Introduction

Female pelvic organs have two portals of entry: one natural and the other surgically created. No surgeon other than a gynaecologist will have the in-depth knowledge of the art and science of making optimum use of the natural orifice (i.e. gynaecological vaginal route for required surgery).

The vaginal approach has always been the hallmark of the gynaecological surgeon. For hysterectomy, the vaginal route has proved its supremacy over alternatives. Only when this natural route cannot be considered, should the gynaecologist choose an alternative (i.e. the abdominal route ), either by laparotomy or laparoscopy. Advantages of using the vaginal route include carrying out an adnexectomy vaginally for a benign ovarian cyst at the time of vaginal hysterectomy and sparing the abdomen or, when the abdominal approach is risky, creating a pneumoperitoneum transvaginally for laparoscopy.

In this chapter, we also look at less common situations in which the vaginal route may be considered as a suitable or useful alternative.

Hysterectomy

How does one prove the need for surgery or justify a surgeon’s decision to carry out a hysterectomy? If hysterectomy is not undertaken, deterioration can disprove the surgeon’s decision to conserve the uterus. Alternatively, if hysterectomy is undertaken, it cannot be shown that conservation of the uterus would not have caused deterioration? Hysterectomy is, therefore, protective for the surgeon as well as the patient. However, hysterectomies may be unethically lucrative where a hysterectomy is not indicated but carried out nonetheless. It is similar to a caesarean section in obstetrics. However, one can prove the suitability of a route or technique selected for hysterectomy.

The introduction of laparoscopic techniques for hysterectomy has prompted gynaecological surgeons to step back and review the advantages and disadvantages of the various techniques for hysterectomy. In 2009, The American College of Obstetrics and Gynecology Committee concluded that vaginal hysterectomy is associated with better outcomes and fewer complications than laparoscopic or abdominal hysterectomy. A Cochrane Review of 34 randomised-controlled trials of abdominal, laparoscopic and vaginal hysterectomies concluded that vaginal hysterectomy has the best outcomes and that, when vaginal hysterectomy is not possible, laparoscopic hysterectomy has advantages over abdominal hysterectomy. Reich, who pioneered the first laparoscopic hysterectomy, recommended vaginal hysterectomy when it can be safely carried out in preference to laparoscopic hysterectomy.

Laparoscopic cuts and laparotomy incision are additional invasions compared with vaginal cuts at vaginal hysterectomy. Although laparoscopic hysterectomy is minimally invasive (number or size of abdominal cuts) it is certainly more invasive than vaginal hysterectomy. Undesirable ‘invasion’ also includes the effect of the level and duration of invasion on all intra-peritoneal contents; the effect of prolonged anaesthesia and operative theatre occupancy; financial invasion; disregard of evidence-based conclusions; and, at times, invasion of ethical practice ( Table 1 ) ( Fig. 1 a and b). Opening the abdomen for hysterectomy, when the same hysterectomy can be safely carried out vaginally or laparoscopically, should make the gynaecologist feel as guilty as an obstetrician carrying out an unindicated caesarean section.

(a) Tonsils are seen and can be easily removed from the natural orifice just as the uterus can be seen and removed vaginally. This is less invasive than Fig. 1 b; (b) tonsils are removed via submandibular laparoscopy just as the uterus can be accessed for removal abdominally by laparoscope.

Hysterectomy

How does one prove the need for surgery or justify a surgeon’s decision to carry out a hysterectomy? If hysterectomy is not undertaken, deterioration can disprove the surgeon’s decision to conserve the uterus. Alternatively, if hysterectomy is undertaken, it cannot be shown that conservation of the uterus would not have caused deterioration? Hysterectomy is, therefore, protective for the surgeon as well as the patient. However, hysterectomies may be unethically lucrative where a hysterectomy is not indicated but carried out nonetheless. It is similar to a caesarean section in obstetrics. However, one can prove the suitability of a route or technique selected for hysterectomy.

The introduction of laparoscopic techniques for hysterectomy has prompted gynaecological surgeons to step back and review the advantages and disadvantages of the various techniques for hysterectomy. In 2009, The American College of Obstetrics and Gynecology Committee concluded that vaginal hysterectomy is associated with better outcomes and fewer complications than laparoscopic or abdominal hysterectomy. A Cochrane Review of 34 randomised-controlled trials of abdominal, laparoscopic and vaginal hysterectomies concluded that vaginal hysterectomy has the best outcomes and that, when vaginal hysterectomy is not possible, laparoscopic hysterectomy has advantages over abdominal hysterectomy. Reich, who pioneered the first laparoscopic hysterectomy, recommended vaginal hysterectomy when it can be safely carried out in preference to laparoscopic hysterectomy.

