Fig. 20.1
Positioning for vaginal hysterectomy: both a stirrups supporting the entire leg and b candy cane stirrups are appropriate
Essential instruments for VH include weighted specula, retractors, tenacula, scissors, and clamps with special design and length. Some vaginal surgeons prefer a self-retaining vaginal retractor system. Lighting is also critically important, which can be improved with a headlight, lighted retractor, or suction/irrigation devices with lighting option.
The use of an indwelling urinary catheter is optional. Leaving some urine in the bladder may help the surgeon recognize cystotomy in a timely fashion. The procedure is initiated by grasping the cervix with tenacula anteriorly and posteriorly. Some may choose to inject vasoconstricting agents into the cervix before making an incision. This initial incision should be made outside the cervical transformation zone, at point of decreased vaginal rugae. Electrocautery can be used to make this incision.
To make the posterior colpotomy (Fig. 20.2a, b), one should first palpate the uterosacral ligaments and posterior fornix to identify the cervix–vagina border. The cul-de-sac is entered at a perpendicular angle with sharp dissection at about 1 cm from the uterosacral ligamentous attachments. This step is facilitated by downward traction provided with an Allis clamp placed about 2 cm from cervico-vaginal reflection. Pediatric laparotomy sponges may be used to pack the bowels and omentum as needed. The location of the anterior part of the colpotomy incision is critical. The bladder location can be determined by the appearance of the rugae in the anterior vagina.
Fig. 20.2
Posterior colpotomy: Cul-de-sac is entered at a perpendicular angle with sharp dissection at about 1 cm from the uterosacral ligamentous attachments. This step is facilitated by downward traction provided with an Allis clamp placed about 2 cm from cervico-vaginal reflection. a Front view and b sagittal view
The anterior incision can be made exactly where the rugae ends. However, it may be safer (especially for less experienced surgeons to make the incision at about 5-mm cephalad to the anterior cervical tenaculum. It is essential to hold the scissors parallel to the cervical axis and press them against the firm surface of the cervix and lower uterine segment. After the so-called vesicouterine septum, a 1.5–2 cm connective tissue band which firmly attaches the bladder to the lower uterine segment, is divided, the avascular vesicouterine space opens leaving only a thin sheet of peritoneum intact (Fig. 20.3a, b). An expert vaginal surgeon may be able to determine the vesicouterine plane precisely and may prefer to complete the anterior colpotomy by identifying the peritoneum floating freely over the lower uterine segment. This may not be necessary, as it is safe to start clamping the uterosacral and cardinal ligaments as long as a retractor is deflecting the bladder, and down and outward traction is applied to the cervix. In many cases anterior entry into the peritoneal cavity may be deferred until after the division and ligation of the uterosacral and cardinal ligaments. Once the cardinal ligaments are transected, the uterus will descend more (Fig. 20.4). Before any attempt for delivery of the uterus, the abdomen must be entered both anteriorly and posteriorly. If the uterus is small, it can be delivered through an anterior or posterior colpotomy, but when it is large, it may have to be removed in several pieces with manual morcellation techniques. It is safe to do this after the uterine arteries are ligated bilaterally.
Fig. 20.3
Anterior colpotomy: After the so-called vesicouterine septum, a 1.5–2 cm connective tissue band which firmly attaches the bladder to the lower uterine segment, is divided, the avascular vesicouterine space opens leaving only a thin sheet of peritoneum intact. a Front view and b sagittal view
Fig. 20.4
Once the uterosacral and especially cardinal ligaments are clamped and transected, the uterus will descend
After the cornual end of the fallopian tubes, round ligaments, and utero-ovarian ligaments are clamped and divided altogether and ligated in one pedicle bilaterally, the uterine specimen can be removed. Confirmation of hemostasis by inspecting the pedicles in a clockwise fashion using sponge on ring forceps and irrigation is a necessary step. After ensuring hemostasis systematically, the vaginal cuff is closed with full-thickness sutures including the peritoneal edge on the posterior side, usually in a transverse fashion. Peritoneal closure is typically not necessary. Optionally, the cuff can be closed sagittally to prevent shortening of the vagina. Ovaries and tubes can also be removed at the time of hysterectomy if so desired. Clamping the round ligament separately may facilitate oophorectomy.
