Vaginal Hysterectomy Is Underused

Ideally, we should be in a position to offer both approaches to the patient and should decide which to use based on examination under anesthesia in the operating room. If neither can be achieved, the patient may require abdominal hysterectomy, but at least we will have made an appropriate attempt at a less invasive procedure.

Until we have data pointing us elsewhere, we should embrace the minimally invasive gold standard of vaginal hysterectomy, employing morcellation for the larger uterus more often and turning to laparoscopy when necessary. Hysterectomies are most commonly done in reproductive-age women with fibroids or bleeding, a significant number of whom have enlarged uteri, so our ability to reduce the rate of abdominal hysterectomy—and increase the rate of the less morbid vaginal approach—is significant.

On the left, a wedge is excised from the posterior uterus. On the right, individual myomas are removed as they are encountered during morcellation. Photos courtesy Dr. Michael Moen

Size Doesn't Have to Count

Despite a trend toward minimally invasive gynecologic surgery, nearly 75% of hysterectomies in the United States are still performed via open laparotomy. The most common reason an open approach is selected by the gynecologic surgeon is concern about uterine size.

As editor of the Master Class columns on gynecologic surgery, I have enlisted Dr. Michael Moen to discuss the technique enabling removal of the larger uterus via a vaginal route.

Dr. Moen directs the division of urogynecology at Advocate Lutheran General Hospital in Park Ridge, Ill. He is also affiliated with the department of ob.gyn. at the University of Illinois at Chicago, and is a cofounder of Illinois Urogynecology Ltd. Dr. Moen is a fellow of both the American College of Obstetricians and Gynecologists and the American College of Surgeons, and is a member of the American Urogynecologic Society, the International Urogynecological Association, the Society of Gynecologic Surgeons, and the American Association of Gynecologic Laparoscopists.

While at the Mayo Clinic in Rochester, Minn., Dr. Moen was the lead author of an article on vaginal hysterectomy in patients with benign uterine enlargement for the Journal of Pelvic Surgery, along with his mentor, Dr. Raymond Lee.

Key Points: Vaginal Morcellation

▸ Ensure uterine mobility.

▸ Control uterine vessels.

▸ Proceed with morcellation of uterus.

Option 1: Wedge Technique

Divide cervix in anteroposterior plane to lower uterine segment.

Excise wedge-shaped portions of uterus.

Option 2: Lash Technique (Intramyometrial Coring)

Make successive circular incisions in myometrium to core it out.

Source: Dr. Miller