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Secrets to Successful Vaginal Hysterectomy ▲

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Secrets to Successful Vaginal Hysterectomy ▲ OBG_1206_Unger.Final 11/20/06 1:40 PM Page 35 OBGMANAGEMENT Secrets to successful James B. Unger, MD Associate Professor, Director of Gynecologic Pelvic Surgery, vaginal hysterectomy Edward J. Crawford Jr, MD, Professor of Gynecologic Surgery, Challenges such as an enlarged uterus or history of pelvic and Residency Program Director, Department of Obstetrics surgery need not precipitate a switch to the abdominal route and Gynecology, Louisiana State University Health Sciences Center, Shreveport, La CASE 1 Problems entering don the vaginal approach just yet. In my the cul-de-sac experience, the anterior peritoneal fold can be high or distorted by fibroids in some M.K. is a 43-year-old gravida 2 para 2 women. The key to successful surgery is a who is undergoing a vaginal hysterectomy® pauseDowden in activity Health to consider Media the case at for menorrhagia. A preoperative pelvic hand and determine whether additional exam and ultrasound suggested a progress can be made safely without 12-week-size uterus with severalCopyright smallFor personalchanging the approach. use only leiomyomata. Her gynecologist estimates the uterine weight at 240 g and notes that Avoid blind entry at all costs the uterus is mobile. M.K. asks that her No less an authority than Heaney1 advised ovaries be removed at the time of against blind attempts to enter the anterior IN THIS ARTICLE hysterectomy because of a family history cul-de-sac. Such attempts are often frus- of ovarian cancer. trating, can involve bleeding, and raise the ❙ Ovaries appear During the initial dissection, the risk of injury to the bladder. However, out of reach surgeon is unable to enter the anterior once the surgeon is confident that the blad- Page 36 cul-de-sac due to distortion created der is free and retracted out of the way, he by an anterior fibroid. The surgeon has or she can proceed without intraperitoneal ❙ History of cesarean entered the posterior cul-de-sac, but entry. This is especially true if the posterior delivery the uterus is too large to manipulate a cul-de-sac has been entered safely. Page 37 finger around anteriorly to identify the peritoneal fold. Although he feels confi- The “climb up” technique dent that the bladder has been adequately In some cases, the surgeon may safely pro- mobilized from the cervix, the surgeon ceed extraperitoneally even if neither cul- is strongly considering abandoning the de-sac has been opened. Krige2 coined the vaginal approach and completing the term “climb up” to describe the extraperi- hysterectomy abdominally. toneal approach to the inaccessible posteri- How should he proceed? or cul-de-sac. He performed extensive extraperitoneal dissection that, if neces- ntry into the peritoneal cavity sary, included both uterosacral and cardi- through the anterior or posterior nal ligaments as well as uterine vessels. A E cul-de-sac can sometimes be chal- surgeon may carry a total extraperitoneal lenging, as this case illustrates. However, dissection completely to the uterine fundus there is no need for the surgeon to aban- as long as the bladder and rectum are free.3 CONTINUED www.obgmanagement.com December 2006 • OBG MANAGEMENT 35 For mass reproduction, content licensing and permissions contact Dowden Health Media. OBG_1206_Unger.Final 11/20/06 1:40 PM Page 36 In M.K.’s case, the surgeon should pro- This technique is a nearly bloodless pro- ceed to take the uterosacral and cardinal cedure that does not violate the endome- ligaments posteriorly without swinging the trial cavity when it is performed properly. clamps around to the anterior aspect of the In addition, any intramyometrial fibroids cervix, if possible. Once these ligaments are can be easily removed. taken, the uterus often descends enough If coring does not decompress the that the anterior peritoneal fold becomes uterus enough for safe delivery, the core accessible. Once it is identified, the anterior can be cut off and the remaining uterus cul-de-sac can be entered safely. can be further morcellated by removing If safe entry still is not possible, the wedges of myometrium or by bivalving surgeon can take the uterine vessels if he or the uterus. Since there is usually more she is confident that the bladder is out of room in the posterior vagina than in the harm’s way. If the fold still cannot be iden- anterior vagina, as much of the wedge tified after this bite, proceed with broad- morcellation as possible should be done ligament clamps, which usually lead to posteriorly. eventual opening of the peritoneal fold. CASE 1 CASE 1 Some progress, Ovaries appear out of reach then surgery stalls After Lash intramyometrial coring, the The surgeon proceeds to operate surgeon successfully removes the uterus. extraperitoneally, as described above, He then turns his attention to the bilateral and successfully enters the anterior adnexectomy. Unfortunately, the ovaries cul-de-sac after the uterine