Prior to the introduction of laparoscopic assistance, vaginal hysterectomy (VH) was the only minimally invasive option for removing the uterus, and for decades studies have shown that vaginal hysterectomy results in significantly less morbidity than does abdominal hysterectomy. Most recently, investigators who reviewed randomized, controlled trials of hysterectomy for the international Cochrane Collaboration concluded that traditional vaginal hysterectomies should be performed “whenever technically feasible”—even in a world of increasingly popular laparoscopic approaches.
In recent years, technologic advances have resulted in innovative approaches for hysterectomy, including laparoscopically assisted vaginal hysterectomy (LAVH), laparoscopic supracervical hysterectomy (LSH), and total laparoscopic hysterectomy. Despite multiple options for minimally invasive hysterectomy and the evidence suggesting that vaginal hysterectomy should be performed whenever feasible, the majority of hysterectomies in the United States are performed abdominally, and the overall rate of vaginal hysterectomy has held steady.
Comfort level is a major determinant of the type of hysterectomy performed. Many surgeons have not performed sufficient laparoscopic surgeries during residency and do not have the opportunity to receive the appropriate additional training needed to perform laparoscopic techniques requiring advanced skills. Moreover, gynecologic surgeons who have been trained in residency to perform basic vaginal hysterectomy too often dismiss this option because of uterine enlargement or other factors, such as nulliparity, endometriosis, or prior pelvic surgery. In the end, too many patients are denied an attempt at a minimally invasive approach and undergo abdominal hysterectomy.
In many of these cases, a traditional, minimally invasive vaginal approach is achievable. By thoroughly evaluating uterine mobility—ideally, in the operating room—and by more frequently using the relatively simple technique of morcellation to remove the large uterus (which is common among patients needing hysterectomies), we can markedly reduce the rate of abdominal hysterectomy and its ensuing morbidities.
Because it is a relatively straightforward, natural extension of a core procedure for many gynecologists, morcellation can be more quickly and universally applied in practice than are the advanced laparoscopic techniques that many of us strive to learn.
Assessing Uterine Mobility
For successful vaginal hysterectomy with morcellation, the lower uterine segment must be mobile enough to allow control of the uterine arteries and entry into the anterior and posterior cul-de-sacs. These are the essential prerequisites for morcellation; once the cul-de-sacs are entered and the uterine vessels are controlled, we will be able to complete the majority of cases regardless of uterine size.
We should assess uterine mobility in every patient, regardless of the presence or absence of presumptive risk factors such as nulliparity, endometriosis, or pelvic adhesions. In general, mobility is sufficient if we are able to pull the cervix down to the lower third of the vagina.
We can assess the patient's uterine mobility during the office visit to have some assurance of the likelihood of being able to perform vaginal hysterectomy. In general, however, mobility will be notably greater once the patient is under anesthesia, and we really should assess it in the operating room in any case. In a broader sense, performing an examination under anesthesia of uterine mobility, vaginal anatomy, and support to the cervix affords us the opportunity to individualize the hysterectomy and determine the best approach for the patient, rather than pigeonhole the patient into any one particular procedure.
In the patient with uterine enlargement, we should aim to be prepared to perform vaginal hysterectomy with morcellation whenever feasible. If uterine support is normal and vaginal hysterectomy is not technically feasible, laparoscopic assistance should be considered. Although there are no studies directly comparing vaginal hysterectomy and LSH, these two procedures may be the best options for the patient with uterine enlargement. The determining factor between these two approaches should be the presence or absence of uterine mobility, and this should be assessed intraoperatively.
This valuable course of intraoperative decision making begins, of course, with a discussion with the patient about the various options, about the goal of performing an appropriate procedure with the least morbidity, and about her preferences on whether her cervix should stay in or not. In essence, we want to be able to involve the patient beforehand and then tell her that “no matter what, when you're in the recovery room, we will have completed the hysterectomy that is best for you.” Often, we will find that vaginal hysterectomy with morcellation is a viable option when we evaluate the patient under anesthesia.
There are two basic types of morcellation: the wedge technique, and the intramyometrial-coring (also known as the Lash) technique.
In the wedge technique, the cervix is bivalved in the anteroposterior plane to the level of the lower uterine segment. Occasionally, this step alone will result in sufficient mobility to allow delivery of the uterine fundus. Once the cervix is bisected, use a clamp—I prefer a Lahey goiter clamp—to grasp the anterior or posterior uterine wall from endometrium to serosa, and excise a wedge-shaped portion of the uterine wall.