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Vaginal hysterectomy: 6 challenges, an arsenal of solutions

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Obesity, fibroids, previous surgeries and other obstacles usually give way to targeted tactics




Newer codes for vaginal hysterectomy capture the work of removing larger uteri without laparoscopy

True or false: When it comes to hysterectomy, surgeons tend to use the route that is safest, least invasive, and most economical.

Sadly, the statement is false. Although vaginal hysterectomy tops all 3 categories, it is the least utilized of surgical routes. The number of vaginal hysterectomies may have increased slightly over the past decade, likely due to the incorporation of laparoscopically assisted vaginal hysterectomy into the mainstream and increased practice with the vaginal component, but fewer than 30% of hysterectomies are performed vaginally.

This article addresses 6 common challenges at vaginal hysterectomy and offers strategies to overcome them.

Laparoscopic strategies ease vaginal hysterectomy, too

Laparoscopic hysterectomy became widely accepted when surgical instruments were developed to overcome the technical challenges inherent in operating with limited access. By incorporating some of the techniques we routinely use for laparoscopic surgery, we can overcome many of the challenges faced during difficult vaginal surgery.


Unfortunately, our population is increasingly rotund. This is not only a significant risk factor for the patient’s health in general, but it poses some unique challenges for surgeons. I must say that, as tough as it may be to complete a hysterectomy vaginally in a morbidly obese woman, I would much rather approach her pelvic organs through the cul-de-sac, which contains no fat cells, than through the abdominal wall—either laparoscopically or abdominally! The trick is gaining access to the posterior cul-de-sac.

How to enter the cul-de-sac

It seems to be a perverse rule of nature, but a tight upper vaginal ring seems almost universal in obese women. Added to the redundant sidewalls and the large buttocks, this tightness makes entry into the anterior or posterior cul-de-sac problematic. Several tricks make peritoneal access possible:

Position the patient to increase access, with the buttocks well over the edge of the operating table. This brings the operative field a bit closer to the surgeon, and permits the use of long-handled retractors posteriorly.

Use candy-cane stirrups to allow assistants better access to the operative field. Adequate assistance is essential in attempting vaginal surgery in the morbidly obese.

Avoid the Trendelenburg position. Although it might seem that this position would facilitate visualization and placement of a posterior weighted speculum, all it does is allow the patient to slide up on the table, making placement of alternate retractors difficult.

Use the right tools. If the posterior weighted speculum will not stay in place or does not afford access to the cul-de-sac due to an upper vaginal ring, use a narrow Deaver retractor posteriorly (without sidewall or anterior retraction). Use a Jacob’s tenaculum on the posterior lip of the cervix and have your assistant pull straight up on the tenaculum while using the Deaver retractor to see the area between the uterosacral ligaments.

Use the uterosacral ligaments as a guide. Another perversity in morbidly obese women: Despite multiparity, they seem to have little or no apical prolapse but lots of vaginal wall redundancy. The cervix is often elongated, but the uterosacral ligaments are sky high.

I palpate these ligaments, injecting them with a combination of vasopressin diluted 1:5 with bupivacaine and epinephrine (for enhanced hemostasis and preemptive analgesia), then use a pencil electrosurgical electrode to rapidly open the vaginal epithelium between the ligaments.

I then use a long, toothed tissue forceps to tent the peritoneum at 90 degrees to the plane of the posterior cul-de-sac and use Mayo scissors to enter the peritoneal cavity. Usually there is a spurt of fluid to mark appropriate entry into the peritoneum.

I then use the blades of my scissors to stretch the peritoneum between the ligaments and place a moistened 4×4 sponge into the incision.

At the onset of the procedure, inject indigo carmine dye intravenously so that any injury to the bladder will be immediately recognized. I have the circulating nurse empty the bladder while she is prepping the patient, but do not leave an indwelling catheter in place during the operation. I find it cumbersome to work around the catheter.

Problematic entries

When entry into the posterior cul-de-sac is difficult, I stop dissection, place a 4×4 sponge into the incision to reduce bleeding from the vagina, and proceed to attempt anterior entry.


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