SURGICAL Techniques Managing complications at the time of vaginal hysterectomy Proper technique for preserving ureteral integrity, repairing cystotomy, ensuring hemostasis, and reducing uterine size for transvaginal removal can help the surgeon avoid pitfalls during vaginal surgery John B. Gebhart, MD, MS areful attention to technique at the OBG Management. For salpingectomy and time of vaginal hysterectomy is vital. salpingo-oophorectomy technique, see my C Equally important is prior consid- article entitled “Salpingectomy after vaginal eration of potential complications and the hysterectomy: Technique, tips, and pearls,” best ways to address them. Four trouble spots which appeared in the November issue of include: this journal. uterine tissue extraction IN THIS • (Although this Both articles are available in the archive ARTICLE is not a complication of vaginal hysterec- at obgmanagement.com and, like this one, tomy, tissue extraction aids in debulking are based on the AAGL Online Master Class Ensuring ureter and removal of a large uterus.) on Vaginal Hysterectomy, a Web-based pro- protection • protection of the ureters (It is important gram cosponsored by the American College to palpate these structures before placing of Obstetricians and Gynecologists and the page 27 cardinal pedicle clamps, to protect ureteral Society of Gynecologic Surgeons. That pro- integrity.) gram is available at https://www.aagl.org Cystotomy repair • repair of inadvertent cystotomy /vaghystwebinar/. page 27 • control of bleeding in the setting of adnexectomy. Bleeding control I focus on optimal approaches to these 4 sce- A step toward success: strategies narios in this article. Begin morcellation by page 29 For a review of vaginal hysterectomy tech- splitting the uterus nique, see “Vaginal hysterectomy with basic Manual morcellation to reduce uterine size instrumentation,” by Barbara S. Levy, MD, and ease transvaginal removal is a useful which appeared in the October 2015 issue of technique to know. Five aspects of manual morcellation warrant emphasis: Dr. Gebhart is Professor of 1. Anterior and posterior entry into the cul- Obstetrics and Gynecology and Surgery and Director of the de-sacs is essential before attempting mor- Fellowship Program in Female cellation. Pelvic Medicine and Reconstructive 2. The blood supply on both sides of the Surgery at the Mayo Clinic in Rochester, Minnesota. uterus must be controlled. 3. During resection, take care to cut only tis- Dr. Gebhart reports that he is a consultant to Allergan sue that can be visualized. Avoid resection and AMS. beyond what you can easily see. CONTINUED ON PAGE 26 obgmanagement.com Vol. 27 No. 12 | December 2015 | OBG Management 25 complications at vaginal hysterectomy CONTINUED FROM PAGE 25 FIGURE 1 Bivalve the uterus A B To begin morcellation, split the uterus down the midline, with tenacula placed at the 3- and 9-o’clock positions, then follow the endocervical canal into the uterine cavity (A). Use a knife blade to take portions of myomas and other tissue to debulk the uterus (B). 4. Once morcellation is completed, always A small amount of bleeding may occur go back and check the pedicles for hemo- because of collateral blood supply from the stasis. During morcellation, these pedicles gonadal pedicles, but it should be minimal, tend to get stretched, and bleeding may as the uterine vessels have been secured. arise that wasn’t present originally. Proceed with morcellation once the 5. Morcellation should be performed only uterus is bivalved. Use a Jacobs tenaculum to after malignancy has been ruled out—it grasp the serosal portion of the uterus. Apply is a technique intended for benign uteri downward traction with your nondominant Perform morcellation only. hand, and use the knife blade to resect por- only after By bivalving the uterus it is possible to tions of the uterus so that it can be debulked. malignancy has follow the endocervical canal up into the When a large myoma is encountered uterine cavity (FIGURE 1). Our technique at during morcellation, it often is possible to been ruled out the Mayo Clinic is to place tenacula at the 3 “finger-fracture” some of the filmy adhesions and 9 o’clock positions prior to bivalving. holding it in place, or to follow the pseudo- capsule of the fibroid in order to shell it out. FIGURE 2 Apply traction In many cases, fibroids can be removed intact using these methods. If intact removal is not possible, debulk the fibroid by taking individual “bites.” Tip. When the uterus is greatly enlarged, grasp it with a tenaculum so that it does not retract when you incise it. When large myo- mas are anticipated, keep an extra tenacu- lum on hand, as well as extra knife blades, as blades dull quickly when used to cut through calcified tissue. Continue to apply traction with your nondominant hand to allow each piece of tissue to be more readily developed (FIGURE 2). Tip. When managing the round-ligament Apply traction with your nondominant hand as you develop the tissue with your dominant hand. complex on each side, stay between the round ligaments (your “goal posts”) to avoid OF AAGL IMAGES COURTESY 26 OBG Management | December 2015 | Vol. 27 No. 12 obgmanagement.com getting too lateral. Keep the cervix intact for FIGURE 3 Palpate the ureters orientation purposes. Focus on diminish- ing the bulk of the uterus so that you can get Deaver retractor in around the utero-ovarian pedicles. 