Secrets to successful vaginal hysterectomy

CASE 1 Ovaries appear out of reach

After Lash intramyometrial coring, the surgeon successfully removes the uterus. He then turns his attention to the bilateral adnexectomy. Unfortunately, the ovaries are higher than anticipated, and he once again considers switching to the abdominal route to remove them.

Is a change in route the best option?

Focus on the round ligaments

The key to safe removal of the adnexa, especially in difficult cases, is the separate transection and ligation of the round ligaments. Many authors have reported high success rates for vaginal oophorectomy using this technique, especially in premenopausal women.^16-19

Separate transection of the round ligament allows the surgeon to accomplish 2 very important tasks:

In many hysterectomy cases when oophorectomy is planned, this maneuver can be carried out prior to removal of the uterus. Once the round ligaments have been reached, the surgeon can deliver the uterine fundus anteriorly, allowing the round ligaments to be clamped and cut. It is not uncommon to be able to remove the uterus with both adnexa still attached.

With a large uterus, it may be necessary to clamp and transect the round ligament after the uterus is out. This does not preclude identification and transection of the round ligament to carry out the maneuvers described above.

Consider your tools

In very difficult cases, specialized clamps or sutures may be necessary. I find long, sturdy, right-angle clamps to be most useful. In addition, endoloop-type sutures often facilitate ligation of the vascular pedicle. The use of newer specialized bipolar electrosurgical instruments may be helpful, although I have no personal experience using them in vaginal surgery.

CASE 1 At closure, concerns about injury

After successful removal of both adnexa using the round-ligament technique, the surgeon is satisfied that he has achieved hemostasis and proceeds with his usual closure. However, he has nagging concerns about the possibility of undetected complications, because this case turned out to be more of a challenge than he had expected. He wonders if there is anything else he can do to ensure that everything is OK.

What would you do?

Besides ensuring satisfactory hemostasis, confirming the integrity of the urinary tract is the most important goal to achieve before leaving the operating room. Unrecognized injuries to the bladder or ureters are unacceptable and will lead to significant morbidity for the patient. I would certainly recommend that the surgeon in M.K.’s case perform cystoscopy after giving the patient intravenous indigo carmine to assure both ureteral patency and integrity of the bladder. I perform cystoscopy after all vaginal hysterectomies.

CASE 2 History of cesarean delivery

C.S. is a 38-year-old gravida 3 para 3 who presents with menometrorrhagia and dysmenorrhea unresponsive to medical therapy. Her first pregnancy resulted in vaginal delivery of a full-term infant without complications. Her second child was delivered via low-segment transverse cesarean section due to a persistent breech presentation at term. Her last child was delivered vaginally, also at term. Two years later C.S. underwent a laparoscopic tubal ligation without complications. That was 4 years ago. She began seeing her current gynecologist 2 years ago, when she moved to a new community.

Pelvic examination reveals a 6-week–size uterus and normal adnexa. Her uterus is mobile, and there does not appear to be any ventral fixation of the uterus to the abdominal wall from the cesarean section. Endometrial biopsy reveals proliferative endometrium only. Saline ultrasound demonstrates a 2-cm submucosal leiomyoma.

C.S. refuses hysteroscopic resection of the myoma and prefers hysterectomy as definitive therapy. She is the business manager for her family’s construction business, and she would like to be able to return to work as soon as possible after her surgery. She requests vaginal hysterectomy with conservation of her ovaries.

What is the best way to proceed at this point?

Many gynecologic surgeons regard previous pelvic surgery, including cesarean delivery, as a relative contraindication to vaginal hysterectomy. Although the major concern seems to be a potential for bladder injury during the bladder dissection, other problems such as ventral fixation of the uterus to the previous abdominal incision also are possible.

Vaginal hysterectomy requires a mobile uterus