Chapter 8.3 Single Port Total Laparoscopic Hysterectomy. Operative Techniques

 Chapter 8.3 Single Port Total Laparoscopic Hysterectomy

GENERAL PRINCIPLES

Definition

■ Single-port laparoscopic (SPL) surgery has also been termed single-incision

laparoscopic surgery (SILS) and laparoendoscopic single-site (LESS)

surgery.

■ SPL hysterectomy is performed through a single incision, most commonly

placed through the umbilicus.

■ The incision can vary in size and location depending on the need for intraabdominal palpation and/or specimen extraction.

■ SPL hysterectomy may apply to either standard laparoscopic or a robotic

single-port approach.

Nonoperative Management

■ Nonoperative management of conditions that may require hysterectomy

(e.g., abnormal uterine bleeding, leiomyoma, endometriosis, chronic pelvic

pain, preinvasive and invasive diseases of the uterus and cervix). Consider:

■ Hormonal therapy (e.g., oral or intramuscular progesterone)

■ Progesterone-releasing intrauterine devices

■ Uterine fibroid embolization

■ Hysteroscopic resection of leiomyoma

■ Endometrial ablation

■ Cervical conization (for cervical dysplasias)

■ Radiation therapy (for cervical and uterine malignancies)

■ Total vaginal hysterectomy (which is less invasive)

■ Total abdominal hysterectomy (for very large uteri that would have to

be morcellated)

IMAGING AND OTHER DIAGNOSTICS

■ Imaging will depend on the indication for hysterectomy. However, pelvic

ultrasonography, saline infusion sonography, or pelvic magnetic resonance

imaging (MRI) will often be performed for patients considering

hysterectomy for abnormal uterine bleeding and leiomyoma.

■ Diagnostic and operative hysteroscopy should be used to rule out

endometrial pathology that can be treated by simple hysteroscopicresection or ablation.

■ Low-grade endometrial cancers do not need pelvic imaging as a group, but

imaging should be individualized based on physical examination and risk of

metastasis. High-grade endometrial cancers should have computed

tomography (CT) of the abdomen and pelvis and either chest radiograph of

CT of the chest.

■ Presumed early-stage cervical cancers should have pelvic MRI to rule out

large tumors or deep cervical wall invasion and a positron emission

tomography (PET) scan should be considered to rule out obvious regional

and distant metastases.

PREOPERATIVE PLANNING

■ Consideration should be made for route of specimen removal (vaginal or

abdominal) and discussed with the patient.

■ Prior surgical history is important to consider in deciding on placement of

the incision.

■ Patients with prior mesh placement in the umbilicus may require

supraumbilical incision.

■ If an ostomy is needed (for endometriosis or locally invasive endometrial

carcinoma), the stoma site can be used as the SPL access site.

SURGICAL MANAGEMENT

■ Proper equipment is essential for the procedure.

■ Visualization: A 30-degree or flexible-tip laparoscope will aid in avoiding

instrument alignment that can cause a loss-of-depth perception.

Alternatively, a 30-degreee bariatric length laparoscope will help get the

assistants and surgeons hands further apart.

■ Access: Multiple commercially available ports are available that allow

two to three instruments to be used along with a camera at one time.

■ Triangulation: Articulating instruments can help with triangulation, but

are not mandatory.

■ External instrument clashing: Use of different length instruments (e.g., a

bariatric grasper and standard length vessel sealing device) can help limit

external instrument clashing.

■ Suturing: Use of the Endo Stitch device (Ethicon Endosurgery, Cincinnati,

OH) allows for easier suturing in SPL.

■ Intracorporeal knot tying techniques can be learned which helps with

this task.

■ Preoperative work-up is the same as for standard and robotic-assisted

laparoscopy.Positioning

■ Patient is placed on the operating table on a beanbag (Fig. 8.3.1A) or a

foam pad (Fig. 8.3.1B) with buttocks extended an inch or two off of the bed.

■ Additional intravenous lines and arterial lines can be placed as needed.

■ Arms should be tucked and padded at the patient’s sides.

■ Arm trays can be used if the arms extend beyond the bed.

■ The regular arm boards can also be used as an alternative if they are also

locked against the operating table.

■ A pad or a blanket should be placed over the patient’s chest and either 3′

cloth tape or a chest strap should be used to maintain position in steep

Trendelenburg (Fig. 8.3.1C).

