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Simplifying the Difficult Vaginal Hysterectomy

Rosanne M. Kho, MD

Vaginal hysterectomy has many advantages to the patient, but can pose a number of intraoperative challenges to the gynecologic surgeon. Utilizing a few specialized techniques and instruments can enable the surgeon to offer this approach to more patients with no decrease in safety or increase in complications.

With 600,000 hysterectomies performed annually, only 21.8% are performed via the vaginal approach—with no substantial increase in rate in the last 13 years.1 This is despite strong evidence that the vaginal hysterectomy involves less morbidity and hospital cost compared with the abdominal and laparoscopic approaches.2 The low vaginal hysterectomy rate may be attributed to inadequate training during residency, resulting in a lack of the requisite skills to perform the procedure.

The common challenges in the difficult vaginal hysterectomy include:

• Obtaining adequate exposure and visualization
• Entering the cul-de-sac, particularly when large fibroids distort anatomy
• Securing vascular pedicles in a limited space
• Avoiding bladder and ureteral injury
• Removing the large uterus
• Removing the adnexae.

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EXPOSURE


As in abdominal hysterectomy, obtaining sufficient exposure for visualization is critical for a successful surgery. The use of a self-retaining retractor, such as the Magrina-Bookwalter Vaginal Retractor System (Codman), aids in providing exposure during vaginal procedures. It is designed to fit the contour of the perineum when the patient is in the high lithotomy position. It can also eliminate the need to use two surgical assistants at the bedside (Figure 1). Self-retracting blades of multiple lengths can be placed in the four quadrants to maximize room for surgery.

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Figure 1. Placement of the Magrina-Bookwalter Vaginal Retractor System (Codman). Image courtesy of Rosanne M. Kho, MD.

In cases where the introital opening is limited (ie, 2.5 cm or less), a 2- to 3-cm longitudinal incision performed with the Bovie cautery on the midline and distal portion of the posterior vaginal wall (as with a midline episiotomy) provides additional width to allow placement of the lateral and posterior self-retracting blades. The use of only one double-toothed tenaculum (Jacobs tenaculum, Aesculap) that is moved from the anterior to posterior cervix may be necessary to minimize the number of instruments in the vagina. A flexible light source (eg, cystoscopy light) held with a Babcock clamp is helpful in visualization of structures deep within the vagina (Figure 2).

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Figure 2. A flexible cystoscopy light held with a Babcock clamp by an assistant is helpful in visualization. Image courtesy of Rosanne M. Kho, MD.

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CUL-DE-SAC

Entry into the anterior cul-de-sac in vaginal hysterectomy is, for many surgeons, one of the most difficult skills to master. Indeed, this is often viewed as the limiting factor in completing the hysterectomy vaginally.

Entry into the posterior cul-de-sac is often easier, and therefore should be performed first. This can be accomplished with traction applied anteriorly on the posterior lip of the cervix using the Jacobs tenaculum and counter-traction applied on the proximal posterior vaginal wall using toothed forceps, followed by a large bite on the vaginal mucosa with a Mayo curved scissors to enter the cul-de-sac.

To enter the anterior cul-de-sac, traction is applied posteriorly on the anterior lip of the cervix with the Jacobs tenaculum. It may be necessary to remove the posterior blade to achieve better exposure of the anterior cervical wall with more pronounced angulation of the lower uterine segment. With ventral traction on the anterior vaginal wall, the bladder is separated from the anterior cervix using sharp dissection with the Mayo curved scissors. The scissor tips are pointed downward at a 30° angle to the plane of the cervix to reveal the avascular vesicouterine space.

Inability to enter into either or both cul-de-sacs should not preclude continuation of the vaginal approach. The uterine arteries can still be secured extraperitoneally until better descensus of the uterus is obtained.

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VASCULAR PEDICLES

Hemostasis can be challenging in vaginal procedures, particularly when placing a suture around the clamp in a limited space and tying it with fingers deep within the vagina. The use of vessel-sealing devices in vaginal hysterectomy overcomes the limitation of tight vaginal access, and has proved to be feasible and safe.3 There are newer devices that include a blade between the jaws of the clamp that advances after the seal is complete.

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BLADDER AND URETERAL INJURY

Once the vesicouterine space is entered, the bladder pillars are gently pushed superiorly and laterally with the index finger to avoid injury during placement of the vessel-sealing clamp. It is imperative for the surgeon to note the location of the ureters, which are easily injured—especially in patients with pelvic prolapse. The ureters can be palpated with the index finger at 2 and 10 o’clock (left and right ureter, respectively) against a curved Deaver retractor placed outside the peritoneum on the lateral vaginal wall (Figure 3). Intraoperative cystoscopy should always be performed at the end of the procedure to check for inadvertent bladder and ureteral injury.

