Vaginal Hysterectomy for Endometrial Cancer
Kenneth D. Hatch
GENERAL PRINCIPLES
Definition
Vaginal hysterectomy has been used as a treatment for endometrial cancer in women who have a high risk of surgical morbidity.
Morbid obesity, diabetes, hypertension, advanced age, cardiovascular disease, pulmonary disease, and renal disease are the most common reasons for selecting vaginal hysterectomy.
Modern anesthetic and postoperative care coupled with minimally invasive surgery has diminished the use of vaginal hysterectomy.
Morbid obesity remains the most common reason for selecting vaginal hysterectomy.
These women are also likely to have type I endometrioid carcinoma with grade 1 tumor and lack of myometrial invasion making node dissection unnecessary.
Women with BMI over 60 may preclude a patient from consideration for abdominal or robotic surgery.
Vaginal hysterectomy may be chosen for women who have comorbid conditions that preclude longer surgical procedures with the Trendelenburg position and the need for general anesthesia.
Anatomic Considerations
Briefly discuss any anatomic considerations as appropriate.
In order to be a candidate for vaginal hysterectomy, the uterus should be small enough to fit through the vagina, there should be no adnexal masses that need abdominal removal, and there should be no history of previous surgery that suggests extensive pelvic adhesions.
An episiotomy or a vaginotomy may be necessary to remove a large uterus.
Morcellation of the uterus should be avoided when malignancy is present.
Nonoperative Management
Progesterone therapy either oral or with an IUD may be a suitable option for women unable to have general or spinal anesthesia.
IMAGING AND OTHER DIAGNOSTICS
See Chapter 9, Open Surgery for Apparent Early-Stage Endometrial Cancer.
PREOPERATIVE PLANNING
Consultation with the appropriate medical specialists should be obtained to evaluate the suitability of the patient to undergo the stress of anesthesia and vaginal hysterectomy.
Women with endometrial cancer and morbid obesity should be counseled about the treatment of endometrial cancer. The appropriate treatment is to perform laparotomy or MIS to evaluate the abdomen and be prepared to perform additional staging if required by the hysterectomy findings. The risk of a complication from that surgery may outweigh the risk that the tumor may spread and if so, a vaginal hysterectomy may be indicated.
Imaging may be necessary to evaluate the size of the uterus and the adnexa to determine the suitability of the patient for vaginal surgery.
SURGICAL MANAGEMENT
Positioning
The patient is placed in the lithotomy position with the legs on the supporting device.
The buttocks will be 2 inches off the end of the table.
The arms are out so IV access is readily available. An arterial line may be indicated.
PROCEDURES AND TECHNIQUES
Vaginal Hysterectomy for Endometrial Cancer
Instruments
The instruments include Deaver retractors, Haney right angle retractors, Breisky retractors, lighted suction irrigator, vessel-sealing bipolar device (Tech Fig. 10.1).
 Tech Figure 10.1. The instruments for a vaginal hysterectomy include Deaver retractor, Heaney retractor, Breisky retractor, lighted suction irrigator, compressed bipolar energy. |
Entering the peritoneum
The labia may be sutured to the thigh for better vision, especially in obese women.
The cervicovaginal junction is incised with the knife.
The prevesical space is developed but one does not need to enter the peritoneum at this time, especially if the uterus has no descensus.
Enter the posterior cul-de-sac first and place a handheld retractor such as the Breisky. It gives more exposure than a weighted speculum and a weighted speculum may not fit in a narrow vagina or when a uterus has no descensus.
Begin the hysterectomy
Clamp the uterosacral ligaments. For the uterus that won’t descend, clamping the uterosacral ligament separate from the cardinal ligament will begin the descensus and later will allow the upper vagina to expand easier without disrupting the suture.
Make sure the base of the bladder is lifted by the Deaver in the prevesical space and then clamp and cut the cardinal ligaments and hold these sutures for later suspension of the vaginal apex.
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