, and then to do the same for the uterosacral ligaments. Finally, the cardinal ligament suture is tied to the uterosacral suture. Alternatively, a suspensory suture may be included in which the cardinal or uterosacral or both ligaments are sutured to the lateral vaginal cuff on each side. More complex variations of preventing future vault prolapse are at the discretion of the surgeon. Strict hemostasis should be observed prior to cuff closure. The vaginal mucosa is closed from anterior to posterior with running suture, ultimately securing it to the posterior peritoneal stitch placed at the beginning of the operation.

Final Steps

Vaginal packs are not required at the completion of vaginal hysterectomy, but some surgeons will use them on occasion to tamponade surface oozing in the immediate postoperative period. When the abdominal entry is particularly challenging anteriorly or there is any other concern for injury to the genitourinary tract, diagnostic cystoscopy should be performed prior to extubation.

Postoperative Care

Box 25-6 Complications and Morbidity

Intraoperative

Rectal injury during posterior dissection

Cystotomy during anterior dissection

Enterotomy due to unanticipated obliteration of the cul-de-sac or incorrect clamp placement

Ureteral transection, ligation, or “kinking”

Hemorrhage

Postoperative

Vaginal or intraperitoneal bleeding

Neurologic deficit from hyperflexion of the hips

Vaginal cuff complications (ie, cellulitis, abscess, or dehiscence)

Genitourinary fistula

Vaginal vault prolapse

Vaginal hysterectomy patients typically have faster return of normal bowel function, easier ambulation, decreased analgesia requirements, shorter duration of hospital stay, and speedier return to normal activities compared to abdominal hysterectomy patients.¹⁰ Rarely, signs of excessive vaginal bleeding and/or hemo-dynamic instability may necessitate a return to the operating room to achieve hemostasis. The Foley catheter is removed on the first postoperative day, the diet quickly advanced, and the patient discharged

LAPAROSCOPIC HYSTERECTOMY

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