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Figure 3. Palpation of the left ureter is performed with the surgeon’s left index finger placed within the peritoneum. The ureter can be palpated at the 2 o’clock position against a Deaver retractor placed extraperitoneally on the vaginal wall. Image courtesy of Rosanne M. Kho, MD.

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LARGE UTERUS

It is impossible to know whether a large uterus can be removed through the vagina until the actual attempt is made. The basic principles of morcellation are applied, regardless of whether the uterus is equivalent to 12-weeks’ or 26-weeks’ gestation.

Orientation of the uterus is maintained by placing a Jacobs tenaculum at 3 and 9 o’clock on the cervix. The cervix should be bivalved starting at the level of the lower uterine segment. If the anterior cul-de-sac has not been entered yet, bivalving should begin at 1 cm below the vesicouterine peritoneal fold before starting morcellation within the uterus (Figure 4).

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Figure 4. If the anterior cul-de-sac has not been entered yet after the uterine arteries are secured, the cervix should be bivalved starting at 1 cm below the vesicouterine peritoneal fold. Image courtesy of Rosanne M. Kho, MD.

Morcellation is performed with a Schroeder tenaculum (Aesculap) placed on the myometrium, followed by wedge excision using a #10 blade. Serial wedges are performed to decompress the uterus. Entry into the anterior cul-de-sac can then be accomplished easily with better uterine descensus and visualization of the peritoneal fold. Forceful traction on the cervix should be avoided during morcellation, as this can cause the vascular pedicles to avulse.

Depending on the size of the uterus, morcellation can take more than an hour. Morcellation can proceed as long as descensus of the uterus is continuously maintained (Figure 5). Increased bleeding is usually encountered when morcellation reaches the fundus. Locating the utero-ovarian pedicles at this point can be helpful in finishing the procedure.

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Figure 5. Morcellation to decompress the large uterus should proceed until the utero-ovarian pedicle is visible. Image courtesy of Rosanne M. Kho, MD.

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ADNEXAE

The need to perform adnexectomy should not prevent the surgeon from using the vaginal approach. When the adnexae are high in the pelvic brim, mobilization can be achieved using the round ligament technique (Figure 6). After the fallopian tube and ovary are placed on traction using a Babcock clamp, the round ligament is isolated and divided. The broad ligament is then incised laterally and parallel to the ovarian vessels with the Bovie cautery. This results in skeletonization and mobilization of the infundibulopelvic ligament from the pelvic sidewall, facilitating placement of a large ovarian clamp. The round ligament technique not only facilitates vaginal adnexectomy, it also ensures removal of the entire tube and ovary to prevent ovarian remnant syndrome. Polyglactin Endoloop ligatures (Ethicon) can be used to bind off the ovarian vessels, eliminating the need to place and tie sutures deep within the vagina.

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Figure 6. The round ligament technique is helpful for mobilizing the adnexae from the pelvic sidewall. The round ligament is isolated and divided with the Bovie cautery to facilitate placement of the clamp on the ovarian vessels. From: Magrina JF, Cornella JL, Lee RA. Vaginal Salpingo-oophorectomy: Surgical Techniques. J Pelvic Surg. 1999;5:348-354, by permission of Mayo Foundation for Medical Education and Research. All rights reserved.

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ABORTING THE VAGINAL APPROACH

Even when the aforementioned techniques are diligently applied, there are situations in which it is necessary to abort the vaginal approach to hysterectomy and convert to a different route (either minilaparotomy or laparoscopy). Such conversion is recommended when further descensus of the uterus cannot be obtained despite morcellation; this is usually signaled when loops of bowel descend into the operative field as opposed to portions of myometrium. Inability to control profuse bleeding—usually from a pedicle that avulses during morcellation—likewise warrants immediate conversion.

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CONCLUSION

Vaginal hysterectomy affords patients less morbidity and faster recovery compared with other approaches. The techniques, devices, and instrumentation described here are available to overcome the many challenges of the difficult vaginal hysterectomy. Nonetheless, conversion to a laparotomy or laparoscopy should not be considered a complication, because every effort has been made to provide the patient with the least invasive approach possible.

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Rosanne M. Kho, MD, is Assistant Professor, Department of Gynecology, Mayo Clinic, Phoenix, AZ.

References

1. Wu JM, Wechter ME, Geller EJ, Nguyen TV, Visco AG. Hysterectomy rates in the United States, 2003. Obstet Gynecol. 2007;110(5):1091-1095.
2. Johnson N, Barlow D, Lethaby A, Tavender E, Curr E, Garry R. Surgical approach to hysterectomy for benign gynecological disease. Cochrane Database Syst Rev. 2006;(2):CD003677.
3. Levy B, Emery L. Randomized trial of suture versus electrosurgical bipolar vessel sealing in vaginal hysterectomy. Obstet Gynecol. 2003; 102(1):147-151.

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