Video Clips on DVD
Anterior Cul-de-sac Entry
Electrosurgical Device-Assisted Vaginal Hysterectomy
Once the decision to perform a hysterectomy has been made, the type and route of hysterectomy must be chosen, and efforts are made to accomplish the surgery as safely as possible. Chapter 4 discusses the pre- and perioperative considerations and informed consent procedure when planning a hysterectomy. The choice of the route of hysterectomy should be individualized to the patient and the indication for surgery. Vaginal hysterectomy has well-documented advantages and relatively lower complication rates in comparison to other types of hysterectomy and should be the route of choice, if possible. For women with benign uterine disease requiring a hysterectomy, there are few absolute contraindications to the vaginal route, and these contraindications tend to be somewhat operator-dependent. In general, if the uterus is too large, or the vagina too narrow for the uterus to be removed safely through the vagina, then a laparoscopic or abdominal alternative must be undertaken. If there is extrauterine disease, such as an adnexal mass, or obliteration of tissue planes adjacent to the uterus, as with severe endometriosis or pelvic adhesive disease, then a vaginal hysterectomy may not be possible. However, in most other cases, assuming that the gynecologic surgeon is skilled and experienced in vaginal surgery, a vaginal hysterectomy can usually be accomplished.
This chapter will review the basic techniques of vaginal hysterectomy and trachelectomy for benign uterine disease. Techniques for more difficult vaginal hysterectomy as with large uterine fibroids, obliterated cul-de-sac, or total prolapse are discussed in detail in Chapter 8 .
Case 1: Menorrhagia
GW is a 46-year-old gravida 3, para 2, aborta 1 woman who presents complaining of worsening menorrhagia with menses lasting 8 to 9 days per month. She states that during the first several days she changes a pad every 1 to 2 hours. Her menses are associated with significant cramping and some low back pain especially during the first 3 days. She has tried medical management with continuous oral contraceptive pills without success. Her physical examination reveals a 6-week-size mobile uterus without adnexal disease or significant pelvic organ prolapse. Her laboratory studies are unremarkable aside from a hematocrit of 31.5%. A Papanicolaou (Pap) smear showed no malignant cells. Office hysteroscopy was benign-appearing without polyps or fibroids, and an office endometrial biopsy was benign. The options of further medical management, levonorgestrel-releasing intrauterine device, endometrial ablation, or hysterectomy were discussed and she prefers a vaginal hysterectomy if possible. She states that she definitely does not desire any further children. She works full-time in a demanding field and prefers the more definitive resolution of her problem.
Discussion of Case
Abnormal bleeding, specifically frequent, heavy menses, can occur within a histologically normal uterus or may be associated with adenomyosis, uterine fibroids, or neoplasia. The spectrum of menorrhagia can range greatly with some women even to the point of iron therapy and blood transfusions. Given that she has continued symptoms in spite of medical management, resulting in anemia and decreased quality of life, it is reasonable to consider hysterectomy as part of her treatment plan. Although treatments such as medicated intrauterine devices or endometrial ablation are effective in many women, hysterectomy has been shown to have a very high satisfaction rate in women with these symptoms and essentially a 100% cure rate of bleeding, cramping, and dysmenorrhea. After a careful informed consent with review of the risks, benefits, and alternatives, and documentation that no further child-bearing is desired, a hysterectomy is chosen.
The gynecologist must assess this patient with pelvic examination to determine whether a vaginal hysterectomy is feasible and do that if possible. Alternatives such as total laparoscopic hysterectomy or laparoscopic supracervical hysterectomy would be reasonable for this patient, if desired by her and her surgeon. In general, unless she is at high risk for ovarian cancer or has a strong desire for ovarian removal, we do not favor prophylactic removal of ovaries in a premenopausal woman having a hysterectomy by whatever route. See Chapter 9 for further discussion of prophylactic oophorectomy.
See DVD Video 7-1 for video demonstration of the techniques for vaginal hysterectomy.
