Clinical Review

The difficult vaginal hysterectomy: 5 keys to success

OBG Manag. 2010 November;22(11):33-47

	Dr. Gebhart describes the surgical skills necessary to perform vaginal hysterectomy—and how to develop them

References

1. Figueiredo O, Figueiredo EG, Figueiredo PG, Pelosi MA, 3rd, Pelosi MA. Vaginal removal of the benign nonprolapsed uterus: experience with 300 consecutive operations. Obstet Gynecol. 1999;94(3):348-351.

2. Rooney CM, Crawford AT, Vassallo BJ, Kleeman SD, Karram MM. Is previous cesarean section a risk for incidental cystotomy at the time of hysterectomy? A case-controlled study. Am J Obstet Gynecol. 2005;193(6):2041-2044.

3. Sesti F, Calonzi F, Ruggeri V, Pietropolli A, Piccione E. A comparison of vaginal, laparoscopic-assisted vaginal, and minilaparotomy hysterectomies for enlarged myomatous uteri. Int J Gynaecol Obstet. 2008;103(3):227-231.

4. Sheth SS, Malpani AN. Vaginal hysterectomy following previous cesarean section. Int J Gynaecol Obstet. 1995;50(2):165-169.

5. Kovac SR. Guidelines to determine the route of hysterectomy. Obstet Gynecol. 1995;85(1):18-23.

6. Unger JB, Meeks GR. Vaginal hysterectomy in women with history of previous cesarean delivery. Am J Obstet Gynecol. 1998;179(6 Pt 1):1473-1478.

7. Paparella P, Sizzi O, Rossetti A, De Benedittis F, Paparella R. Vaginal hysterectomy in generally considered contraindications to vaginal surgery. Arch Gynecol Obstet. 2004;270(2):104-109.

8. Schindlbeck C, Klauser K, Dian D, Janni W, Friese K. Comparison of total laparoscopic, vaginal and abdominal hysterectomy. Arch Gynecol Obstet. 2008;277(4):331-337.

9. Nazah I, Robin F, Jais JP, et al. Comparison between bisection/ morcellation and myometrial coring for reducing large uteri during vaginal hysterectomy or laparoscopically assisted vaginal hysterectomy: results of a randomized prospective study. Acta Obstet Gynecol Scand. 2003;82(11):1037-1042.

10. Wexner SD, Bergamaschi R, Lacy A, et al. The current status of robotic pelvic surgery: results of a multinational interdisciplinary consensus conference. Surg Endosc. 2009;23(2):438-442.

11. Johnson N, Barlow D, Lethaby A, Tavender E, Curr E, Garry R. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. 2006;(2):CD003677.-

12. Chen CC, Korn A, Klingele C, et al. Objective assessment of vaginal surgical skills. Am J Obstet Gynecol. 2010;203(1):79.e1-8.

13. Keshavarz H, Hillis SD, Kieke BA, Marchbanks PA. Hysterectomy surveillance—United States, 1994-1999. MMWR CDC Surveill Summ. 2002;51(SS05):1-8.http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5105a1.htm. Published July 12, 2002. Accessed October 3, 2010.

14. Whiteman MK, Hillis SD, Jamieson DJ, et al. Inpatient hysterectomy surveillance in the United States, 2000-2004. Am J Obstet Gynecol. 2008;198(1):34.e1-7.

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16. Julian TM. Vaginal hysterectomy: an apparent exception to evidence-based decision making. Obstet Gynecol. 2008;111(4):812-813.

5. Good morcellation technique

Morcellation facilitates removal of the large uterus. As experience with morcellation increases, the surgeon will be able to remove larger and larger uteri vaginally. However, it is critical to secure the uterine vessels before morcellation begins, and it is preferable to have entered both cul-de-sacs as well. Once those steps have been accomplished, bi-valve the cervix in the midline, following the endocervical canal to stay in the midline (FIGURES 9,10). Use a tenaculum to grasp bites of the uterus in an anterior and posterior fashion (FIGURE 11). This step reduces uterine size until the fundus can be inverted and the utero-ovarian pedicles secured. Be sure to excise uterine tissue under direct visualization to avoid inadvertent injury to the bowel and bladder.

FIGURE 9 Begin morcellation

Once the uterine vessels have been controlled, morcellation may begin.

FIGURE 10 Bi-valve the cervix

Bi-valve the cervix in the midline, following the endocervical canal.

FIGURE 11 Excise the fibroid

Fibroids may be excised sharply with the aid of a scalpel and traction supplied by a tenaculum.

WATCH THE VIDEO: Vaginal hysterectomy with morcellation for the enlarged uterus

We need to do more vaginal procedures

Of the roughly 600,000 hysterectomies performed each year in the United States, roughly 60% are performed abdominally.^13,14 More and more hysterectomies are being done laparoscopically or with robotic assistance, and fewer straight vaginal hysterectomies are performed.¹⁵ Recent graduates are less likely than their predecessors to be up-to-date on this important skill set—a fact that may lead to further decreases in the number of hysterectomies performed vaginally each year.¹⁶

We need to make every effort to increase the rate of vaginal hysterectomy. Not only is it better for the patient; it saves precious health-care dollars.

CASE: resolved

The vaginal approach was chosen for this patient. After ligation of the uterine vessels, morcellation allowed for a successful hysterectomy without complication.

DON’T MISS THE 3 VIDEOS RELATED TO THIS ARTICLE

1. Vaginal hysterectomy with entry into the anterior cul-de-sac

2. Transvaginal cystotomy repair

3. Vaginal hysterectomy with morcellation for the enlarged uterus

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