CASE: Is the vaginal route appropriate?
A 46-year-old woman (para 2 with 1 cesarean delivery) who has a history of benign menorrhagia comes to your office seeking definitive treatment after medical therapy fails to alleviate her bleeding. pelvic examination reveals a uterus of 14-weeks’ size that descends to the distal vagina, with good vaginal access. What options for hysterectomy do you offer to the patient?
There are few absolute contraindications to a vaginal approach to hysterectomy. Among them are advanced pelvic malignancy, severe endometriosis, and a suspicious adnexal mass. Contraindications do not include a history of pelvic surgery, cesarean delivery, or an enlarged uterus. Such circumstances may increase the challenges involved in performing vaginal hysterectomy, but data suggest that it is achievable in these settings.1-7
Vaginal hysterectomy offers substantial benefits, making the challenges worthwhile in most cases. It is the original minimally invasive approach to hysterectomy. It yields outcomes, postoperative discomfort levels, and recovery times similar to those of laparoscopic-assisted vaginal hysterectomy, total laparoscopic hysterectomy, and robotic- assisted hysterectomy—but the vaginal approach is more cost-effective.3,8-11
This article focuses on strategies and techniques for accomplishing the difficult vaginal hysterectomy, describing five keys to success:
- surgical experience
- adequate exposure
- entry into the anterior cul-de-sac
- uterine mobility (or the ability to create it)
- good morcellation technique.
For clarity throughout this article, we assume that hysterectomy is being performed for benign indications.
1. Surgical experience
Vaginal hysterectomy can be performed successfully in the setting of nulliparity, uterine enlargement, and a history of cesarean delivery, provided the surgeon has the appropriate skill set, assistance, and patience. Little is lost if the operation is attempted vaginally but needs to be converted to a laparoscopic or open approach. If the surgeon persists in attempting to complete each hysterectomy vaginally, he or she will gradually improve in skill and eventually gain the ability to complete tougher cases without the need to convert.
Chen and colleagues developed and validated the Vaginal Surgical Skills Index (VSSI), identifying 13 aspects of successful vaginal surgery:
- inspection
- incision
- maintenance of visibility
- use of assistance
- knowledge of instruments
- tissue and instrument handling
- electrosurgery
- knot-tying and ligation
- hemostasis
- procedure completion
- time and motion
- flow and forward planning
- knowledge of the procedure.12
Thirty-seven trainees from two institutions were evaluated during 76 surgical procedures. The trainees were supervised by five surgeons, who completed the evaluations immediately after each procedure. A sixth surgeon from a different institution watched videos of each procedure and acted as a blinded external reviewer.
Chen and colleagues found good inter-rater and intra-rater reliability and high internal consistency for the VSSI, one of the first tools to objectively assess vaginal surgery skills.
2. Obtaining adequate exposure
Good anesthesia, proper lighting, and fixed retraction are invaluable when operating vaginally. A weighted speculum with Deaver retractors at 3, 9, and 12 o’clock provide good visualization if assistants are available. Self- retaining retractors are also useful (FIGURE 1).
FIGURE 1 Fixed retraction
A Magrina-Bookwalter fixed vaginal retractor in place at the time of surgery.We prefer to empty the bladder before making the vaginal incision, although no data suggest that doing so helps to avoid inadvertent bladder injury.
3. Entry into the anterior cul-de-sac
We prefer to enter the anterior cul-de-sac first. The pertinent risk in vaginal hysterectomy is injury to the bladder. Because anatomic planes are undisturbed at this point, we feel entry into the anterior cul-de-sac gives the surgeon the best opportunity to avoid injury. If it is a struggle or lack of uterine descent makes it difficult, then start with entry into the posterior cul-de-sac (see “gaining mobility”).
FIGURE 2 Palpate the bladder reflection
A. Use the index finger to palpate the bladder reflection. B. Note it with a marking.In a patient who does not have a history of surgery, palpation of the bladder reflection on the anterior uterus can help determine the appropriate site for the initial incision (FIGURE 2). Place a Deaver retractor anteriorly to assist with retraction. It is important to make the first incision deep enough to set up entry into the anterior cul-de-sac (FIGURE 3).
FIGURE 3 Incise the vaginal epithelium
A sharp and deep incision aids in identification of the appropriate plane.With traction on the uterus, grasp the anterior vaginal epithelium and elevate it to allow sharp dissection and mobilization of the bladder (FIGURE 4). We prefer sharp dissection rather than blunt dissection because it maintains surgical planes and is more precise.