Prophylactic antibiotics are a must to avoid postoperative vaginal cuff infections and pelvic abscess. Smokers and women with preexisting bacterial vaginosis are at highest risk for infection. I ask women to discontinue smoking at least 2 weeks prior to surgery and inform all smokers that their risk of infection is heightened. I treat anaerobic overgrowth in the vagina prior to surgery to help prevent infections in women with bacterial vaginosis.
The timing of prophylactic antibiotics is important. Intravenous first-generation cephalosporins must be administered within 60 minutes of the initial incision, but it is important to give them early enough for them to adequately disseminate to tissue before the colpotomy incision.
DVT prophylaxis is especially important for women with large uteri. Routine use of sequential compression stockings is both cost-effective and equivalent to the prophylactic use of subcutaneous heparin, so I use them for all patients undergoing vaginal hysterectomy. Early ambulation (usually within 2 hours of surgery) is also helpful in avoiding thromboses.
90% of hysterectomies can be performed vaginally
Using the techniques described in this article, I have been able to perform over 90% of the hysterectomies in my practice vaginally. More than 50% of my patients are either morbidly obese, nulliparous, or have had previous abdominal surgery of some type.
The instruments I find most useful are the lighted suction irrigator and the vessel-sealing Heaney-type clamp.
Establishing a routine and approaching technically challenging cases with a systematic and standardized set of techniques make the vaginal route possible for the vast majority of patients with benign disease.
Dr. Levy has served as a consultant to ValleyLab.