Managing complications at the time of vaginal hysterectomy

Protect the ureters: Palpate them before clamping the pedicles
Palpating the ureters at the time of hysterectomy can protect their integrity during the procedure. The following technique has been used at the Mayo Clinic for many years and allows for location of the ureter so a cardinal pedicle clamp can be placed without injury.

Enter the anterior cul-de-sac so that you can insert a finger and palpate the ureter before you place the cardinal pedicle clamp on each side. Place Deaver retractors at the 12 o’clock and 2- to 3-o’clock positions. Insert your nondominant index finger into the anterior cul-de-sac and palpate the ureter against the Deaver clamp in the 2- to 3-o’clock position (FIGURE 3). (The ureter can be felt between your index finger and the Deaver retractor.) The ureter will have the most descent in a uterus that has some prolapse, compared with a nonprolapsed uterus.

FIGURE 3 Palpate the uretersPlace an index finger into the anterior cul-de-sac and palpate the ureter against the Deaver retractor at the 2- to 3-o’clock position.

Tip. One common error is mistaking the edge of the vaginal cuff for the ureter. Be certain that you insert your finger deeply into the cul-de-sac so that it is the ureter you feel and not the cuff edge.

Successful cystotomy repair technique
Inadvertent cystotomy is a common fear for surgeons at the time of vaginal hysterectomy. I prefer to empty the bladder before beginning the hysterectomy because it reduces the target zone that a distended bladder pre­sents. Some surgeons prefer to maintain a bit of fluid in the bladder so that, if they cut into the bladder, a small urine stream results. The approach is a matter of preference.

Cystotomy is most common during anterior dissection. If it occurs, recognize it and mark the defect with suture. Do not attempt to repair the hole at this point, but opt to finish the hysterectomy.

Cystoscopy is an important element of cystotomy repair. Once the hysterectomy is completed, look inside the bladder and determine where the defect is in relationship to the ureteral orifices. Typically, it will be beyond the interureteric ridge, along the posterior portion of the bladder, usually in the midline.

As critical as the repair itself is management of bladder drainage afterward. If you repair the hole thoroughly and drain the bladder adequately for 14 days, the defect should heal fully.

Technique for entry into anterior cul-de-sac
One way to avert bladder injury is to enter the anterior cul-de-sac very carefully. Begin by ensuring that the bladder is empty and placing a Deaver retractor at the 12 o’clock position. Also place tenacula anteriorly and posteriorly to help direct traction. This will allow good visualization of the bladder reflection.

Tip. One common mistake is making the incision too low or too near the cervix, which makes dissection more difficult and increases the likelihood that you will enter the wrong plane. Be sure you know where the bladder is, and make an adequate incision that is not too distal. Otherwise, dissection will be harder to carry out.

I prefer to make one clean incision with the knife, rather than multiple incisions, because multiple cuts increase the likelihood that you will inadvertently injure the wrong tissue. Use good traction and countertraction, and hug the uterus. Work low on the uterus, but not in the uterus. If you cut into muscle, you will get more bleeding and may end up digging a hole.

After you make the incision, put your finger through it to help develop that space further. You can confirm entry into the peritoneum by noting the characteristic slippery feel of the peritoneal lining. After you insert a Deaver retractor anteriorly, reinsert your finger and mobilize the area further. Then you can easily reach in and tent the peritoneum to cut it.

Technique for cystotomy repair
Two-layer closure is a minimum. On occasion, a third layer may be beneficial. Begin with running closure of the first layer using 2-0 chromic suture—a good suture choice in the urinary tract. This suture is inflammatory, which will help seal the wound, but it also dissolves quickly, preventing stone formation.

Use through-and-through closure on the first layer, followed by a second imbricating layer. If desired, use the peritoneum as a third layer.

Horizontal repair is typical, although vertical closure may be necessary if the defect is near a ureteral orifice and horizontal closure might compromise that side. That decision must be made intraoperatively.

When vertical repair is necessary, begin your repair just above the defect, placing the suture through and through. The hole should be visible. There is no need to be extramucosal in needle placement. Simply get a good bite of the tissue and run the repair down the bladder wall.