CASE Bleeding, a large uterus, and no response to hormones
“M.G.,” a 42-year-old nullipara, complains of menstrual periods that last 10 days and occur on a 28-day cycle. She says the bleeding is extremely heavy, with frequent, copious clotting. She routinely avoids planning social activities around the time of her period and occasionally cancels nonessential engagements because of it. Over the past year, this professional woman has missed 6 days of work because of the problem with her menses.
When you ask about her history, she reports that another gynecologist first palpated an enlarged and irregular uterus 5 years earlier, and an ultrasound at that time revealed a multinodular fundus of approximately 12 weeks’ size. Oral contraceptives were prescribed, but the problem returned to pretreatment levels over the next 3 years. Oral medroxyprogesterone acetate was added to the regimen without success. Hysteroscopy and a dilation and curettage revealed no submucous fibroids, but by then the uterus had enlarged to 14 weeks’ size. M.G. was counseled about continued conservative management, uterine artery embolization, endometrial ablation, and vaginal hysterectomy. She now wants to go ahead with total vaginal hysterectomy and ovarian preservation.
Is the vaginal approach feasible?
Vaginal hysterectomy is not only feasible, it is preferred. Although laparoscopic surgeons are fond of using the phrase “minimally invasive surgery” to describe their procedures, when it comes to hysterectomy, only the vaginal route qualifies for this superlative description. And although uterine size does sometimes limit use of the vaginal route, it need do so in only a minority of cases.
This article describes surgical techniques for vaginal removal of the large uterus, using morcellation, coring, cervicectomy, and other strategies.
Is the vaginal approach always best?
Guidelines addressing this question were developed by the Society of Pelvic Reconstructive Surgeons and evaluated by Kovac et al (FIGURE 1).1 These guidelines, widely used around the world, recommend the vaginal approach for the small, mobile uterus in a pelvis that has no substantial, identifiable pathology. The guidelines recommend the abdominal route when an adnexal mass of unknown character is present or malignancy is suspected. They suggest the use of laparoscopy to identify or quantify pathology and to help convert cases from the abdominal route to laparoscopically assisted vaginal hysterectomy.
I view these guidelines as a minimum standard of care. As a surgeon’s confidence and skills increase, wider application of the vaginal route should be possible in progressively challenging cases. In the personal series of expert surgeons, use of the vaginal route often exceeds 90%. In contrast, the overall US average is 25%, including laparoscopically assisted procedures.2,3
The indications for salpingo-oophorectomy remain the same regardless of route. At present, the adnexa are removed in only 10% of vaginal hysterectomies and in 60% of abdominal procedures.2,3 However, successful routine removal of the adnexa through the vagina is well documented in the literature.4
Contraindications. There are few absolute contraindications to vaginal hysterectomy beyond known or suspected malignancy, but some conditions do increase the technical skill required (TABLE). Nor do complications increase, provided the surgeon has the proper skill and instrumentations.
FIGURE 1 How to choose a hysterectomy route
Source: Kovac SR et al1; used by permission of the American Journal of Obstetrics and Gynecology.TABLE
Contraindications to vaginal hysterectomy
Every procedure involves 3 basic tasks
Before the uterus can be removed vaginally, the surgeon must:
- enter the peritoneal cavity,
- divide the uterosacral, cardinal, and pubourethral ligamentous attachments of the paracolpium, and
- ligate the uterine artery.
Posterior entry is usually easier
Although peritoneal entry may be anterior or posterior, the latter is almost always easier. Apply an Allis clamp to the vaginal epithelium over the posterior cul-de-sac approximately 2 to 4 cm behind the cervix. Apply a small amount of traction to the clamp to create a vertical crease, which denotes the proper location for colpotomy. Palpate the crease manually to ensure no bowel is present. Then make a full-thickness incision with sharp scissors to enter the peritoneal cavity. Incomplete incisions and blunt dissection simply slow the process.