Vaginal Hysterectomy
Cecile A. Unger
General Principles
Definition
Total vaginal hysterectomy is an operation that can be performed when removal of the uterus is indicated in cases of either benign disease or carcinoma in situ of the cervix.
Vaginal hysterectomy is most often performed in cases of pelvic pain, abnormal uterine bleeding, or uterovaginal prolapse.
Preoperative Planning
The preoperative health assessment for any hysterectomy includes a complete history and physical examination. There is no routinely recommended imaging, cardiopulmonary testing, or laboratory tests. This type of testing is ordered for patients based on their medical comorbidities. Many hospitals have their own requirements for preoperative assessments, which are often based on the patient’s age in combination with their medical comorbidities and frailty.
A normal Papanicolaou (Pap) smear should be documented before hysterectomy. In patients who are at risk for endometrial cancer, endometrial sampling should also be obtained. If cancer or an adnexal mass or cyst is suspected, a transvaginal ultrasound is necessary.
Careful review of a patient’s medication list is important before performing a hysterectomy. Because of the increased risk of bleeding due their antiplatelet effects, all nonsteroidal anti-inflammatory drugs and aspirin should be stopped at least 7 days before surgery. Multivitamins containing vitamin E should also be discontinued 10 to 14 days before surgery. Because of the increased risk of venous thromboembolic events, oral contraceptive pills and hormone replacement therapies should ideally be stopped 4 to 6 weeks before surgery. This may be challenging in women who are on hormone therapies for abnormal bleeding, but cessation should be considered.
Before proceeding with hysterectomy, assessment of a patient’s risk for intra- or postoperative anemia and need for autologous blood products is necessary. This is especially important for patients with abnormal uterine bleeding and baseline anemia. These patients should also be evaluated for preoperative iron supplementation or transfusion.
Informed consent should be obtained in the office. Patients should be well informed of the risks and benefits of the procedure, as well as the alternatives to hysterectomy. Most importantly, confirmation of completion of childbearing must be done.
Prior to surgery, a pregnancy test is necessary in all patients of reproductive age.
Hysterectomy is a clean-contaminated procedure, and prophylactic intravenous antibiotics should be ordered, to be administered within 60 minutes of incision time. First- or second-generation cephalosporins are first-line antibiotics.
All patients undergoing hysterectomy are considered “moderate risk” and require venous thromboembolism prophylaxis. In most patients, either low-dose unfractionated heparin, low–molecular-weight heparin, or intermittent pneumatic compression devices are recommended. In higher-risk patients, dual prophylaxis, and in some cases, postoperative prophylaxis may be necessary.
Route of hysterectomy is dependent on the following factors: vaginal caliber and accessibility to the uterus, uterine size and shape, uterine mobility, cancer and extrauterine disease, surgeon skillset, available support facilities, and surgeon and patient preference.
A thorough bimanual examination is necessary prior to deciding on route of hysterectomy. Care should be taken to note the following factors to help determine the degree of difficulty that will be present in performing the procedure: the size, mobility, and descent of the uterus; the size and shape of the bony pelvis (a pubic arch of less than 90 degrees may preclude a vaginal hysterectomy whereas a wide angle will facilitate the approach); the caliber of the introitus and the vagina.
Surgical Management
According to the American College of Obstetricians and Gynecologists (ACOG),1 vaginal hysterectomy is the safest and most cost-effective method to remove the uterus for noncancerous reasons. In general, based on current data, vaginal hysterectomy is associated with better outcomes and fewer complications.
There are few absolute contraindications to the vaginal approach for hysterectomy; however, there are 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 one of these factors, vaginal hysterectomy should be the approach of choice whenever feasible given its well-documented advantages.
There are some conditions and patient-specific characteristics that can make vaginal hysterectomy technically challenging. These factors are not contraindications to vaginal hysterectomy, but should be identified preoperatively and anticipated at the time of surgery.
These conditions include the enlarged or undescended uterus, previous cesarean sections, and uterine prolapse. These factors should be taken into consideration during surgical planning, and while they may make the procedure more challenging, can be overcome with a few helpful pearls that we will review in this chapter.
Positioning
Patients are positioned in dorsal lithotomy position using either candy cane stirrups (Fig. 8.5.1), or yellow fin stirrups (Fig. 8.5.2). Patients should be positioned so that the edge of the buttocks is at the edge of the surgical table. Care is taken
not to hyperflex or extend the legs in order to avoid postoperative neuropathies. Foam can be used to pad the bony prominences of the limbs, and also to fill dead space in the stirrups. The arms can be left out at the sides, and are positioned in anatomic position with care taken to not hyperextend the limbs to avoid brachial plexus injuries.
Figure 8.5.1. Dorsal lithotomy positioning using candy cane stirrups.
Figure 8.5.2. Dorsal lithotomy positioning using yellowfin stirrups.
Approach
The procedure is performed transvaginally.
Procedures and Techniques (Video 8.5)Preparation
Once the patient is positioned, the vulva and vagina are fully prepped with betadine or a surgical soap solution.
The patient is draped in a sterile fashion.
A Foley catheter is placed and can be left to continuous drainage for the case, or it can be clamped off and intermittently emptied throughout the case.
