Several techniques may be utilized to perform a hysterectomy in the setting of pelvic organ prolapse. Vaginal hysterectomy, the most commonly employed technique, will be the focus of the majority of this chapter.

It is uncommon in our experience that pelvic organ prolapse involves just one compartment. Having said that, the main focus of this chapter is to deal with the steps of vaginal hysterectomy and apical support, in the setting of apical prolapse. Thus, we will leave the details of anterior and posterior compartment support to other chapters within this text.

Rationale for Approach

The vaginal approach to hysterectomy in the setting of prolapse has a rich history and offers a minimally invasive, cost-effective approach with short operating times, quick recovery, and minimal morbidity. Removal of the uterus is often straightforward; however, as the degree of prolapse increases, the potential difficulty and risk for injury also increases because the loss of anatomic support distorts anatomic planes (Figure 30-1). Lastly, a procedure to support the vaginal apex, once the hysterectomy has been completed, is critical as Level I support is central in anchoring the support for other compartments.

Preoperative

The clinical and diagnostic evaluation of prolapse is covered elsewhere in this book. Please refer Chapter 4 for appropriate details. We prefer a Betadine douche (dilute vinegar if iodine allergy) to reduce the vaginal flora and two fleet enemas the morning of surgery to evacuate the distal rectum. An antibiotic (1–3 g of a first-generation cephalosporin depending on the patient’s weight) should be administered an hour or less before the incision.

Intraoperative—Vaginal Hysterectomy

If the patient has impaired range of motion of the hips or lower extremities, it is wise to position the patient in lithotomy position prior to the induction of anesthesia. This maneuver assesses her tolerance or intolerance of lithotomy and appropriate adjustments can be made. She is then placed under regional or general anesthesia and repositioned. A pelvic examination is then performed under anesthesia to assess the vagina, uterus, and adnexa. The patient is prepped and draped. We prefer to empty the bladder via an in–out catheterization at this point to reduce any “bulge” from a distended bladder and make it less likely to encounter the bladder during the dissection. Alternatively, leaving some urine in the bladder provides a visible “gush” of fluid if the bladder is inadvertently entered during dissection. A weighted speculum is placed at 6 o’clock and Deaver retractors at 9, 12, and 3 o’clock.

The cervix is grasped with vulsellum tenacula and a circumferential incision is made (Figure 30-2). The incision may be tailored to assist with shortening of the vagina, if so desired. Attention should be paid to the lower margin of the bladder to prevent inadvertent injury. The anterior or posterior cul-de-sac may be entered at this point. We have always preferred to enter the anterior cul-de-sac initially, as the pertinent risk at hysterectomy is urinary tract injury. In entering anteriorly initially, the vesicouterine surgical plane is less disturbed and this makes entry more likely from the start, especially in the setting of prolapse. The vesicouterine dissection is carried out by staying in the midline and sharply mobilizing the bladder off the lower uterine segment with scissors. Downward traction on the uterus by the tenaculum along with anterior retraction by the 12-o’clock Deaver retractor facilitates this dissection (Figure 30-3). An index finger is inserted anteriorly and the space further developed. The peritoneal reflection is identified by its characteristic appearance and “slippery” feel. With traction on the anterior peritoneum with a toothed forceps, the peritoneal reflection is sharply incised with a scissors (Figure 30-4). The anterior Deaver is placed within the defect and identification of small bowel loops confirms anterior entry. In the event of inadvertent cystotomy, the site of injury should be marked with a suture and the appropriate plane between the bladder and uterus identified. The cystotomy should be repaired after the hysterectomy has been completed. If anterior cul-de-sac entry is difficult, try to enter posteriorly and wrap a finger around the fundus into the anterior cul-de-sac to assist in dissection (Figures 30-5 and 30-6).