ST. LOUIS — The vast majority of benign hysterectomies can – and should – be performed vaginally, according to Dr. Carl W. Zimmerman.
In fact, more than 90% of uteri weighing less than 250 g are accessible and can safely be removed vaginally by using guidelines endorsed by the board of directors of the Society of Pelvic Reconstructive Surgeons. Considerable evidence exists that many larger uteri also can be removed safely via the vaginal route, he said at the conference, which was sponsored by the society.
Despite this evidence, however, the minimally invasive vaginal approach remains underused in the United States, said Dr. Zimmerman, professor of obstetrics and gynecology at Vanderbilt University, Nashville, Tenn.
A lack of experience, familiarity with technique, and confidence is the main reasons why surgeons avoid the vaginal approach in favor of more invasive abdominal, laparoscopic, and robotic techniques. While the choice for vaginal hysterectomy should be made based – to a certain extent – on guidelines, it is important to consider skill acquisition, experience and competency, he said.
He encouraged those who are “on a learning curve” in terms of performing vaginal hysterectomy in patients with large uteri to obtain more experience by using this technique for uteri of 14–16 week size.
“That may sound big, but you'll be amazed, you'll be empowered, and your patients will do well,” he said, strongly recommending consideration of the concept of removing larger uteri by this method.
He outlined five main steps that must be completed to successfully remove an enlarged uterus vaginally, and provided tips on surgical instrumentation that can facilitate vaginal hysterectomy in cases involving a large uterus.
The first step is entry into the peritoneal cavity. This can be accomplished anteriorly or posteriorly, but experienced operators will delay entry into the anterior segment until the uterosacral and cardinal ligaments have been detached, and therefore they typically enter posteriorly.
“It's often available to you, and it's the easiest entry into the peritoneal cavity,” he said of the posterior approach.
The next two steps are to detach the uterosacral and cardinal ligaments, and to ligate the uterine artery.
Keep in mind that fibroids are the most common cause of uterine enlargement, and that most of the anatomical distortions in the fibroid uterus are limited to the area superior to the uterine artery. This “concept of uterine anatomic distortion” means that once steps 1–3 are completed, you “can be innovative about the way you debulk and remove the uterus. Once you have secured the support system, and you have divided the blood supply, then it becomes a mechanical exercise in converting a roughly globular structure into either various components that will come out, or a shape that will change and come out,” he explained.
Once the fourth step of debulking and removing the uterus is completed, the final step – vaginal adnexectomy – can be performed as needed based on the same indications that would be used if a scope was in place, or if the procedure was done abdominally, he said.
As for the best approaches to debulking the uterus, Dr. Zimmerman said morcellation is his primary technique, followed by coring, which is very useful for the adenomyotic uterus – and is particularly valuable for managing uteri up to 17 weeks in size.
The typical tools used in gynecologic surgery, such as Haney clamps, straight needle holders, and short instruments may be inadequate for performing vaginal hysterectomy involving large uteri. Instruments Dr. Zimmerman recommends for improving surgical skill and outcome include:
▸ Retractors. The correct retractors are one of the keys to success in vaginal hysterectomy; shop around and find the type that fits best into your system, Dr. Zimmerman advised. He listed Heaney, Harrington, malleable ribbon, Breisky-Navratil, and Steiner-Auvard among good options. Deaver retractors should be avoided because they increase risk of bladder injury, he said.
▸ Scissors. The right scissors can help with debulking when difficult angles are encountered. Jorgenson scissors, which Dr. Zimmerman learned to use in abdominal hysterectomy, are also useful in vaginal hysterectomy, because they create a right angle very valuable for debulking the uterus. Martin cartilage scissors, which have sharp points at the tips that can allow for insertion into a myoma and allow wedges to be cut, are very helpful, he said. Even a very dense or calcified myoma can be transected and debulked using these scissors.
▸ Lights. Whatever you choose to use to gain extra light is a good idea, he added. The Vital Vue surgical light, and a newer version – the Versalight, which is a multifunctional surgical light that provides irrigation, suction, and retraction, are good options. Dr. Zimmerman disclosed that he helped design the Versalight.