Incidence

Hysterectomy still remains one of the most frequently performed gynaecological procedures, with about 600,000 carried out in the USA and 100,000 in England per year. The chance of a woman undergoing a hysterectomy at the age of 55 years is one in five in the UK and one in four in Australia, and the chance of hysterectomy by the age of 60 years is approximately 1 in three in the USA.

Most of these hysterectomies are carried out abdominally except when utero vaginal prolapse is the pathology at hand. Despite the advent of endometrial ablation procedures, and the introduction of levonorgesterol intrauterine system as newer modalities for managing menorrhagia, the hysterectomy rate worldwide has not decreased significantly, except in Scandinavian countries and recently in the UK.

The ratio of vaginal hysterectomy to abdominal hysterectomy varies from one to three, to one to four, depending on the skills of the surgeons. Experienced surgeons have shifted the ratio to three to four for vaginal hysterectomy.

Indications

Indications

Contraindications

Universally accepted contraindications include the uterus being larger than a 12-week pregnancy, absence of free mobility, and adnexal pathology. The contraindications have been challenged by astute gynaecologists with great expertise in vaginal hysterectomy. The absolute contraindications are presented in Table 2 . Relative contraindications are presented in Table 3 .

According to the American Congress of Obstetricians and Gynecologists, the most common reason for hysterectomy is multi-fibroid uteri (40.7%), followed by endometriosis (17.7%) and uterine prolapse (14.5%).

Current US national data show that standard abdominal hysterectomy is the method of choice in 66% of cases. Vaginal hysterectomy is carried out in 22% of cases, and laparoscopic hysterectomy in 12% of cases.

When choosing the route and method of hysterectomy, the clinician should take into consideration how the procedure may be carried out most safely and cost effectively to fulfill the medical needs of the patient.

Most research supports the opinion that, when feasible, vaginal hysterectomy is the safest and the most cost-effective route by which to remove the uterus.

Factors that influence the route of hysterectomy

Factors that may influence the route of hysterectomy for benign causes includes the size and the shape of the vagina and uterus, accessibility to the uterus, extent of extra-uterine disease, and the need for concurrent procedures, surgeon training and experience, available hospital technology, and preference of the informed patient.

A narrow sub-pubic arch (greater than 90°), a narrow vagina, and an undescended immobile uterus, nulliparity, prior caesarean section delivery, and an enlarged uterus, have been proposed as contraindications for vaginal hysterectomy. Many skilled vaginal surgeons have conducted large studies of vaginal hysterectomy in nulliparous women.

Uterine mobility can usually be improved by dividing the utero-sacral and cardinal ligaments sufficiently to allow vaginal hysterectomy, even in cases of minimal uterine descent.

When the uterus is enlarged, vaginal hysterectomy can often be accomplished safely by using uterine size reduction techniques, such as wedge morcellation, amputation of the cervix, uterine bisection, and intra-myometrial coring.

In a randomised-controlled trial, when residents followed specific guidelines for selection and performance of hysterectomy, the percentage of vaginal hysterectomies for benign conditions was more than 90%. Uterine morcellation and other uterine size-reduction techniques were only necessary in 11% of the cases. The route of hysterectomy is presented in Fig. 1 .

Determining the route of hysterectomy.

Extra-uterine disease, such as adnexal pathology, severe endometriosis, adhesions, or previous gynaecological surgery, leading to adhesion formation, may preclude vaginal hysterectomy. In these cases, however, it may be prudent to visualise the pelvis with a laparoscope before deciding on the route of hysterectomy.

A more conservative approach to elective salpingo-oophorectomy at routine vaginal hysterectomy is currently favoured over the more traditional guidelines. A significant advantage exists for retaining the ovaries for the post-menopausal hormonal secretion. Adequate evidence therefore supports a more conservative approach unless absolute indications for oophorectomy exist. The success of removing ovaries vaginally varies greatly, and is reported to range between 65 and 98% in three good studies.