Laparoscopic cuts and laparotomy incision are additional invasions compared with vaginal cuts at vaginal hysterectomy. Although laparoscopic hysterectomy is minimally invasive (number or size of abdominal cuts) it is certainly more invasive than vaginal hysterectomy. Undesirable ‘invasion’ also includes the effect of the level and duration of invasion on all intra-peritoneal contents; the effect of prolonged anaesthesia and operative theatre occupancy; financial invasion; disregard of evidence-based conclusions; and, at times, invasion of ethical practice ( Table 1 ) ( Fig. 1 a and b). Opening the abdomen for hysterectomy, when the same hysterectomy can be safely carried out vaginally or laparoscopically, should make the gynaecologist feel as guilty as an obstetrician carrying out an unindicated caesarean section.

(a) Tonsils are seen and can be easily removed from the natural orifice just as the uterus can be seen and removed vaginally. This is less invasive than Fig. 1 b; (b) tonsils are removed via submandibular laparoscopy just as the uterus can be accessed for removal abdominally by laparoscope.

Dysfunctional uterine bleeding and adenomyosis

The VALUE national hysterectomy study carried out in the UK in 2002 showed that dysfunctional uterine bleeding accounted for 43% of 37,000 hysterectomies studied. Only 21% of the hysterectomies were vaginal. The National health Service in the UK could save 22,000 bed days if 80% of all hysterectomies are carried out vaginally.

Uterine fibroids

Fibroids are the most common indication for hysterectomy. Technique for removal or route of hysterectomy is determined by total uterine size and volume. Clinical evidence does not support the use of abdominal removal, laparoscopic hysterectomy or laparoscopic-assisted vaginal hysterectomy (LAVH), if the size of the uterus is of a 12-week pregnancy or less, or if the uterus has a volume of 250–300 cm ³ or less. However, if the size or volume of the uterus is greater, LAVH or total abdominal hysterectomy is indicated, or if it is within the surgeon’s possible guestimated reach, then a trial vaginal hysterectomy can be attempted.

The following factors can be used as a guide to which surgical intervention is most suitable: accessibility and size of fibroid; debulking experience; pelvic factor in the form of uterine descent on traction, including ‘give’ obtained after progressive severance of lateral connections, tissue suppleness and available uterus-free space.

Debulking

Debulking is carried out only after the uterine vessels are well secured. It is easier in a myomatous rather than an adenomyotic uterus, and with posterior rather than an anterior wall myoma. Preoperative GnRH for selective women has a role. Even when fundal height is at the same level on palpation, uterine size and bulk can grossly differ ( Fig. 2 ). Uterine volume is a much better indicator than obstetric-based uterine size. Normal uterus volumes are between 40 and 60 cm ³ .

All three uteri are equal in height (10 cm; fundal palpation) but grossly different in size (volume of 195, 290 and 485 cm ³ ) owing to other dimensions being different.

It is important that when the uterus is palpably the size of an 18–20 week pregnancy, or has a volume greater than 500 cm ³ , the three corresponding uterine dimensions differ markedly (i.e. should not be equally 10–12 cm or more). The utero-cervical angle between the lateral cervical surface and ascending uterine wall from the cervix should be around 140 ^° , but a reduction in the angle to 90 ^° makes lateral access difficult and vaginal hysterectomy impossible to carry out ( Fig. 3 ).

The depicted angle between lateral cervical and uterine borders, greater than 140 ^° , makes access and reach easier. Reduction of the angle towards 90 ^° makes access and reach difficult or impossible. Published with permission.

Caesarean section

Today in most countries, over 20% of births are carried out by caesarean section, and this figure may rise disproportionately. It is therefore conceivable that the surgeon of tomorrow will be confronted by the need to carry out hysterectomies in women who have had one or multiple previous caesarean sections. Women who have not delivered vaginally and have had previous caesarean sections are ‘vaginally nulliparous’ and ‘abdominally parous’.