At the end of the procedure, many recommend cystoscopy to confirm ureteral integrity, but this may not be needed routinely, as ureteral injury is least likely with VH. Vigorous jets confirm ureteral patency. Vaginal packing is typically not necessary. Leaving an indwelling Foley catheter is not standard unless indicated for a concomitant procedure. Oral intake may start as tolerated. Same-day discharge may be possible in some cases if pain control is appropriate.
One should consider utilizing laparoscopy if it is unsafe to complete the procedure due to uterine size, adhesions, or unexpected pathology. Even though most cases can be accomplished with traditional surgical instruments, vessel sealing bipolar devices have been well-tested and are appropriate to use in difficult, if not all, cases of VH. Endoloops, hemostatic clips, and other hemostatic devices should also be made available for complicated cases.
Complications
When hysterectomies performed for malignancies and perinatal indications are excluded, the mortality rate of hysterectomy is estimated to be in the range of 1–3 in 10,000. A recently updated meta-analysis on hysterectomy approaches by the Cochrane Library included 34 trials with 4495 women (2). This analysis showed that VH is the least complicated and the shortest hysterectomy approach. The most frequent complications of VH are infections and bleeding. Hematoma formation from contained bleeding, if not relieved, may eventually lead to an infectious process. Most bleeding complications arise from the area between the utero-ovarian and uterine artery pedicles, and sometimes from the posterior vaginal cuff. Among the other less common complications, bladder injury usually occurs well above the trigone, therefore, not near the ureters. One must avoid blunt dissection of the bladder, especially in women with a history of previous cesarean delivery. While gynecologists are responsible for most ureteral injuries, the majority of which occur during hysterectomies, this occurs less commonly in VH. Vaginal cuff dehiscence with or without evisceration, a serious complication unique to hysterectomy, occurs less frequently in VH (0.2–0.3%) vs. LH (>1%) (8). The risk of bowel injury is small (0.15–0.7%) and statistically similar in all hysterectomy approaches.
Conversion to laparotomy should not be considered a complication, as a prudent surgeon will use the safest method when unexpected conditions are encountered during any surgery. Most studies including this meta-analysis were underpowered for many outcome measures (2). Importantly, the information regarding the long-term effects of hysterectomy routes is sparse.
Other Transvaginal Procedures
The shortest distance to the abdominal cavity is through the posterior vaginal fornix, where the full-thickness vaginal wall has very few fibromuscular elements. Combined thickness of the vaginal wall and adjacent peritoneal lining is about 5 mm. All vaginal surgeons are well aware that the area immediately distal to the attachment of the uterosacral ligaments is safe for approximately 3–4 cm, as the rectum is not attached there, and changes its direction toward the left side of the pelvic cavity. In recent years, interest in exploring even less invasive approaches has resulted in reappraisal of transvaginal surgery by both gynecologic surgeons and general surgeons (9).
Historically, transvaginal access to the abdominal cavity has been used in several ways for a variety of indications:
Culdocentesis, aspiration of fluid collected in the cul-de-sac via needle puncture of the posterior fornix, used to be a key step in the differential diagnosis of ruptured ectopic pregnancy before sensitive pregnancy tests and pelvic ultrasonography (Fig. 20.5).
Fig. 20.5
Culdocentesis: Aspiration of fluid collected in the cul-de-sac via needle puncture of the posterior fornix, which used to be a key step in the differential diagnosis of ruptured ectopic pregnancy
Culdotomy is the entry into the cul-de-sac by means of an incision in the posterior vaginal fornix. When this is performed as the first step of VH, it is often called colpotomy. This access can be used with traditional surgical or laparoscopic instruments to perform tubal sterilization, salpingectomy, oophorectomy, abscess drainage, and myomectomy. Most recently, this route has been used by pioneers of the NOTES movement to perform procedures such as nephrectomy, appendectomy, and cholecystectomy, which are detailed elsewhere in this textbook.
In culdoscopy, an endoscope is inserted into the abdominal cavity through the culdotomy incision for the evaluation of pelvic structures or tubal sterilization. When this access is combined with laparoscopy as a port site for instrumentation or specimen retrieval, it is considered culdolaparoscopy. Advocates of the latter technique suggest that making the entry under laparoscopic visualization may reduce the risk of visceral injury (10).
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