Surgical Techniques

Hysterectomy in patients with history of prior cesarean delivery: A reverse dissection technique for vesicouterine adhesions

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Completing the surgery

Once the bladder is freely mobilized and all adhesions have been dissected, the cervix is circumferentially amputated using monopolar cautery. The vaginal cuff can then be closed from either a laparoscopic or vaginal approach using polyglactin 910 (0-Vicryl) or barbed (V-Loc) suture in a running or interrupted fashion. Our practice uses a 1.5-cm margin depth with each suture. At the end of the surgery, routine cystoscopy is performed to verify distal ureteral patency.16 Postoperatively, we manage these patients using a fast-track, or enhanced recovery, model.17

These videos demonstrate the reverse vesicouterine fold dissection technique

From the Center for Special Minimally Invasive and Robotic Surgery

https://youtu.be/wgGssnd1JAo

Reverse vesicouterine fold dissection for total laparoscopic hysterectomy

  • Case 1: TLH with development of the "new space": The technique with prior C-section
  • Case 2: A straightforward case: Dysmenorrhea and menorrhagia
  • Case 3: History of multiple C-sections with adhesions and fibroids

https://youtu.be/6vHamfPZhdY

Reverse vesicouterine fold dissection for total laparoscopic hysterectomy after prior cesarean delivery

An effective technique in challenging situations

Genitourinary injury is a common complication of hysterectomy.18 The proximity of the bladder and ureters to the field of dissection during a hysterectomy can be especially challenging when the anatomy is distorted by adhesion formation from prior surgeries. One study demonstrated a 1.3% incidence of urinary tract injuries during laparoscopic hysterectomy.6 This included 0.54% ureteral injuries, 0.71% urinary bladder injuries, and 0.06% combined bladder and ureteral injuries.6 Particularly among patients with a prior CD, the risk of bladder injury can be significantly heightened.18

The reverse vesicouterine fold dissection technique that we described offers multiple benefits. By starting the procedure from an untouched and avascular plane, dissection into the plane of the prior adhesions can be circumvented; thus, bleeding is limited and injury to the bladder and ureters is avoided or minimized. By using blunt and sharp dissection, thermal injury and delayed necrosis can be mitigated. Finally, with bladder mobilization well below the colpotomy site, more adequate vaginal tissue is free to be incorporated into the vaginal cuff closure, thereby limiting the risk of cuff dehiscence.16

While we have found this technique effective for patients with prior cesarean deliveries, it also may be applied to any patient who has a scarred anterior cul-de-sac. This could include patients with prior myomectomy, cesarean scar defect, or endometriosis. Despite the technique being a safeguard against bladder injury, surgeons must still use care in developing the spaces to avoid ureteral injury, especially in a setting of distorted anatomy.

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