Women who have had caesarean sections may develop adhesions. For access to vesico-uterine peritoneum, the bladder needs to be safely separated from the uterus. Access is usually gained through uterocervical broad ligament space, from available lateral space. This procedure is supported by gratifying scientific evidence. Sizzi and Rossetti use the same space at LAVH as well as abdominal hysterectomy. John M. Monaghan, a noted gynaecological oncologist (personal communication) finds this space useful for accessing the vesico-uterine peritoneum. Surgeons who want to learn and progress may choose to practice such access in five to 10 vaginal hysterectomies in women who have not had previous caesarean sections. Finding the access point from the central area in women who have had previous caesarean sections will only increase the risk of bladder trauma.

The decision to carry out vaginal hysterectomy in women who have had previous caesarean sections should be guided by two questions: ‘with the same pelvic findings, in the absence of caesarean section in past, would I attempt vaginal hysterectomy?’ If the response is yes, then the second question is ‘will I be able to access the vesico-uterine peritoneum?’ Gynaecologists need to remember that previous caesarean sections per se can never contraindicate vaginal hysterectomy.

Nullipara

Obesity

The UK, USA and Canada now have significant and increasing obese populations. In addition to intraoperative difficulties, postoperative complication rates have risen in obese women, including pulmonary compromise, venous thrombosis, wound infection and dehiscence.

In the absence of absolute contraindications for vaginal hysterectomy, obesity should be a positive indication for the surgeon to carry out hysterectomy vaginally, and consider obesity as a contraindication for taking the abdominal route either for laparotomy or laparoscopy ( Fig. 4 ).

A morbidly obese woman with body mass index of 80 underwent a straightforward vaginal hysterectomy with bilateral salpingo–oophorectomy with a hospital stay of 48 h.

Other indications for vaginal hysterectomy

Other indications for vaginal hysterectomy include benign hydatidiform moles in elderly multiparous women. Abdominal hysterectomy can pose certain risks, and certain situations demand avoidance of abdominal surgery, even for the most ardent practitioner. These include previous ventral scar hernioplasty, morbidly obese women, repeated keloids, abdominal tuberculosis (disturbed abdomen), and women at high risk.

Subtotal hysterectomy

Dr. Parker, teacher of Howard Jones, the eminent US gynaecologist, once commented that supra-cervical hysterectomy was an operation devised by, and for, incompetent surgeons, which should be relegated to the history books. In 1974, Howkins and Stallworthy apologised for including a chapter on subtotal hysterectomy in their book Bonney’s Gynecologic Surgery . Paradoxically, the incidence of laparoscopic supracervical subtotal hysterectomy is increasing, and has now reached 20% in California, USA.

Complications can occur with total laparoscopic hysterectomy, and it seems that subtotal hysterectomy prevents subtotal laparoscopic surgeons from causing trauma to a woman’s bladder, ureters, or both. Despite proven disadvantages, we wonder at laparoscopic surgeons recommending, almost marketing, subtotal hysterectomy. Steer remarked that younger gynaecological oncologists do not feel they have anything to prove by removing the cervix compared with older gynaecological surgeons who are more likely to remove the cervix, fitting in with the ‘Macho factor’.

In the developing world, ‘pap’ smears are rare to infrequent. Leaving behind an ‘innocent cervix’ because the surgeon is unwilling to carry out total laparoscopic hysterectomy (because it may traumatise the bladder, ureters, or both), in our opinion, is tantamount to moral degradation. This approach certainly makes them proficient in subtotal hysterectomy. Comparisons cannot be made between total hysterectomy and subtotal or supracervical hysterectomy, just as comparisons cannot be made between complete and incomplete hysterectomy. We recommend subtotal or supracervical hysterectomy in the following circumstances: the ureter, colon, or both, are at risk of trauma because of dense adhesions; the anaesthetist asks to complete the surgery quickly in the interest of the patient; and the woman is keen to preserve her cervix. When keen to preserve the cervix, the vaginal route may be considered or preferred for subtotal hysterectomy as an alternative to laparoscopic subtotal hysterectomy.

Concommitant oophorectomy at vaginal hysterectomy

A report in 2002 showed that, in women aged 55–60 years, oophorectomy was carried out in 92% during abdominal hysterectomy, 96.6% during LAVH, and only 9.4% during vaginal hysterectomy. Clearly, this surgical deficiency results in partial treatment.