12-o’clock position To control the utero-ovarian pedicle on the patient’s right side, place a finger Left ureter underneath it, with traction applied. Place a Heaney clamp from the top down. Repeat this action on the patient’s left side, but place the Heaney clamp from the bottom up. Manual morcellation of tissue is useful Uterosacral ligament in small uteri that are tough to access, but Cardinal ligament the procedure is very helpful in large uteri in order to remove them transvaginally. Deaver retractor in 3-o’clock position Uterosacral ligament Protect the ureters: Palpate them before Place an index finger into the anterior cul-de-sac and palpate the ureter clamping the pedicles against the Deaver retractor at the 2- to 3-o’clock position. Palpating the ureters at the time of hyster- ectomy can protect their integrity during I prefer to empty the bladder before begin- the procedure. The following technique has ning the hysterectomy because it reduces been used at the Mayo Clinic for many years the target zone that a distended bladder pre- and allows for location of the ureter so a car- sents. Some surgeons prefer to maintain a bit dinal pedicle clamp can be placed without of fluid in the bladder so that, if they cut into injury. the bladder, a small urine stream results. The Enter the anterior cul-de-sac so that you approach is a matter of preference. Careful entry into can insert a finger and palpate the ureter Cystotomy is most common during the anterior before you place the cardinal pedicle clamp anterior dissection. If it occurs, recognize cul-de-sac on each side. Place Deaver retractors at the it and mark the defect with suture. Do not 12 o’clock and 2- to 3-o’clock positions. Insert attempt to repair the hole at this point, but is vital to avert your nondominant index finger into the ante- opt to finish the hysterectomy. bladder injury rior cul-de-sac and palpate the ureter against Cystoscopy is an important element of the Deaver clamp in the 2- to 3-o’clock posi- cystotomy repair. Once the hysterectomy tion (FIGURE 3). (The ureter can be felt between is completed, look inside the bladder and your index finger and the Deaver retractor.) determine where the defect is in relation- The ureter will have the most descent in a ship to the ureteral orifices. Typically, it will uterus that has some prolapse, compared be beyond the interureteric ridge, along the with a nonprolapsed uterus. posterior portion of the bladder, usually in Tip. One common error is mistaking the the midline. edge of the vaginal cuff for the ureter. Be cer- As critical as the repair itself is manage- Access the AAGL- tain that you insert your finger deeply into ment of bladder drainage afterward. If you produced and the cul-de-sac so that it is the ureter you feel repair the hole thoroughly and drain the ACOG and SGS and not the cuff edge. bladder adequately for 14 days, the defect co-sponsored should heal fully. “AAGL online course on vaginal Successful cystotomy Technique for entry into hysterectomy” at repair technique anterior cul-de-sac https://www.aagl Inadvertent cystotomy is a common fear for One way to avert bladder injury is to enter .org/vaghystwebinar IMAGE COURTESY OF AAGL IMAGE COURTESY surgeons at the time of vaginal hysterectomy. the anterior cul-de-sac very carefully. Begin obgmanagement.com Vol. 27 No. 12 | December 2015 | OBG Management 27 complications at vaginal hysterectomy by ensuring that the bladder is empty and feel of the peritoneal lining. After you insert a placing a Deaver retractor at the 12 o’clock Deaver retractor anteriorly, reinsert your fin- position. Also place tenacula anteriorly ger and mobilize the area further. Then you and posteriorly to help direct traction. This can easily reach in and tent the peritoneum will allow good visualization of the bladder to cut it. reflection. Tip. One common mistake is making the Technique for cystotomy repair incision too low or too near the cervix, Two-layer closure is a minimum. On occa- which makes dissection more difficult and sion, a third layer may be beneficial. Begin increases the likelihood that you will enter with running closure of the first layer using the wrong plane.