vessels are are higher than anticipated, and he once ligated. However, after several additional again considers switching to the abdomi- bites of broad ligament on each side, nal route to remove them. progress stalls because of uterine size. Is a change in route the best option? The surgeon seems to be stuck and is FAST TRACK growing increasingly frustrated. Focus on the round ligaments It is essential that What is the best way around this The key to safe removal of the adnexa, impasse? especially in difficult cases, is the separate the uterine vessels transection and ligation of the round liga- be ligated before Morcellation can involve ments. Many authors have reported high morcellation a range of techniques success rates for vaginal oophorectomy begins Whenever a large uterus prevents further using this technique, especially in pre- progress, and the uterine vessels have been menopausal women.16–19 ligated, uterine morcellation can be per- Separate transection of the round liga- formed. Morcellation techniques originat- ment allows the surgeon to accomplish 2 ed when vaginal hysterectomy was the very important tasks: archetypal gynecologic operation,4–7 and • develop a secure vascular infundibu- include uterine bisection,8–11 Lash intramy- lopelvic pedicle of sufficient length for ometrial coring,6,8,9 myomectomy,10,11 and ligation and wedge debulking.9 Although every surgeon • adequately mobilize the adnexa for has a favorite, some or all of these proce- removal. dures may be necessary in the same Once the round ligament is ligated patient.12–15 In all cases it is mandatory that and transected, I like to keep it on stretch the uterine vessels be ligated before any so that the broad-ligament peritoneum morcellation procedure is initiated. can be opened parallel to the ovarian ves- In my experience, a uterus in the sels, much as it is done in the abdominal range of 240 g usually lends itself very approach. This allows the ovary to nicely to Lash intramyometrial coring. descend; it also isolates the infundibu- 36 OBG MANAGEMENT • December 2006 OBG_1206_Unger.Final 11/20/06 1:40 PM Page 37 Secrets to successful vaginal hysterectomy ▲ lopelvic ligament with the ovarian ves- Unrecognized injuries to the bladder or sels, thus enabling more secure ligation ureters are unacceptable and will lead to of the vessels and reducing the risk of significant morbidity for the patient. I ureteral injury. would certainly recommend that the sur- In many hysterectomy cases when geon in M.K.’s case perform cystoscopy oophorectomy is planned, this maneuver after giving the patient intravenous indigo can be carried out prior to removal of the carmine to assure both ureteral patency uterus. Once the round ligaments have and integrity of the bladder. I perform cys- been reached, the surgeon can deliver the toscopy after all vaginal hysterectomies. uterine fundus anteriorly, allowing the round ligaments to be clamped and cut. It CASE 2 is not uncommon to be able to remove the History of cesarean delivery uterus with both adnexa still attached. With a large uterus, it may be neces- C.S. is a 38-year-old gravida 3 para 3 sary to clamp and transect the round liga- who presents with menometrorrhagia and ment after the uterus is out. This does not dysmenorrhea unresponsive to medical preclude identification and transection of therapy. Her first pregnancy resulted in the round ligament to carry out the vaginal delivery of a full-term infant maneuvers described above. without complications. Her second child was delivered via low-segment transverse Consider your tools cesarean section due to a persistent In very difficult cases, specialized clamps breech presentation at term. Her last or sutures may be necessary. I find long, child was delivered vaginally, also at term. sturdy, right-angle clamps to be most use- Two years later C.S. underwent a laparo- ful. In addition, endoloop-type sutures scopic tubal ligation without complica- often facilitate ligation of the vascular tions. That was 4 years ago. She began pedicle. The use of newer specialized bipo- seeing her current gynecologist 2 years lar electrosurgical instruments may be ago, when she moved to a new community. helpful, although I have no personal expe- Pelvic examination reveals a FAST TRACK rience using them in vaginal surgery. 6-week–size uterus and normal adnexa. Perform Her uterus is mobile, and there does not CASE 1 At closure, appear to be any ventral fixation of the cystoscopy concerns about injury uterus to the abdominal wall from the after all vaginal cesarean section. Endometrial biopsy hysterectomies After successful removal of both adnexa reveals proliferative endometrium only. using the round-ligament technique, the Saline ultrasound demonstrates a 2-cm surgeon is satisfied that he has achieved submucosal leiomyoma. hemostasis and proceeds with his usual C.S. refuses hysteroscopic resection closure. However, he has nagging con- of the myoma and prefers hysterectomy cerns about the possibility of undetected as definitive therapy.
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