American College of Obstetrics and Gynecology guidelines recommend the use of laparoscopic assistance only for difficult oophorectomy at vaginal hysterectomy. Removal of ovaries at vaginal hysterectomy is usually not difficult. The technique has been used in more than 1500 women, with a 3–4% failure rate. It is important not to preserve the ovaries simply because hysterectomy is carried out vaginally or switch technique to abdominal hysterectomy or LAVH simply because the ovaries are to be removed. It is useful to ask the question: ‘if I were to carry out the hysterectomy abdominally, would I have retained or removed the ovaries?’ Postmenopausal women with third-degree uterine prolapse are ideal candidates from whom to learn and master this technique.

Examination under anaesthesia and place of evaluatory laparoscopy

Examination under anaesthesia carried out just before the start of hysterectomy, with the woman only in lithotomy position, should serve as the gold standard for making decisions about the appropriate route and technique to be used. Every hysterectomy should be preceded by an examination under anaesthesia for better assessment and, in the absence of pelvic pathology, to ensure that every uterus has physiological descent, sufficient to carry out a vaginal hysterectomy.

Vaginal hysterectomy combined with non-gynaecological surgery

Dual pathologies are now tackled during the same surgical session to take advantage of single anaesthesia and hospitalisation. This will result in reduced cost and shorter convalescence. A classic example of the least invasive procedure is laparoscopic cholecystectomy combined with vaginal hysterectomy. Both are less invasive compared with alternatives. Even in this case, laparoscopic hysterectomy will need additional ports on the abdomen, and hence vaginal hysterectomy will prove to be less invasive.

Other procedures that can be combined with vaginal hysterectomy include repair of large umbilical hernia, repair of high ventral scar hernia, or appendicectomy via Mcburney’s incision, and excision of breast fibroadenoma.

Litigation or diffidence?

Sharon et al. evaluated routine cystoscopy after laparoscopic hysterectomy. To avoid law suits, it may become necessary to carry out cystoscopy in all cases of hysterectomy to confirm normalcy and to exclude ligated or transected ureter. For vaginal hysterectomy or LAVH, ureteral injury needs to be 2% before routine cystoscopy can become cost-effective. The trend is definitely towards routine cystoscopy after major vaginal gynaecological surgery.

We strongly feel that routine cystoscopy is a retrogressive step. Have we stooped so low in our surgical skills as to feel insecure? Should we not then consider routinely testing the gastrointestinal tract with a barium enema, barium meal or an endoscopy after abdominal or laparoscopic bowel-related surgery even with seemingly intact bowel? In fact, even testing the bladder with methylene blue at the end of every vaginal hysterectomy reflects and belittles the surgeon and his operative skill. We do use methylene blue to test bladder integrity but rarely.

What can promote the use of vaginal hysterectomy?

Careful clinical assessment, reliable sonographic findings and examination under anaesthesia will commonly find no contraindication to vaginal hysterectomy. This should also be taken to mean no indication to opening the abdomen or using more invasive laparoscopic technique for hysterectomy. Not carrying out vaginal hysterectomy for dysfunctional uterine bleeding or adenomyosis without contraindication is like carrying out a caesarean section in obstetrics without indication and not permitting vaginal delivery.

All of the above can only succeed if senior gynaecological surgeons are available to be emulated. Dunn et al. showed that the incidence of vaginal hysterectomy increased from 37% to 60% in a residency programme at the University of Colorado, USA. Similarly, in Warwick, England, Olah and Khalil felt that the advantages of vaginal hysterectomy are distinct and hence, with specific efforts, converted subtotal (73%) and total abdominal hysterectomy (27%) to vaginal hysterectomy in all 29 cases. We recommend a target of 80% hysterectomies via the vaginal route.

Our esteemed teacher Professor Chandrakant G. Saraiya, Former President of The Federation of Obstetric and Gynaecological Societies of India and an incomparable teacher, often used to quote Hippocrates: ‘if you can do no good, do no harm’. Harer, former President of The American College of Obstetricians and Gynecologists, wrote: ‘those who care for patients must consider factors beyond the mechanics’. For those who want to, abundant published material is available from which to learn, imbibe and practice. The mindset of the surgeon is pivotal, as there has to be a ‘will’ to perform and progress in the best interests of patients.