VAGINAL HYSTERECTOMY CHALLENGE 5: Large myomatous uterus
A uterus of any size can be removed vaginally as long as there is mobility with access to the uterine arteries. The one exception: a patient with a small, normal uterus and a massive pedunculated myoma arising from the top of the fundus. If the fibroid cannot be pulled into the true pelvis for morcellation, it cannot be removed transvaginally. Fortunately, this situation is quite rare.
Keep the uterine serosa intact to maintain orientation.
Split the uterus from 12 to 6 o’clock (bivalving). Protect the bladder with a Deaver retractor anteriorly, and protect the posterior vaginal epithelium with the weighted speculum posteriorly.
Remove chunks of tissue from the inside of the specimen. Orient your scalpel blade so that you are always cutting toward the center of the specimen. That way, if the blade slips, you will not accidentally injure tissue on the pelvic sidewall.
Use Lahey thyroid clamps to place the tissue you plan to remove under tension. Finding the capsule of each myoma and gently separating it from the surrounding myometrium facilitates delivery of larger fibroids into the endometrial cavity. Some myomas require morcellation themselves for removal.
Replace the scalpel blade periodically to keep it sharp. Calcified fibroids can dull the blade rapidly.
Work systematically to remove as much central tissue as possible. Try to keep a clean, sharp margin of tissue around the edges for easy grasping. Torn, irregular tissue is very difficult to grab and may cause significant frustration.
If access becomes limited, try clamping additional pedicles on each side of the specimen. A tiny amount of additional descensus can make a huge difference.
Do not administer GnRH agonists prior to surgery. The uterus may shrink, but the myomas tend to become quite soft and difficult to remove. If the patient is seriously anemic, give norethindrone acetate, 5 to 20 mg daily, to stop bleeding and allow the patient’s red blood cell volume to improve before elective surgery.
Use a vessel-sealing instrument to control the pedicles. This strategy produces optimal hemostasis to permit a dry field during morcellation. Moreover, the seals do not get disrupted when the large uterus is pulled past them. Placing suture around pedicles when there is a large, bulky uterus in the pelvis is challenging at best, and it is frustrating to see significant bleeding after removal of the specimen. This problem does not seem to occur with the sealing devices.
Know when to quit! We should not promise any patient a minimally invasive operation. If there is uncontrolled bleeding or no progress after 5 to 10 minutes, convert to a laparoscopic or abdominal approach.
I schedule cases I know will be challenging as “possible” laparoscopic or open hysterectomy. This alerts the OR staff to have additional equipment ready and nearby should we need it. It is not a surgical failure or complication to convert a minimally invasive hysterectomy to a more invasive technique when appropriate. Better to have tried and failed than never to have tried at all!
VAGINAL HYSTERECTOMY CHALLENGE 6: Avoiding complications
The most common complications of vaginal hysterectomy are bleeding, infection, and injury to the bladder. Ureteral injury is less common at vaginal hysterectomy than with the abdominal or laparoscopic approaches. Thus, I do not think routine cystoscopy is essential after uncomplicated vaginal hysterectomy, although I recommend intravenous administration of indigo carmine dye at the beginning of the procedure to enable rapid recognition of even a small bladder laceration. Sharp, careful dissection of the bladder off the lower uterine segment and the avoidance of finger dissection (especially with a gauze sponge) keep these injuries to a minimum.
Minimize bleeding by using newer vessel-sealing technologies rather than suture for most of the pedicles. I attach the uterosacral–cardinal ligament pedicles to the vaginal cuff at closure with suture. I suture the first pedicle once I have entered the posterior cul-de-sac and hold that suture to stay oriented.
Pay attention to patient positioning. Careful positioning will help you avoid neurological injuries. Avoid hyperflexion at the hips, which stretches the femoral nerve. Large nerves have comparatively little blood supply, so stretching them for prolonged periods can cause hypoxic injury. Although such injuries are almost always rapidly reversible, they are disconcerting for both the patient and her surgeon.
When operating on a very thin woman with a bony sacrum, I like to place egg-crate foam beneath the buttocks to provide some cushioning. I am also very careful with these women to keep their legs in a neutral position, and I watch my surgical assistants to be sure they are not leaning on the patient during the procedure.