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Determining the best route for hysterectomy

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Transverse incisions such as the commonly used Pfannenstiel, Cherney, and Maylard compromise upper abdominal exposure but are more cosmetically appealing than vertical incisions. Each of these involves a lower abdominal transverse skin incision and a transverse fascial incision. With the Pfannenstiel technique, the rectus fascia is separated from the rectus muscles, and the muscles are split vertically in the midline, allowing access to the peritoneal cavity. This is the quickest transverse incision to make but provides the least exposure.

If a Pfannenstiel incision has been made and additional lateral pelvic exposure is needed, convert the incision to a Cherney. Both the Cherney and Maylard incisions provide additional exposure to the pelvis, especially laterally, which is advantageous when complex pathology is limited to the pelvis. The Cherney incision involves dividing the rectus muscles from the pubic symphysis, whereas the Maylard incision entails horizontal transection of the rectus muscles at the level of the fascial incision. With the Maylard technique, the rectus fascia is not separated from the underlying muscles as it is in the Cherney incision. If upper abdominal exposure becomes necessary, all of these incisions can be extended upward from their lateral margin, creating a “J.” Alternatively, a second incision can be made in the upper abdomen.

Another option is mini-laparotomy (an incision less than 6 cm). Hoffman and Lynch reported success with this technique for hysterectomy in select patients.10 Most of the procedures were completed with minimal use of retractors by exteriorizing the uterus via one of the aforementioned incisions. They found this approach to be safe and effective in nonobese women in whom a vaginal approach was precluded due to anatomy.

Use the mini-laparotomy approach when there is a suspicious adnexal mass that can be removed through a small abdominal incision.11 In addition, a large benign-appearing cystic adnexal mass can be drained, and the procedure then completed through this incision. Proceed cautiously, however, since an occasional unanticipated carcinoma will be encountered, and the act of drainage will result in the need for chemotherapy in a woman with otherwise early-stage disease. If cancer is suspected, consider a vertical minilaparotomy, which allows easy extension into the upper abdomen should surgical staging or debulking become necessary.

Advantages and disadvantages. The abdominal approach offers the best exposure of the pelvic and upper abdominal cavity but is associated with a high rate of complications, including fever and excessive blood loss. We surmise that postoperative recovery with a mini-laparotomy is likely to be improved compared with the traditional abdominal technique.

Figure 1

Opt for abdominal hysterectomy when a considerably enlarged uterus due to numerous fibroids is encountered.

Vaginal hysterectomy

Patient selection. Choose the vaginal route when pelvic support defects are present (Figure 2), but bear in mind that the course of the ureter changes with worsening degrees of uterine prolapse. We have found the ureter to be palpable in the bladder pillar in most women undergoing VH for prolapse, which helps avoid intraoperative ureteral injury.

The ovaries can be safely removed through the vagina in a large percentage of patients.

Obese, elderly, and otherwise medically debilitated patients also will benefit from the vaginal approach. Avoiding an abdominal wound in these women has obvious advantages. Also, vaginal surgery is associated with a reduction in postoperative pulmonary complications when compared with AH.6,12

Vaginal accessibility inevitably influences the decision to proceed vaginally with a hysterectomy. An inadequate bony pelvis is reason to forgo a VH. Orthopedic conditions and muscular contractures of the lower extremities, which prevent safe positioning, also inhibit this approach. Some surgeons also consider prior abdominal or pelvic surgery a reason to avoid vaginal hysterectomy, while others find this route a means of eluding potential adhesions.

We are strong advocates of vaginal surgery and do not consider nulliparity, lack of uterine descent, or prior abdominopelvic surgery to be strict contraindications for VH. A Schuchardt incision may overcome a small introitus, and a mobile uterus often will descend as the uterosacral and cardinal ligaments are divided.

In women with a prior cesarean delivery, it may be easier to enter the vesicouterine space by approaching it from the less-scarred vaginal side. In a study of more than 200 patients with a previous cesarean who underwent VH, Sheth and Malpani found no increase in complications and concluded that VH is the route of choice in this patient population.13 When unsuspected pelvic adhesions are encountered, carefully dissect them transvaginally and complete the procedure.

Besides accessibility, uterine size must be considered. However, size alone should present a dilemma in only about 15% of patients since most hysterectomy specimens are 12 weeks’ gestational size or smaller.14

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