Vaginal Hysterectomy

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Benefits

• Vaginal hysterectomy compared with abdominal hysterectomy
  • Shorter duration of hospital stay
  • Faster return to normal activity
  • Fewer febrile episodes or unspecified infections
• Vaginal hysterectomy compared with laparoscopic hysterectomy
  • Shorter operating time
• Most cost-effective route of hysterectomy (when compared to both abdominal and laparoscopic)

Prerequisites

• No evidence of advanced malignancy
• No evidence of complex adnexalmass
• No concern for pelvic adhesions
• No evidence of acute infection
• Hemoglobin maximized (consider pretreatment to optimize if Hgb < 10)

Advanced Skills

• Advanced skills required for:
  • Uterine size over 12 weeks
  • Prior pelvic surgery
  • Nulliparity
  • Suspected severe endometriosis(generally with BSO)
  • Suspected obliteration of cul-de-sac

Indications

• Benign uterine pathology
  • Uterine leiomyoma
  • Abnormal uterine bleeding–evaluated and benign
  • Adenomyosis
• Pelvic organ prolapse(with cuff support procedure)
• Precancerous or early stage cancer of cervix or endometrium(with gynecologic oncologist consult/backup)
  • Recurrent CIN III, in situ,or Stage Ia1 cervical cancer
  • Endometrial hyperplasia
  • Stage I, Grade I endometrial cancer

Fundamental Anatomy

• Bladder
  • Connected to the cervix only by 1-2 cm, then an avascular plane is entered
  • Separating the bladder from the anterior peritoneum mobilized the ureters laterally, allowing for the clamping of the uterine arteries only once the bladder is off the uterus and the ureters are safely anterior and lateral to the operating field
• Blood supply
  • Major blood supply from uterine arteries
  • Ascending uterine artery branch communicates with ovarian arteries
  • Ovarian arteries
• Ureters
• Rectum
  • Rectum is not attached to the vaginal apex

Complications

• Bleeding
  • Most common site is between utero-ovarian and uterine artery pedicles
  • Second most common is posterior vaginal cuff
• Bladder injury
  • Location of cystotomy: most commonly above trigone (not near ureteral orifices)
  • Minimize blunt dissection with a history of previous cesarean delivery
• Ureteral injury
  • This is least likely with vaginal route than abdominal or laparoscopic
• Infection
• BoweI injury

Preparation

• CBC
• Type and screen
  • Cross-match 2 units of PRBCs for Hgb < 10 g/dl
• Current cervical screening
• Endometrial biopsy for abnormal uterine bleeding
• Transvaginal ultrasound advisable
• Bowel prep not necessary

Informed Consent

• Alternative treatment options
• Elective adnexectomy risks/benefits reviewed
• General risks of surgery
  • Bleeding requiring transfusion < 2%
  • Infection
    • Urinary tract infection is most common
• Specific risks of hysterectomy
  • Potential damage to lower urinary tract or GI tract requiring further surgery
  • Potential need for open abdominal surgery if vaginal hysterectomy is not feasible
• Sterility

Preoperative Considerations

• Anesthesiatype
• Deep Vein Thrombosis (DVT) prophylaxis Sequential Compression Devices (SCDs)+/-Heparin
• Single dose antibiotic prophylaxis
• Time out

Prophylactic Antibiotics

• Cephalosporins are the antibiotics of choice
  • Adjust dose for BMI > 35
• Should be administered just before induction
• Redosing should occur if surgery > 3 hours or blood loss > 1500 ml
• Agents of choice in women with hypersensitivity to penicillin or cephalosporins include:
  • Clindamycin plus gentamycin or quinolone
  • Metronidazole plus gentamycin or quinolone

Prophylaxis for Venous Thromboembolism

Risk Classification for Venous Thromboembolism in Patients Undergoing Surgery Without Prophylaxis

