Vaginal Hysterectomy Is Underused

Continue this process until the uterine fundus can be delivered and the remaining pedicles clamped and cut to allow removal of the uterus. Typically, you will encounter individual myomas and can remove these separately.

The Lash technique—or intramyometrial coring—involves a circular incision in the myometrium at the level of the upper cervix. Make successive circumferential incisions, and you will essentially core out the myometrium while the integrity of the endometrial cavity is maintained.

Because the coring technique allows the removal of an intact endometrium, it may be an advantage if you are concerned about unexpected endometrial pathology. With office biopsies and modern imaging techniques, the chance of an unexpected finding of significant pathology should be minimal. Overall, I believe, the wedge technique is technically easier.

In either case, morcellation follows entry into both the anterior and posterior cul-de-sacs and control of the uterine vessels. Generally, I attempt anterior entry first, which allows me to palpate the ureters prior to clamping and cutting the pedicles. Other surgeons advocate entering the posterior cul-de-sac first, because the inability to enter posteriorly is generally considered an indication to abandon the vaginal approach. Regardless of order, both cul-de-sacs must be entered and the uterine vasculare pedicles controlled before proceeding with morcellation.

While at the Mayo Clinic a decade ago, my colleagues and I reviewed the hysterectomies performed over a 2-year period in patients with a uterine weight of 200–600 g. Patients with adnexal masses and malignancy were excluded.

Of 298 patients who were evaluated in the operating room, nearly half (48%) of those with a uterine weight of 200–400 g were deemed to be candidates for vaginal hysterectomy, based on the presence of sufficient uterine mobility. Even in the group with uterine weights of 400–600 g, 11% of patients had sufficient mobility to allow a vaginal approach. This included nulliparous patients and those with previous pelvic surgery and endometriosis.

Vaginal hysterectomy was successful in 97% of these patients, and its complication rate was significantly lower than that of abdominal hysterectomy, regardless of uterine weight. Morcellation, we found, was required in approximately 70%.

The study showed that although uterine size limits its use, the most important factor in deciding to perform vaginal hysterectomy was the presence of uterine mobility and accessibility. It also showed that because some patients with nulliparity, previous pelvic surgery, and endometriosis will still have sufficient mobility, these factors should not be considered as contraindications to the vaginal approach.

Incorporating Laparoscopy

Over the past decade, rates of LAVH have risen significantly, while the overall rate of vaginal hysterectomy has remained stable. This is concerning because, undoubtedly, many of these patients are candidates for traditional vaginal hysterectomy. Numerous studies, including the recent Cochrane Collaboration review, have shown that LAVH does not improve morbidity over traditional vaginal hysterectomy, and is more time consuming and costly.

Ideally, the use of the laparoscope should allow abdominal hysterectomy to be converted to a minimally invasive procedure. As I see it, the laparoscope can be used to address situations that result in uterine immobility, such as nulliparity, adhesions, and endometriosis, thus allowing conversion of these cases to LAVH.

Additionally, we can use laparoscopy to ensure ovarian removal at the time of vaginal hysterectomy, although some would suggest proceeding with traditional vaginal hysterectomy first and only employing laparoscopy if you're having technical difficulty removing the ovaries vaginally. Multiple studies report more than 90% success in removing ovaries at the time of vaginal hysterectomy, suggesting that laparoscopic assistance for ovarian removal should be required in less than 10% of cases.

My own experience with ovarian removal is similar to these studies, so I prefer to attempt vaginal removal first and reserve the use of the laparoscope for the few patients in whom I find it necessary.

Total vs. Supracervical Hysterectomy

The recent introduction of the laparoscopic morcellator allows removal of an enlarged uterus with a laparoscopic approach and has resulted in an increased use of LSH for patients with uterine enlargement.

Although some surgeons counsel patients that keeping their cervix will result in improved pelvic support and sexual function, studies comparing total hysterectomy with supracervical hysterectomy have shown no difference in bladder function and sexual function and support the premise that it's the anatomy of the vagina, and not the presence of the cervix, that is important. (We still need well-designed randomized, controlled trials that compare the morbidities and outcomes of LSH with LAVH and vaginal hysterectomy.)

In patients who already have normal pelvic support, LSH utilizing the laparoscopic morcellator may offer the best option for removal of the enlarged uterus, whereas those patients with uterine mobility are best treated by vaginal hysterectomy with traditional morcellation.