Preoperative Evaluation

Patients being considered for vaginal hysterectomy as a definitive surgical therapy for symptomatic uterine or pelvic organ prolapse should be screened preoperatively for uterine fibroids, endometrial abnormalities, occult uterine or adnexal masses, and cervical dysplasia or carcinoma. Before vaginal hysterectomy is undertaken, a Papanicolaou test should be performed as indicated. In addition, if the patient has a history of abnormal uterine bleeding or if the surgeon desires to determine the size of the uterus and check for the presence and size of any fibroids, transvaginal pelvic ultrasonography should be done. Pelvic magnetic resonance imaging is an alternative option if further detailed imaging is warranted.

The presence of an enlarged uterus or sizable fibroids may preclude a vaginal route for hysterectomy if the uterus cannot be delivered vaginally after division of the pedicles. Endometrial thickening in a postmenopausal woman or the presence of endometrial polyps or masses requires preoperative biopsy to rule out dysplasia or carcinoma. The findings may lead to a change in operative planning. In addition, visualization of adnexal masses on pelvic ultrasonography could necessitate oophorectomy via abdominal or laparoscopically assisted hysterectomy. The patient’s family history, specifically a familial risk of breast and ovarian cancer, or a prior positive screening result for the BRCA gene should also be taken into account and may guide decision making regarding the advisability of concurrent oophorectomy.

As mentioned earlier, a preoperative Papanicolaou test is another essential component of evaluation before vaginal hysterectomy. Cervical dysplasia or carcinoma in situ should be identified before surgery so that enough surrounding vaginal tissue can be resected to ensure margins free of neoplastic disease. This is especially important in any woman who has had high-risk human papillomavirus disease that has previously been associated with the appearance of atypical or dysplastic endocervical cells.

Patient Selection

Simple vaginal hysterectomy is an ideal option for the postmenopausal woman with symptomatic uterine prolapse who desires definitive treatment and is not interested in uterine preservation. Concurrent apical suspension with anterior and/or posterior repair as well as antiincontinence procedures can also be performed if indicated. Sexual function can be maintained by giving careful attention to preservation of vaginal length, depth, and caliber. The vaginal approach is implemented more readily than the abdominal approach in obese patients as well as in patients who have undergone prior abdominal or pelvic surgery. Furthermore, vaginal hysterectomy with or without concurrent prolapse repair can be achieved under regional anesthesia, which may be ideal for any patient with compromised pulmonary function or cognitive dysfunction for whom general anesthesia is best avoided.

Surgical Anatomy

The uterus is composed of two main parts: the uterine corpus (or body) and the cervix. The corpus consists of the endometrial cavity surrounded by the myometrium and the serosa. The cervix, attached to the lateral fornices of the vagina, leads from the vagina to the endometrial cavity via the cervical canal (Fig. 5-1). The main support of the uterus comes from the uterosacral and cardinal ligaments. These two integrated connective tissue structures extend from their origin at the cervix and upper vagina to the pelvic sidewall (cardinal ligament) and to the sacrum (uterosacral ligament) and provide level I support for the uterus. Above these support structures lies the broad ligament composed of anterior and posterior leaves of visceral and parietal peritoneum that connect the uterus to the adnexa (Fig. 5-2). The blood supply to the uterus comes from branches of the internal iliac artery (Fig. 5-3). The uterine artery travels through the cardinal ligament and crosses over the ureter 1 to 2 cm lateral to the cervix. Before it enters into the uterus near the junction of the corpus and the cervix, the uterine artery sends off the vaginal artery, which supplies the upper portion of the vagina (see Fig. 5-3). The ovarian arteries are direct branches of the aorta.

Figure 5-1 Sagittal view of the uterus, cervix, and vagina.

(From Walters MD, Barber MD. Hysterectomy for Benign Disease. Philadelphia: Saunders; 2010. Female Pelvic Surgery Video Atlas Series.)

Figure 5-2 Closer view of the uterus, cervix, ovaries, fallopian tubes, and the broad ligament.

(From Drake RL, Vogl AW, Mitchell AWM, et al. Gray’s Atlas of Anatomy. Philadelphia: Churchill Livingstone; 2008:229.)

Figure 5-3 The aorta provides the blood supply to the pelvic structures. It bifurcates at approximately L4 and L5 into the right and left common iliac arteries. The inferior vena cava, into which the right and left common iliac veins return their blood flow, is located to the right of the aortic bifurcation. The left common iliac vein travels anterior to the sacrum medial to the aortic bifurcation and joins the right common iliac vein posterior to the right common iliac artery. The common iliac arteries then divide into the external iliac and internal iliac (hypogastric) arteries. The external iliac artery is located medial to the psoas muscle, and the external iliac vein is much larger and lies posterior and medial to the artery. The external iliac vein also covers the obturator fossa, where the obturator neurovascular bundle and lymph nodes are located medial to the obturator internus muscle. The internal iliac, or hypogastric, artery branches into the anterior and posterior divisions. The posterior division travels toward the ischial spine branching into the lateral sacral, iliolumbar, and superior gluteal arteries. The anterior division of the internal iliac artery branches into the obliterated umbilical, uterine, superior vesical, obturator, vaginal, and inferior gluteal and pudendal arteries.

(From Walters MD, Barber MD. Hysterectomy for Benign Disease. Philadelphia: Saunders; 2010. Female Pelvic Surgery Video Atlas Series.)

Surgical Technique for Simple Vaginal Hysterectomy

In this section we limit our discussion to vaginal hysterectomy for the treatment of POP. This technique (with some modifications) can be applied to uterine prolapse of varying degrees (Pelvic Organ Prolapse Quantification [POP-Q] stages II to IV) and uteri of different sizes. In addition the technique can be combined with vaginal oophorectomy when desired. In all cases in which vaginal hysterectomy is performed for the repair of POP, a procedure to address the cul-de-sac and restore and/or maintain apical support is necessary. (See Chapter 6 for discussion and demonstration of vaginal repair of enterocele and apical prolapse.)

1. After anesthesia is induced, lower-extremity sequential compression devices are applied, and the patient is placed in the exaggerated dorsal lithotomy position. Surgical preparation and draping are performed in the usual sterile fashion. We prefer to use an “all-in-one” lithotomy drape that includes leg covers and a midline subvaginal pouch to drain blood and fluids intraoperatively. The drape may be sutured to the perineum with silk sutures to avoid exposure of the anus in the operative field.

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