Level of Risk	Definition	Successful Prevention Strategies
Low	Surgery lasting less than 30 minutes in patients younger than 40 years with no additional risk factors	No specific prophylaxis; early and "aggressive" mobilization
Moderate	Surgery lasting less than 30 minutes in patients with additional risk factors; surgery lasting less than 30 minutes in patients aged 40-60 years with no additional risk factors; major surgery in patients younger than 40 years with no additional risk factors	Low-dose unfractionated herapin (5,000 units every 12 hours), low molecular weight heparin (5,000 units dalteparin or 40 mg enoxaparin daily), or intermittent pneumatic compression device
High	Surgery lasting less than 30 minutes in patients older than 60 years or with additional risk factors; major surgery in patients older than 40 years or with additional risk factors	Low-dose unfractionated heparin (5,000 units every 8 hours), low molecular weight heparin (5,000 units dalteparin or 40 mg enoxaparin daily), or intermittent pneumatic compression device
Highest	Major surgery in patients older than 60 years plus prior venous thromboembolism, cancer, or molecular hypercoagulable state	Low-dose unfractionated heparin (5,000 units every 8 hours), low molecular weight heparin (5,000 units dalteparin or 40 mg enoxaparin daily), or intermittent pneumatic compression device/graduated compression stockings + low-dose unfractionated heparin or low molecular weight heparin Consider continuing prophylaxis for 2-4 weeks after discharge

Modified from Geerts WH, Pineo GF, Heit JA, Bergquist D, Lassen MR, Colwell CW, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference in Antithrombotic and Thrombolytic Therapy. Chest 2004;126(suppl):338S-400S.

Patient Positioning

• Dorsal lithotomy position
• Angles: At least 60°between thigh and torso, and at least 90°at the knee
• Stirrups supporting the entire leg or “candy cane” stirrups
• Buttock extending slightly over the edge of the table
• Limited Trendelenburg

Surgeon Positioning

• Sit or stand
• Surgeons who sit should consider elevating the chair/stool andusing steps for their own feet so the assistants don't have to bend down

Instruments

• Retractors
• Regular size weighted speculum
• Steiner-Auvard® long weighted speculum
• Modified Deaver®
• Breisky-Navratil® vaginal retractor
• Right angle retractor

• Tenacula for grasping the cervix
  • Lahey®
  • Single tooth
  • Jacobs®
  • Towel clips

Clamps

• Heaney Ballentine®
• Zeppellin®
• Vascular right angle clamp

Other Instruments to Consider

• Retraction
  • Magrina-Bookwalter® vaginal retractor system
• Ligation devices
  • Hemoclips, various sizes
  • Vessel sealing devices
  • Endoloop
• Focused lighting
  • Lighted retractors
  • Headlight
  • Cystoscopy light held with a Babcock® clamp

Procedure: Bladder Drainage

• Decompress bladder initially, and intermittently as needed
• Indwelling catheter optional, consider leaving some urine in bladder for immediate recognition of a cystotomy

Step 1: Incision

• Grasp the cervix with tenacula anteriorly and posteriorly
• Inject vasoconstricting agent circumferentially in cervicovaginal junction
• Begin incision outside the cervical transformation zone, at point of decreased vaginal rugae
• Incision may be made with energy or sharply
• Gently dissect vagina off cervix curcumfertially

Step 2: Posterior Colpotomy

• Palpate uterosacral ligaments and posterior fornix to assess safe point of entry in the posterior fornix.
• Feel for “slippery” peritoneal reflection.
• Lift the posterior fornix with an Allis® clamp.
• Enter at a perpendicular angle. Posterior entry should be with sharp dissection.
• Enter peritoneal cavity posteriorly and verify correct entry visually and/or by palpation of uterine serosa.
• Trendelenburg or Pediatric laparotomy sponges may be used to pack the bowel and omentum.

 

Step 3: Anterior Colpotomy

• Keep scissors parallel to the uterocervical axis.
• Bladder base is attached to the cervix for only about 1-2 cm distally.
• Bladder must be dissected cautiously and protected.
• Feel for “slippery” peritoneal refection.
• Enter peritoneal cavity anteriorly. Verify correct entry visually and/or by palpation of uterine serosa.
• Minimum requirement for ligation of broad ligament uterine vessels.
• Avascular vesicouterine plane is entered.
• Bladder is deflected.
• Only layer before peritoneal entry is the peritoneum.

 

Step 4: Uterosacral and Cardinal Ligaments

• Clamp, transect and suture the uterosacral ligaments in theirentirety.
• Considering tagginguterosacrals for use in culdoplasty.
• Clamp, transect,and ligatecardinal ligaments.
• Note: This step is still possible extraperitoneally when peritoneal entry is not accomplished. Peritoneal entry will be facilitated by better descensus of the uterus.

