We’ve come a long way since Conrad Langebeck performed the first vaginal hysterectomy in 1813. For the inaugural surgery, Langebeck used no anesthesia, gloves, or other sterilization strategies, and he held the suture in his teeth at one point during the operation! (The patient survived.)1
Despite our dramatic progress since then, too many of us still perform benign hysterectomy by an approach other than vaginal. And too many of us still perform vaginal hysterectomy the way it was taught in the 1950s—frequently a backbreaking, frustrating undertaking.
That approach is unnecessary. In recent years, the technological world has developed many useful tools for minimally invasive gynecologic surgery, some of which greatly facilitate vaginal hysterectomy. In this Update, I focus on 3 of them:
- vessel-sealing devices
- a unique visualization system
- a lighted suction irrigator.
It is my hope that you will incorporate these tools into your vaginal hysterectomy cases and gain some of the significant benefits they have to offer. The revival of vaginal hysterectomy and vaginal surgery in general is all about using the best tools that we have available and using them well, cost-
effectively, and thoughtfully to improve the experience of both surgeon and patient.
Not only is vaginal hysterectomy more cosmetically pleasing but it also has a lower complication rate than laparoscopic, robot-assisted, or laparotomic hysterectomy, requiring no incisions through the abdominal wall. The original natural orifice translumenal endoscopic surgery (NOTES) procedure also is less expensive than laparoscopic or robot-assisted hysterectomy. Vaginal hysterectomy has so much to recommend it, in fact, that the biggest barrier to widespread use may simply be the lack of industry support.
According to the latest committee opinion from the American College of Obstetricians and Gynecologists (ACOG), “When choosing the route and method of hysterectomy, the physician should take into consideration how the procedure may be performed most safely and cost-effectively to fulfill the medical needs of the patient. Most literature supports the opinion that, when feasible, vaginal hysterectomy is the safest and most cost-effective route by which to remove the uterus.”2
A 2009 Cochrane review of surgical approaches to hysterectomy found that vaginal hysterectomy should be performed in preference to abdominal hysterectomy whenever possible.3 Yet data from 2008 indicate that almost 50% of all hysterectomies were still being performed using an open abdominal approach, and laparoscopic hysterectomy made up almost another 25%.4
To address the disparity between the
evidence and practice, ACOG has joined forces with the AAGL and the Society for
Gynecologic Surgeons (SGS) to present an online master course on vaginal hysterectomy, available at http://www.aagl.org/vaghystwebinar. This course features videos and live demonstrations on cadaveric models and is free to physicians, with continuing medical education (CME) credits available.
In any surgery, the need to achieve reliable hemostasis is critical. In vaginal hysterectomy, this goal traditionally has been attained by clamping and suturing of the vessels. In many respects, vaginal surgeons seem to have gotten trapped in the mindset that we need to suture during vaginal surgery—and train residents to suture, too. When it comes to laparoscopic surgery, however, the reverse is true. In that setting, vessel-sealing devices are used to seal blood vessels with “supraphysiologic burst pressure equal to that of previously used surgical clips or ligatures.”5
Why is vessel sealing necessarily better than suturing?
It’s safer, for one thing, eliminating the need to pass needles back and forth. It also frees the scrub technician to become the surgical assistant because there are no needles to load and unload. In order for suture to hold around a pedicle, it is necessary to have tissue adjacent to it. The surgeon ties and cuts but must have something beyond the suture or the suture won’t hold. That something is dead, devascularized tissue. Before healing can occur, all this tissue must be absorbed by the body. That is not the case with vessel sealing, which fuses the walls of the blood vessels, leaving less foreign material and dead tissue behind.
The literature offers several randomized comparisons of bipolar vessel sealing and suturing during vaginal hysterectomy, and all of them find increased benefits for the vessel-sealing approach.
For example, in 2003, I published a randomized comparison looking specifically at blood loss and operative time.6 Sixty women in a single surgical practice were randomly allocated to vessel sealing or sutures for hemostasis during vaginal hysterectomy. In the vessel-sealing group, the mean operative time was 39.1 minutes (range, 22–93), compared with 53.6 minutes in the suturing group (range, 37–160; P = .003). Mean estimated blood loss also was significantly lower with vessel sealing, at 68.9 mL (range, 20–200) versus 126.7 mL for suturing (range, 25–600;
P = .005). Complication rates and length of stay were similar between groups.6
