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Vaginal Hysterectomy with Basic Instrumentation SURGICAL Techniques Vaginal hysterectomy with basic instrumentation An expert vaginal surgeon details her technique for this procedure, including tips and tricks to facilitate surgery in a woman with a narrow introitus Barbara S. Levy, MD n the United States, gynecologic surgeons class in vaginal hysterectomy produced by remove approximately one uterus every the AAGL and co-sponsored by the Am- I minute of the year.1 That rate translates erican College of Obstetricians and Gyne- to more than 525,000 hysterectomies annu- cologists and the Society of Gynecologic ally in this country alone. Yet, despite the Surgeons. This master class offers continuing widespread availability of information on the medical education credits and is avail- benefits of a vaginal approach to hysterec- able at http://www.aagl.org/vaghystwebinar. tomy, the great majority of these operations— For a look at innovative tools for this close to 50%—are still performed via an open procedure, see my “Update on Vaginal abdominal approach.2 Hysterectomy” in the September 2015 issue IN THIS ARTICLE As I pointed out last month in my of this journal at obgmanagement.com. “Update on Vaginal Hysterectomy,” the 5 solutions vaginal approach not only is more cosmeti- to difficult cally pleasing than laparoscopic and robot- Vaginal hysterectomy has vaginal access assisted hysterectomy (not to mention open few contraindications abdominal surgery) but also has a lower Many commonly cited contraindications to Page 29 complication rate.3 the vaginal approach are not, in fact, absolute As I also noted, one reason for the low contraindications. An open or laparoscopic The need to take rate of vaginal hysterectomy may be the approach is preferred when the patient has small bites assumption, on the part of many gynecologic a known cancer, of course, and when deep of tissue surgeons, that the techniques and tools they infiltrating endometriosis is present at the Page 33 learned to use during training are still the rectovaginal septum. However, previous pel- only options available today. That assump- vic surgery, nulliparity, an enlarged uterus, Uterine tion is wrong. or lack of a prior vaginal delivery need not reduction In this article, I describe the technique exclude the vaginal approach. Nor does a strategies for vaginal hysterectomy using basic instru- narrow introitus necessarily mandate a lapa- mentation. This article is based on a master roscopic or open abdominal approach. In Page 36 fact, in this article, I describe my basic tech- Dr. Levy is Vice President for nique in a patient (a cadaver) with a very Health Policy at the American narrow pubic arch, and I offer strategies for Congress of Obstetricians and Gynecologists in Washington, DC, gaining some needed mobility and avoiding and a past president of AAGL. complications (TABLES 1 AND 2, page 29). Next month, in the November issue of OBG Management, John B. Gebhart, MD, The author reports no financial relationships relevant to this article. will describe his vaginal technique for right salpingectomy with ovarian preservation, CONTINUED ON PAGE 29 28 OBG Management | October 2015 | Vol. 27 No. 10 obgmanagement.com vaginal hysterectomy CONTINUED FROM PAGE 28 TABLE 1 5 solutions to difficult TABLE 2 Avoiding complications: vaginal access 7 pearls • Be flexible in your choice of retractors. • Position the patient carefully, with the but- • Eliminate as much metal as possible; a tocks at least 1 inch over the edge of the retractor may not always be necessary. table, and pad the sacrum on thin patients. • Maintain a detailed knowledge of • Use routine prophylaxis for deep venous anatomy—and know it upside down! thrombosis (DVT). • Carry out careful dissection and clamp • Give 1 dose of a 1st-generation cepha- placement prior to peritoneal entry anteri- losporin approximately 15 to 30 minutes orly or posteriorly. prior to the initial incision. • Split the cervix carefully in the midline to • Maintain meticulous hemostasis. delineate the bladder reflection. • Handle all tissue carefully, as though the patient were awake. • Ensure early ambulation to reduce the risk as well as his technique for right salpingo- of DVT. oophorectomy. • Avoid use of an indwelling catheter. Proper patient positioning Inject the uterosacral ligaments is key Grasp the cervix using a Jacobs vulsellum You can simplify the operation by position- tenaculum. Use of a single tenaculum allows ing the patient so that her buttocks are over for much more movement than the use of the edge of the table fairly far—at least 1 inch instruments placed anteriorly and posteri- beyond the edge of the table for optimal orly. The Jacobs tenaculum obtains a better exposure and greater access. If the patient is purchase on the tissue than a single tooth thin, it then becomes important