 

Clamp Placement and Hemostasis

Important Considerations

• Suturing
  • Heaney transfixion technique
• Open clamps widely and slide off cervix or lower uterine corpus before clamping down in an effort to include all vascular collaterals
• Leave no soft tissue between the clamp and the uterocervical tissue
• Consider curved and straight clamps as needed
• After peritoneal entry, all clamp placements must include anterior and posterior edges of the peritoneum to ensure occlusion of all collaterals with ovarian vasculature

Protecting the Ureters

• Traction on the cervix and retraction of the bladder will reduce ureteral injury risk by displacing the ureters away from the clamps
• Ureteral identification through anterior colpotomy possible
• The ureters can be palpated with the index finger at 2 o’clock or at 10 o’clock against a curved Deaver retractor placed outside the peritoneal cavity on the lateral vaginal wall
• Best protection of ureters is safe entry and retraction of bladder after anterior colpotomy

Step 5: Delivery of the Uterus

• Uterus usually descends after cardinal ligaments are transected
• Before any attempt for delivery of the uterus or morcellation, abdomen must be entered both anteriorly and posteriorlyand uterine vessels clamped
• If uterus is small, deliver fundus through anterior or posterior colpotomy
• If uterus is large, consider bivalving, intra-myometrial coring, morcellation

Step 6: Upper Pedicles

• The upper pedicle includes o Cornual end of the fallopian tubes o Round ligaments o Ovarian ligaments
• Upper pedicles are usually clamped together
• In anticipation of too large pedicles, round ligaments can be clamped and ligated separately which may facilitate adnexal removal
• Double ligation of the upper pedicle may be prudent.

Step 7: Hemostasis Check

• Remove uterus only once all ligaments and vessels are ligated and secured
• Evaluate pedicles in a systematicfashion using moist sponge on ring forceps +/-irrigation
• The area between the upper pedicles and the uterosacral ligaments is a commonarea for bleeding

Step 8: Remove Adnexa (if part of preopplan)

• Elective oophorectomy in a women with typicalrisk for ovarian cancer is not recommended before menopause
• Separate clamping of the round ligament may facilitate adnexal removal
• Consider
  • Vessel sealing energy device
  • Endoloop
  • Right angle clamp

Step 9: Closure of Vaginal Cuff

• Incorporate uterosacral ligaments into cuff and take purchases from intervening cul-de-sac peritoneum to support the apex and prevent enterocele formation
• Consider Culdoplasty
  • Vaginal cuff support by attaching the uterosacral and cardinal ligaments to the peritoneal surface
  • Helps obliterate the cul-de-sac
• Incorporate full thickness of cuff including peritoneal edge on posterior side
• Peritoneal closure may help obliterate the culde sac, but is not necessary
• Cuff is usually closed in a transverse fashionor after culdoplasty, cuff can be closed vertically to prevent shortening of the vagina

 

Step 10: Conclusion

• Cystoscopy may not be needed routinely as ureteral injury is least likely with vaginal hysterectomy
  • Vigorous jets reassureureteral patency
• Packing is not necessary
• Indwelling catheter is not necessary unless indicated for a concomitant procedure
• Oral intake may start as tolerated
• Same day discharge is possible and reasonable

Consider Having Standby

• Laparoscopy
  • If unable to complete due to difficulty, adhesions or unexpected pathology
• Hemoclip

Post Operative Orders

Active Management in the Recovery Room Active Management in the Recovery Room

1. Restore normal body temperature
2. Pain management – multi-modal analgesia protocols such as NSAID’s and opioids as needed for breakthrough pain
3. Nausea control to permit immediate oral intake
4. VTE prophylaxis – tailored to the patient’s risk
5. Early ambulation within 1 hour of discharge from the recovery area

Foley management – Can remove once your patient is able to ambulate to the restroom. If concomitant prolapse procedure was performed, you can perform voiding trials as indicated.

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References

1. Zakaria MA, Levy BS. Outpatient vaginal hysterectomy. Obstet Gynecol 2012;120:1355-61.
2. Mann, W. and Stovall, T. (Eds.) Mann/Stovall Gynecologic Surgery. Churchill Livingstone, New York: 1996.

Contributing Authors

• Jeffrey Cornella, MD, Mayo Clinic - Scottsdale, Arizona
• Rajiv Gala, MD, University of Queensland Ochsner Clinical School
• Oz Harmanli, MD, Baystate Medical Center, Tufts University School of Medicine
• Michael Moen, MD, Advocate Lutheran General Hospital
• Mikio Nihira, MD, MPH, The University of Oklahoma College of Medicine 
• Carl Zimmerman, MD, Vanderbilt University School of Medicine

Developed in association with The Society for Gynecologic Surgeons.