Vaginal hysterectomy techniques

Vaginal hysterectomy techniques are fairly standard worldwide. Equipment used for vaginal hysterectomies differ between countries and individual gynaecologists. The intention here is to highlight points of differentiation so that a successful vaginal hysterectomy can be achieved with minimal complications and ease of operative procedure. The points discussed can help improve the reader’s skills and to maximise the success of the vaginal hysterectomy procedure. The steps are as follows: (1) adequately reflect the bladder onto the anterior aspect and open the pouch of Douglas safely in the posterior fornix; (2) sever the posterior and lateral ligaments and the blood supply to the uterus; (3) having catheterised the woman in an extended lithotomy position, create adequate traction to the anterior and posterior lip of the cervix with two clamps; (4) vasopressin or ornipressin (POR-8 vaso-constricting agent) is used to infiltrate the region of the cervical vesicle fusion area, about 1–1.5 cm from the external lip of the cervix; (5) this is followed by infiltration of the utero-sacral ligaments region in the pouch of Douglas to adequately identify the Pouch of Douglas safely ( Fig. 2 ). (6) once the region is adequately infiltrated, a diathermy blade, preferably, is used to make a half-moon incision from 10 o’clock to 2 o’clock position on the anterior lip of the cervix towards the bladder base with ornipressin, a vaso-constricting agent; (7) thereafter, a v-shaped incision or a u-shaped incision is made in the posterior region of the Pouch of Douglas from 7 o’clock to 4 o’clock position. The pouch of Douglas is not opened at this stage. That leaves the vagina intact between 2 o’clock and 4 o’clock and the 10 o’clock and 7 o’clock position. It is in this region that the descending branch of the uterine artery or the cervical branch of the uterine artery is present. This particular vessel is independently clamped cut and tied by putting a clamp in the gap between the 2 o’clock and 4 o’clock position, and similarly on the contralateral side from the 10 o’clock and 7 o’clock position ( Figs. 3 and 4 ); (8) once this is ligated, formally open the pouch of Douglas by palpating the area between the utero-sacral ligaments once the incision has been made with the diathermy knife. The vagina is reflected off the peritoneum, the peritoneum cut open with scissors, and the incision extended to each of the utero-sacral ligaments. Adequate palpation will confirm the presence of adhesions and the situation of the utero-sacral ligaments; (9) from here, the universal procedure is continued as practised worldwide. The utero-sacral cardinal ligament complex is cut and tied on both sides, and that pedicle then ligated or stitched to the initial uterine pedicle that was taken. These two pedicles are then clamped, and the threads are kept hanging onto one of the gynecological instruments deemed fit. The bladder is now reflected and the reflection of the bladder is initiated by using the ‘utero vesicle broad ligament space’ as popularised by Shirish Sheth from Mumbai, India ( Fig. 5 ); the bladder is best reflected laterally than in the central region where it is attached to the cervix. This is the crux of a successful reflection of a bladder. Once the bladder is reflected adequately, the uterine vessels are clamped, cut and tied on either side; the pedicle is held with a suture about10 cm long, and a stitch is taken to the original utero-sacral ligament pedicle so that the gap between the uterine vessels and the utero-sacral ligament has been closed by suturing that pedicle onto the utero-sacral ligament; (10) once the uterine vessels are ligated on both sides, the best manoeuvre at this stage is to amputate the cervix irrespective of the size of the uterus ( Fig. 6 ). The reason for this is so that the surgeon can gain a sense of half completing the procedure and being in total control of the hysterectomy up to this stage ( Figs. 7 and 8 ). A Hegar dilator may be inserted in the uterine cavity to assess the length of the uterine cavity and how much work lies ahead; (11) the bladder peritoneum is now completely reflected and the utero vesicle peritoneum opened; the uterus is visible on the anterior aspect. At this stage a repeat uterine vessel clamp is taken on both sides and uterine vessel clamped cut and tied; the pedicle is once again stitched onto the utero sacral vaginal pedicle, thereby closing the gap between the second uterine ligation and first uterine ligation. This tap will significantly decrease bleeding between the vascular pedicles; (12) at this stage, the instruments that are holding the cervix are removed from the 12 o’clock and 6 o’clock position and placed on the 3 o’clock and 9 o’clock position, and the uterus is bisected from the cervix anteriorly and thereafter posteriorly. Having successfully bisected the uterus, one-half of the uterus is pushed in the pelvis and the other half the instrument is removed from the internal orifice level and placed towards the cornual end of the uterus; (13) one-half of the uterus is now pulled medially, the cornual end is clamped cut and tied on both sides, and the residual length of the suture material will help again to stitch towards the original utero-sacral cardinal ligament complex, thereby closing the gap between the cornual end and the uterine vessels; (14) at this stage, a wet gauze swab is inserted in the peritoneal cavity, and the posterior peritoneum and the posterior vaginal wall is held up with three clamps; (15) the vault of the vagina is then closed in the same way as for an abdominal hysterectomy. A stitch is taken from 2 o’clock to 4o’clock position on the vagina. The stitch continues from 4 o’clock position to the full thickness of the vagina and the peritoneum on the inner aspect of the pelvis and then the stitch continues to the angle at 1 o’clock position and this manoeuvre is repeated once again from the 4 o’clock and 1 o’clock position; the stitch is ligated and this forms the purse string stitch on one side or on the left side of the patient. The sutures held are from the cornual end and the two uterine artery clamps and the utero sacral cardinal complex sutures are also cut. The same manoeuvre is repeated on the other side by inserting the stitch from the inner aspect of the peritoneum at 7 o’clock position coming out on the vaginal end taking a stitch on the vagina from 7 o’clock to the 10 o’clock position and coming down to 7o’clock position ( Fig. 9 ).

