FIGURE 4 Dissect the bladder free of the uterus
We recommend sharp dissection to free the bladder from the uterus.Once the peritoneum is identified, grasp, elevate, and incise it (FIGURE 5). Insert scissors through the peritoneal defect, spread the tips widely, and place the anterior Deaver retractor intraperitoneally (FIGURE 6) so that bowel can be visualized (FIGURE 7).
FIGURE 5 Use traction and counter-traction
Sharp entry into the peritoneal cavity is enhanced through the use of traction and counter-traction.
FIGURE 6 Open the peritoneal defect
Place scissors into the peritoneal defect and spread the blades wide.
FIGURE 7 Visualize the bowel
Visualization of the bowel confirms an intraperitoneal location.
WATCH THE VIDEO: Vaginal hysterectomy with entry into the anterior cul-de-sac
If the patient has a history of cesarean delivery, entry into the anterior cul-de-sac can be more challenging. Several maneuvers can help avert bladder injury:
- Stay on the uterus during dissection into the vesicovaginal space. It is better to stay deep and cut into the uterus than to dissect superficially and end up with a cystotomy.
- Retrograde fill the bladder to identify the plane between the bladder and the uterus.
- Postpone entry into the anterior cul-desac until after posterior entry, ligation of the uterosacral ligaments, and the first “bite” of the cardinal ligaments.
- Use a uterine sound, bent into a “U” shape, passing it through the urethra into the bladder and allowing the point to come back toward the surgeon (while it is in the bladder). Manipulation of this sound through external palpation should make it possible to identify the bladder reflection.
- In the setting of a small uterus, after entering the posterior cul-de-sac, pass a finger along the back of the uterus, around the fundus, and back toward the surgeon. This maneuver identifies the optimal spot for dissection between the bladder and the uterus.
When cervical elongation is encountered during entry into the cul-de-sac, the peritoneal reflection will be higher (both anteriorly and posteriorly), and additional bites on the pedicles, as well as additional dissection, may be required before entry is accomplished (FIGURE 8).
FIGURE 8 When the cervix is elongated
When the cervix is elongated, the peritoneal reflection, both anteriorly and posteriorly, is much higher on the uterus (near the small myoma).
If cystotomy occurs during an attempt to enter the anterior cul-de-sac, a number of steps can lead to successful repair. Rather than repair the defect immediately, mark it with a suture for later identification. Once the uterus is removed, inspect the bladder carefully to identify any additional injuries, then repair the cystotomy using absorbable 2-0 suture on a tapered needle (we prefer chromic suture).
Begin by taking a full-thickness bite of tissue, just lateral to the edge of the cystotomy. Then run the suture, incorporating the bladder epithelium into the closure. Place a second, imbricating layer of the same suture. Last, if possible, sew the peritoneum beneath the bladder over the repair for an additional layer of reinforcement.
WATCH THE VIDEO: Transvaginal cystotomy repair
Cystoscopy helps to visualize the repair and test for water-tightness, and assess ureteral patency.
Keep the bladder on catheter drainage for 10 to 14 days.
In the setting of nulliparity or a small, well-supported uterus, it may be necessary to create mobility to accomplish the hysterectomy vaginally. Begin by entering the posterior cul-de-sac and cutting and suture ligating the uterosacral ligaments. Then take the first bite of the cardinal pedicles bilaterally. This typically facilitates uterine descent, making it possible to enter the anterior culde-sac and accomplish the hysterectomy.
On occasion, once the uterine arteries have been secured, you can split (bi-valve) the uterus to gain access to the utero-ovarian pedicles and complete the hysterectomy.
Don’t settle on a route prematurely
It is important to understand the individual patient’s anatomy and underlying disease process before deciding on an appropriate surgical route. For this reason, a general medical and surgical history and a focused physical exam should precede any decision to operate. During the pelvic examination, note the size and mobility of the uterus, any associated uterovaginal prolapse, the presence of any adnexal mass or tenderness, vaginal capacity, and the adequacy of the pubic arch.
If you are unable to determine the size of the uterus on examination, owing to the patients’ body habitus or discomfort, pelvic ultrasonography may be helpful.
When office examination is difficult, or when it is impossible to gather substantial information about uterine characteristics, an examination under anesthesia is an excellent way to help determine the optimal route of hysterectomy. Provided the patient is properly apprised about this examination beforehand, the surgeon can then proceed to the appropriate surgical route once the exam is completed.
Ensure consent for all aspects of the procedure
As for any surgery, the informed consent discussion is important. Regardless of the hysterectomy approach, this discussion should include a mention of risks, benefits, and alternatives to surgery; the possible need for additional procedures (in the setting of unexpected pathology); and consent or decline of blood products, if needed. if photography or videotaping of the procedure is desired, this option needs to be discussed as well.
When a vaginal approach is planned, there is always a small chance that it will have to be converted to a laparoscopic or open approach. This possibility should be relayed to the patient during the preoperative discussion.
Inevitably, some cases fall on the border between the vaginal approach and another route. When this happens, we prefer to ask the patient to consent to the aforementioned examination under anesthesia, with the understanding that we may proceed as indicated to hysterectomy, based on the findings of that exam.
For example, in the opening case, the informed consent discussion would likely go something like this:
Mrs. Smith, because of fibroids, your uterus is enlarged to about the size of a small cantaloupe. Because you have had a vaginal delivery and your uterus is mobile, I think I will be able to remove it through the vagina. If vaginal removal is possible, you are likely to have a shorter recovery and a lower risk of complications than if a different approach is required. However, if I am unable to do a vaginal hysterectomy, an abdominal operation may need to be performed and would involve either a laparoscopy or an incision in the lower abdomen. I would like to evaluate things after you are asleep in the operating room. At that time, I will make the final decision about the best route for your hysterectomy.
For the exam, the anesthetized patient should be placed in the dorsal lithotomy position with her legs in stirrups. Often, there is greater vaginal access and uterine mobility at this time.