Before surgery appropriate perioperative intravenous antibiotics and antiembolic prophylaxis are routinely given. Vaginal hysterectomy begins with appropriate positioning of the patient. Vaginal hysterectomy is performed with the patient in the dorsal lithotomy position with her feet in “candy-cane” ( Fig. 7-1 ) or Allen stirrups. The patient’s buttocks should extend slightly over the edge of the table so that the posterior retractor can easily be placed. The thighs are somewhat abducted and the hips flexed. Excessive flexion and abduction of the thigh should be avoided, as this can lead to position-induced injuries. “Candy-cane” stirrups are preferable for deep vaginal surgery and when two vaginal surgical assistants are needed. An examination under anesthesia is performed to confirm the uterine size, degree of uterine mobility, the width of the vaginal canal, and the presence or absence of pelvic (especially adnexal) disease. The freedom of the cul-de-sac should be noted and a rectovaginal bimanual examination done. Elongation of the cervix is noted to help identify the point at which the incision through the vagina should begin. The vaginal, perineal, and lower abdominal areas are prepped in the normal fashion and the patient is sterilely draped. The urinary bladder is then emptied with a catheter. This catheter can be left in for intermittent emptying of the bladder or continuous drainage, or it can be removed and the bladder periodically catheterized.
A weighted speculum is placed in the vagina to depress the posterior vaginal wall, and the anterior vaginal wall is lifted with a Heaney retractor. The cervix is grasped with two single-toothed or a double-toothed tenacula, and downward traction is placed on the cervix. Vasoconstrictors such as vasopressin or a prepared solution of 0.5% lidocaine with 1:200,000 epinephrine are used routinely if no contraindications exist. Vasopressin injected in the cervix or pericervical tissue just before incision has been shown in randomized trials to decrease operative blood loss, without an increase in morbidity ( ), but does not improve postoperative pain control ( ). A paracervical block also can be given before vaginal hysterectomy if desired; this has been shown to decrease postoperative pain and narcotic requirements after surgery ( ; ). The surgeon should remember that the maximum amount of lidocaine with epinephrine used should not exceed 7 mg/kg or 500 mg total in the healthy adult, and the dose of bupivacaine with epinephrine, if used, should generally not exceed 225 mg. Should a medical contraindication to the use of vasopressors or epinephrine be present, injectable saline provides the benefits of hydrodistention but without the benefit of vasoconstriction or any increase in cardiovascular risks.
Either a knife or electrosurgical instrument is used to make the initial incision through the vaginal mucosa at the cervicovaginal junction ( Fig. 7-2 ). The position and depth of this incision are important because they determine access to the appropriate planes that will lead to the anterior and posterior cul-de-sacs. The appropriate location of the incision is at the site of the bladder reflection, which is indicated by the crease formed in the vaginal mucosa when the cervix is pushed slightly upward. If this location cannot be identified, one should make the incision low rather than high to avoid any potential bladder injury. The circumferential incision is accomplished and continued down to the cervical stroma. Downward traction of the tenacula and gentle countertraction by the retractors help to determine the appropriate depth of the incision. Once the appropriate depth of the incision is reached the vaginal tissue will fall away from the underlying cervical tissue because there is a direct plane between these two tissues.
The vagina is mobilized both anteriorly and posteriorly using sharp dissection. Careful palpation of the subvaginal tissues posteriorly will usually help identify the location of the cul-de-sac before entry. The posterior cul-de-sac is sharply entered with Mayo scissors ( Fig. 7-3 ) and then explored digitally for any adhesive disease, masses, or bowel ( Fig. 7-4 ). At times, bleeding may be encountered from the posterior vaginal cuff, and this is controlled with a running interlocking suture or perhaps cauterization. A long-weighted Steiner-Auvard vaginal speculum is then placed in the posterior cul-de-sac.
The uterus is pulled outward and somewhat to the opposite side. One half of an opened Haney clamp is introduced into the posterior cul-de-sac, rotated nearly to the horizontal, and the uterosacral ligament is clamped ( Fig. 7-5 ). The pedicle is cut with either Mayo scissors or a scalpel. The author prefers to ligate the pedicle with an absorbable suture, usually No. 0 Vicryl on the CT-1 needle. Pop-off sutures are convenient for the flow of the surgery. The cut pedicle is suture-ligated with a transfixing-type suture in which the needle enters the upper part of the ligament pedicle just behind the tip of the Haney clamp; it is withdrawn, and then reintroduced into the pedicle at its midpoint. The uterosacral ligament sutures are usually tagged for later identification. It is convenient to alternate clamping of the pedicles on opposite sides instead of clamping up one side of the uterus and then the other. This helps to gradually improve uterine mobility and exposure, and decreases back-bleeding that can occur from the uterine vessels.