Tenaculum placement and injection
A short-weighted retractor is placed in the vagina, exposing the cervix.
A small right-angle retractor is used to elevate the anterior vaginal wall and a second right-angle retractor displaces one lateral vaginal wall and exposes the cervix.
Two single-tooth tenacula are placed in a vertical fashion at the 3 and 9 o’clock positions of the cervix through the full thickness of the stroma. Alternatively, two single-tooth tenacula such as a Jacobs tenaculum can be applied to the mid-anterior and posterior lips of the cervix (Tech Fig. 8.5.1).
Tech Figure 8.5.1. Sagittal view of the pelvic organs. Positioning of the retractors at 12 and 6 o’clock and placement of two single-tooth tenacula on the cervix at the start of a vaginal hysterectomy. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2015, all rights reserved.
Gentle traction is applied to the tenacula and approximately 10 cc of local anesthetic with a dilute vasoconstricting agent (we recommend using 0.5% lidocaine with 1:200,000 units epinephrine) is injected circumferentially beneath the vaginal epithelium at its junction with the cervix. This creates a hydrodissection plane for the colpotomy and helps with hemostasis as well.
Colpotomy and entry into the posterior cul-de-sac
A scalpel or Bovie cautery can be used to create the colpotomy. A circumferential incision is made in the vaginal epithelium until the cervical stroma in reached (Tech Figs. 8.5.2 and 8.5.3). The incision should stay above the pubovesical cervical fascia anteriorly and the perirectal fascia posteriorly. Right-angle retractors can be placed at the 3 and 9 o’clock positions to help protect the vaginal sidewalls while the incision is made. Curved Mayo scissors are then used to dissect the vagina off of the cervical stroma anteriorly and posteriorly. Traction on the cervix should be maintained during this dissection to avoid injury to the surrounding viscera and to help identify the correct dissection planes.
The tenacula are then pulled upwards toward the pubic bone until the posterior peritoneum of the cul-de-sac is identified. The peritoneum is grasped and tented away from the cervix and then entered sharply with the curved Mayo scissors (Tech Figs. 8.5.4 and 8.5.5). Confirmation of entry is made by visualization and/or palpation.
A finger is placed in the cul-de-sac, and the short-weight retractor is removed and replaced with a long-billed weighted retractor (Tech Fig. 8.5.6).
Tech Figure 8.5.2. Cervical incision; initial colpotomy. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2015, all rights reserved.
Tech Figure 8.5.3. Cervical incision; initial colpotomy.
Tech Figure 8.5.4. Entry into the posterior cul-de-sac. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2015, all rights reserved.
Tech Figure 8.5.5. Entry into the posterior cul-de-sac.
Tech Figure 8.5.6. Placement of a long weighted retractor into the posterior cul-de-sac. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2015, all rights reserved.
Suture ligation of the uterosacral ligaments
Many providers enter the anterior cul-de-sac before ligating the uterosacral pedicles. We believe that suture ligation of the uterosacral ligaments prior to anterior entry facilitates descent of the uterine specimen, making it easier to identify the vesicouterine reflection, and decreasing the risk of injury to the bladder at the time of anterior entry.
The cervix is placed on upward and lateral retraction using the tenacula. A curved Heaney clamp is placed in the posterior cul-de-sac with one blade underneath the uterosacral ligament and the opposite blade over the uterosacral ligament (Tech Fig. 8.5.7). In order to prevent possible ureteral injury, it is important to place the clamp along the uterine cervix so that some tissue of the cervix is included in this clamp.
A curved Mayo scissor is used to transect the pedicle and a No. 0 polyglactin suture is used to tie off of the pedicle before releasing the clamp. A Heaney fixation stitch of No. 0 polyglactin is used for all pedicles (Tech Figs. 8.5.8 and 8.5.9). The uterosacral ligaments are suture ligated bilaterally using this method.
If there is oozing of blood at the posterior vaginal cuff, the posterior peritoneum can be reefed to the vaginal epithelium between the uterosacral pedicles using a No. 2-0 or 0 polyglactin suture in a running locked fashion.
Tech Figure 8.5.7. Clamping of the right uterosacral ligament.
Tech Figure 8.5.8. Clamping, transection, and suture ligation of the uterosacral ligament. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2015, all rights reserved.
Tech Figure 8.5.9. Suture ligation of the right uterosacral ligament.
Entry into the anterior cul-de-sac
Downward traction is applied to the cervix and the anterior vaginal epithelium and underlying bladder are dissected off of the cervix and lower uterine segment.
A right-angle retractor is placed under the vaginal epithelium and is used to elevate the bladder to help facilitate dissection (Tech Fig. 8.5.10).
Anterior dissection is carried all the way to the vesicouterine peritoneal reflection. This is considered by many to be one of the most challenging steps of the vaginal hysterectomy. However, if dissection is not carried up to the vesicouterine fold, entry into the anterior cul-de-sac will be very challenging, and there is an increased risk of injury to the bladder. The right-angle retractor can then be placed underneath the bladder to better visualize the vesicouterine fold, which appears like a thin white transverse line across the lower uterine segment.
With downward traction on the cervix, the vesicouterine fold is tented upwards with pickup forceps and it is entered using the curved Mayo scissors (Tech Figs. 8.5.11 and 8.5.12).
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