Injection of Vasoconstricting Agent on the Anterior and posterior aspect (Pouch of Douglas) of cervix. Half moon incision on anterior aspect of Cervix, with electrical blade.

V -shaped incision on posterior aspect of cervix, with electrical blade. Clamp, cut and ligate the vagina between the anterior and posterior incision.

Anatomy of Uterine artery and Ureter- for Vaginal and Laparoscopic Hysterectomy.

Identification of the Utero-vasical Broad Ligament Space, on patients left side.

Clamp, cut and ligate the UteroSacral and Cardinal Ligaments.

Anatomy of Cervix, Ureters (two centimetres from lateral aspect of cervix) and Uterine Vessels Trigone of bladder.

Uterine vessels being Ligated. Amputation of Cervix. Removal of Fibroid.

Following bisection of Uterus, One half of the uterus being removed from cornual end. Closure of the Vault, and insertion of Low Vacuum bottle drain, in the Obese patient.

Procedural modifications for uteri with specific pathologies

Previous caesarean section

Specific modifications for women who have had previous caesarean sections I, II or III are as follows: (1) 30-ml methylene blue is instilled in the bladder once it has been emptied via a self-retaining Foleys catheter. This will significantly help to identify accidental damage to the bladder and also identify the specific site at which the bladder has been nicked or avulsed. The possibility of bladder nick or avulsion is also present with women who have had previous caesarean sections; these women have to be appropriately counselled; (2) the second manoeuvre is to reflect the bladder of a woman who has had a previous caesarean section. The reflection of the bladder is more successful if a large volume of vaso-constricted agent diluted in 1 in 100 of POR-8 is instilled before the initial half-moon incision is made, and once again after the cervix has been amputated; (3) the trick when reflecting the bladder is to once again identify the ‘utero vesicle broad ligament’ (Sheth) by beginning laterally and reflecting towards the 1 o’clock direction on the woman’s left side and similarly at 11 o’clock direction in the woman’s right side. No attempt should be made to reflect the bladder in the midline because it is here that the caesarean section scar has made the bladder morbidly adherent; (4) this space is best used before the first uterine vessel is ligated, amputation of the cervix performed and then once again the bladder reflected before the second uterine vessel is ligated. After the second uterine vessel is ligated on both sides, an attempt is made to reflect the bladder in the midline having approached the reflection of the bladder at a higher level towards the fundus of the uterus and not where the bladder is stuck at the cervix at the level of the internal orifice.

Once the bladder is reflected, the same manoeuvres are carried out in accordance with the original operative procedures discussed.

If one is uncomfortable with the haemostasis during the procedure or at the end of the operation before closing the vault of the vagina, a laparoscopic cannula is inserted in the midline and sealed to insufflate (CO2) the peritoneal cavity from the vault of the vagina. A laparoscope is now inserted via the umbilicus and additional second and third ports inserted so that one can adequately mobilise the bowel and a peritoneal lavage to clear up all the clots. A bipolar forceps is used to perform meticulous haemostasis and, if still in doubt, leave a 3-mm drain through the suprapubic cannula.

The above specific manoeuvres will make most of the hysterectomies possible without compromising the woman’s wellbeing, and the surgeon will always feeling comfortable being in total control of the operation.

According to Wood et al., evidence shows that carrying out peritoneal lavage and haemostasis significantly improves postoperative morbidity and recovery. They recommend this whenever one is uncomfortable with the haemostasis or significant bleeding occurs during the operative procedure. Specific indications for pre-hysterectomy laparoscopy for vaginal hysterectomy are presented in Table 4 .

Preoperative laparoscopies should be carried out to evaluate pelvic pathology in order to decrease the number of abdominal hysterectomies carried out because of pathology present (e.g. previous pelvic inflammatory disease, causes of chronic pelvic pain, presence and stage of endometriosis, pouch of Douglas pathology, and the effect of previous gynaecological or general surgical operative procedures that could be corrected laparoscopically before proceeding with a vaginal hysterectomy). Hence, it will be prudent to evaluate the pelvis laparoscopically, rectify the pathology, and continue with a successful vaginal hysterectomy.

Kovac has shown that little benefit is to be gained by continuing the procedure laparoscopically once the laparoscopic correction has been performed, because complications increase at laparoscopic hysterectomy compared with vaginal hysterectomy.

The manoeuvre to ligate the uterine vessels laparoscopically as well as laparoscopic reflection of the bladder is associated with a high incidence of bladder trauma and ureteric complications.

If judicious choice is made to carry out a preoperative laparoscopy, many abdominal hysterectomies may be converted to vaginal hysterectomies.