Vaginal hysterectomy (VH) with or without vaginal wall and perineal repair, is the commonest type of hysterectomy in our institute; worldwide literature shows that it is the preferred route for benign disease of the uterus. Routine indications include uterine prolapse, abnormal uterine bleeding, adenomyosis, fibroids up to 12 weeks’ size and endometrial hyperplasia. The “difficult vaginal hysterectomy” is a well defined entity and in the hands of skilled vaginal surgeons, expanded indications for VH like non-descended vaginal hysterectomy (NDVH), uterus > 12 weeks’ size, multiple fibroids, concomitant oophorectomy or salpingo- oophorectomy, previous uterine or abdominal surgeries (previous LSCS, previous tubal ligation, myomectomy, sling surgery, adnexal surgery, bowel surgery), are possible. Probably the only contraindications for VH are previous vesicovaginal and rectovaginal fistula repair and previous Fothergill’s surgery. Anticipation and preparation are keys to success and most surgeons will be prepared for these difficult cases; however surgical difficulties may be encountered even in routine or relatively simple VH and this article addresses these issues.
The challenges in both routine and difficult cases are similar and include: adequate exposure and visualization, opening of anterior vesicouterine peritoneum (A pouch) and posterior cul-de-sac (P pouch), securing pedicles and achieving hemostasis in a narrow space, avoiding injury to bladder and rectum, and retrieving the uterus.
Preoperatively, two parameters which should be assessed are uterine mobility and size. In the absence of previous surgeries and adhesions, most uteri, even those of nulliparous women, will demonstrate physiologic descent. If the vagina is of adequate capacity so as to allow access to the uterosacral ligament complex, it will be possible to remove even an immobile non-descended uterus via the vaginal route once the ligaments are divided. More subjective is the judgment of uterine size, which we routinely express in weeks’ of gestation. This measure considers only the height of the uterine fundus and not the bulk; obviously the bulkier uteri are difficult to remove vaginally and if terminology and interpretation are not uniform, the surgeon may be stumped at surgery with a uterus broader than expected. Some authors have recommended preoperative uterine volume assessment by USG: a uterus of 8 – 10 weeks’ size is approximately 150–200 cm3 in volume and is easily removed vaginally, and may not require USG. On the other hand, if the uterus is > 10 -12 weeks’, the volume may be in excess of 250–300 cm3, warranting reassessment under anesthesia.
Examination under anesthesia (EUA) is a crucial step prior to VH as surprises like enlarged uterus or adnexal pathology may be encountered. Apart from examining descent and mobility, it is imperative to assess the upper vagina, which should not be narrow at the apex, and should allow at least 2 fingerbreadths. Sheth SS introduced the concept of “trial VH” akin to “trial forceps”, where facilities for rescue surgery via laparoscopy or laparotomy are kept ready.
Adequate visualization and exposure are achieved by small simple checks:
- Lithotomy position with the patient’s buttocks at the edge of the table and stirrups high up with the legs slightly hyperflexed. This will improve the surgical field and prevent abutment of speculum against the table.
- The operating surgeon should adjust the height of the table so as to bring the patient’s pelvis at eye level; this will not only aid vision but will also decrease strain on the surgeon’s arms and shoulders
- The assistants should stand within the stirrups
- The surgeon should do away with multiple retractors, especially right angle retractors which are space- occupying. Rather, the simple labial stitch or circular retractor systems with elastic stays and hooks should be employed
- Structures deep in the vagina are better visualized with either a head lamp or pelvic illuminators. An easy modification is to mount the light source so that it is immobile and frees the assistants’ hand, or the assistant can hold the light source with a Babcock forceps
Opening of A pouch is the Achilles heel of many vaginal surgeons, especially during the learning curve, and is in fact seen as the limiting factor of VH. The anterior incision at the very start of the VH is where most errors occur.
- In bulky uteri the error is usually that the plane of cleavage is too deep and inadvertently the superficial layers of myometrium are incised. This can be rectified by applying Allis’ forceps to the upper cut edge and dissecting sharply just above it, to enter the A pouch
- Another common error is to restrict the anterior incision to the midline. In case the incision is too superficial or the correct plane is not achieved, it is beneficial to carry the incision laterally and dissect the bladder pillars well away, and approach the A pouch from the lateral aspect. This helps for both large prolapsed uteri as well as cases with supravaginal elongation and is the preferred approach for scarred uteri
- For postmenopausal women with atrophic narrow uteri but massive vaginal wall prolapse, it may be helpful to dissect the entire vagina and raise anterior and posterior flaps, elevate the dissected bladder with Babcock forceps, and then enter the A pouch below the instrument
The P pouch usually poses less difficulty than the A pouch but sometimes it may be high. The dictum while dissecting is to stay close to the uterus or approach the pouch from the lateral side; often the uterosacral ligaments and sometimes even the uterine arteries can be ligated extra-peritoneally until descent improves.
Securing pedicles and achieving hemostasis can be challenging; modifications which have been suggested are:
- Avoidance of hand knots deep in the vagina
- Use of long thin needle holders and clamps
- Right angle forceps or bipolar forceps, which can control bleeding high up and on lateral pelvic wall
- Vessel sealing devices are advantageous in tight spaces. Newer devices include a blade which cuts after the hemostatic seal is complete
Retrieving the enlarged uterus involves debulking or volume reducing steps like bisection, coring, morcellation, myomectomy or a combination, after securing the uterine arteries. This step may take some time and the surgeon should persist. Conversion to laparoscopy or laparotomy is rare but usually occurs at this point. Myoma screw may be used as it gives excellent traction or the cervix and lower part of uterus may be removed first, and traction applied on the remaining uterus, to facilitate its removal.
In conclusion, as the surgeon’s knowledge of anatomy, training and vaginal skills improve, difficulties can be easily overcome. Proponents of VH believe that “every hysterectomy should be planned primarily by the vaginal route and, unless contraindicated, be performed via the vaginal route. The December issue of our journal carries three articles on this subject which we hope will benefit the reader.