to pad the and is considerably less likely to tear through sacrum because, when she is positioned that the tissue. Position the patient far off the table, all her weight comes to rest Before beginning the hysterectomy, carefully, with the on the sacrum. In overweight patients, this is locate the uterosacral ligaments and inject buttocks at least not an issue, but for thin patients, I place a bit each one at its junction with the cervix, aspi- 1 inch over the edge of egg crate or gel beneath the sacrum. rating slightly before infiltrating the ligament of the table For the procedure, I prefer to place my with 0.25% to 0.50% bupivacaine with epi- instruments on a tray that is kept on my lap. nephrine, with dilute vasopressin mixed in. This arrangement frees the scrub technician (I place 1 unit in 20 mL of the local solution.) from having to hand tools over my shoulder— Injection of this solution achieves 2 goals: and it saves time. I use a narrow, covered • improved intraoperative hemostasis Mayo stand, and I place a stepstool beneath • postoperative pain relief. my feet to keep my knees at right angles so Use a short needle with a needle extender that things don’t slip during the operation. attached to a control syringe rather than a spinal needle for greater control. Surgical technique Enter the posterior peritoneal cavity Choose an appropriate retractor Before entering the peritoneal cavity, cre- In a woman with a narrow introitus, I find ate a right angle with the Jacobs tenaculum that a posterior weighted speculum takes up and Deaver retractor in relation to the surgi- too much space. Once I place a clamp on the cal field (FIGURE 1, page 32). This right angle cervix with that speculum in place, I don’t is difficult to achieve when you are using a have much room to work. However, if I sub- weighted speculum in a tight vagina. Once stitute a small Deaver retractor, which is nar- you have a right angle, tent the vaginal tissue rower, I gain more workspace. in the midline (FIGURE 2, page 32). CONTINUED ON PAGE 32 obgmanagement.com Vol. 27 No. 10 | October 2015 | OBG Management 29 vaginal hysterectomy CONTINUED FROM PAGE 29 FIGURE 1 Create a right angle FIGURE 2 Tent the vaginal tissue Before entering the peritoneal cavity, create a right angle with the Jacobs Once you have achieved a right angle, tent the tenaculum and Deaver retractor in relation to the surgical field. vaginal tissue in the midline (arrow). In a nulliparous patient or a woman with Avoid the bladder a tight pelvis, you may discover that the peri- Move the Deaver retractor to the anterior toneum is pulled up between the uterosacral position, switch the Jacobs clamp to the ligaments. One common pitfall arises when anterior cervix, and pull straight down. Now the surgeon, having dissected the vaginal that you have incised the vaginal epithelium epithelium, continues cutting into the vagi- posteriorly, the length of the cervix should nal epithelium instead of reaching into the be apparent to you, and you can easily deter- peritoneal cavity. Palpate the tissue to ensure mine the location of the bladder reflection. that there is no bowel in the way and stay at Keep in mind that, in a postmenopausal Keep in mind that, right angles while confidently grasping the patient, there will be fewer vaginal rugae to in a postmenopausal peritoneum with a toothed forceps. guide you. Place the Jacobs tenaculum as patient, there will be I like to use a bit of electrosurgery to close to the midline as possible so that you fewer vaginal rugae incise the vaginal wall. I don’t begin at the can confidently grab the tissue without fear to guide you to the cervix but incise more distally into the vagi- of grabbing the bladder. If you tilt the Jacobs bladder reflection nal epithelium approximately 2 cm from the clamp, you can feel the edge of the bladder cervicovaginal junction. This strategy pre- reflection. Remember that postmenopausal vents dissection into the cervix and/or rec- patients with prolapse (or, occasionally, obese tovaginal septum rather than the posterior FIGURE 3 Incise the vaginal cul-de-sac (FIGURE 3). Once the incision is made, it is possible epithelium to feel the posterior peritoneum. And as you tent the peritoneum, you can then very con- fidently extend the incision and enter the cavity posteriorly. In a patient with significant adhesions such as this one, I feel around posteriorly to determine exactly where I am. One tactic I use is to release the tenaculum and regrasp the cervix with it. This allows for improved visualization and movement of the cervix as the procedure progresses. Depending on the Incise the vaginal epithelium approximately 2 cm case, it may be necessary to insert a sponge from the cervicovaginal junction (arrow). to hold bowel out of the way. OF AAGL IMAGES COURTESY 32 OBG Management | October 2015 | Vol.
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