■ See Figure 8.3.2A–C.

Figure 8.3.1. Patient position. A: Positioning on a foam pad with hands padded and

chest strap in place. B: Positioning using a bean bag with arms tucked, all pressure

points padded and chest strap in place. C: Full Trendelenburg position during

procedure.

Figure 8.3.2. Flexible laparoscope and hand positioning straight instrumentation. A:

The flexible laparoscope allows you to “see around corners.” B: Position of hands

working on the right side of the pelvis. C: “Crossing over” with left hand during left-sided

pelvic dissection.

Approach

■ Typical approach uses the umbilicus as the entry point into the abdomen.

■ Infraumbilical, transumbilical, and Omega incisions are the most

commonly used incisions.

■ Alternative sites can be used if there is history of umbilical surgery or

mesh.

■ In patients with prior abdominoplasty or myocutaneous flap harvesting,

the umbilicus is in its native location on the abdominal wall, but may

have underlying mesh associated with it.

■ An ostomy site can be used for access if ostomy is planned for advanced

cancer or endometriosis.

■ Closure of the vaginal cuff may be performed laparoscopically or

transvaginally.

■ The lowest risk of vaginal cuff dehiscence was noted with transvaginal

closure in some studies1:

■ TLH laparoscopic suturing 0.86%

■ TLH vaginal suturing 0.3%

■ Abdominal hysterectomy 0.21%

■ Vaginal hysterectomy 0.18%Procedures and Techniques (Video 8.3)

Anesthesia and positioning

■ Following general anesthesia, the patient is placed in the low lithotomy position

with arms tucked and padded at the sides and a strap placed across the patient’s

chest.

■ Tolerance of steep Trendelenburg position can be tested prior to prepping the

patient.

Prepping and draping

■ Vagina, perineum, and abdomen are sterilely prepared and the patient draped.

Antibiotics and bladder drainage

■ The appropriate intravenous antibiotics are given and a Foley catheter is inserted

into the bladder.

Manipulation of the uterus

The uterine manipulator is placed (if being used). In endometrial cancer or

hyperplasia consider cauterizing fallopian tubes laparoscopically prior to placement

of manipulator.

Local anesthesia

We use 0.25% or 0.5% bupivacaine injected circumferentially around the umbilicus

for local anesthesia prior to making the incision (Tech Fig. 8.3.1A).

Tech Figure 8.3.1. Abdominal access and port placement with the GelPOINT®. A: An

“umbilical block” using 6 to 10 mL of bupivacaine.

Abdominal incision

■ Typical transumbilical abdominal entry is carried out by grasping the edges of the

umbilicus at 3 and 9 o’clock with Allis clamps (Tech Fig. 8.3.1B), incising the

umbilicus ~1.5 cm in the midline through its base (Tech Fig. 8.3.1C), replacing the

Allis clamps just below the skin at the base of the umbilicus and everting the

umbilical skin outward, incising the fascia with curved Mayo scissors, grasping

the peritoneum with hemostats and entering the peritoneum sharply. The

peritoneum and fascia are the extended with electrocautery.Tech Figure 8.3.1. (continued) B: Grasp the umbilicus at 3 and 9 o’clock with Allis

clamps. C: Incise the skin 1.5 to 2 cm across the edges and trough the base of the

umbilicus, then grasp and transect the fascia, then the peritoneum to 1.5 to 2 cm.

Abdominal access device placement

■ The single-port access device is placed (Tech Fig. 8.3.1D–I).Tech Figure 8.3.1. (continued) D: Place an s-retractor to assist with placement of the

ring of the retractor sleeve. E: Roll outer ring of the sleeve inward to tighten. F: This will

expand the incision and protect the wound. G: Place the instrument shield. H: Place

three to four trocars through the gel starting wide and aiming each to center of gel. I:

Placement of the gel cap onto the ring.

Abdominal survey and pelvic washingsMethodical abdominal and pelvic survey should be carried out to identify any

additional pathology. Pelvic washings should be obtained for cases done for highgrade endometrial cancer and re-staging of ovarian cancer, if indicated.

Pelvic sidewall anatomy and access

■ Pelvic sidewall anatomy can be identified transperitoneally in some patients (Tech

Fig. 8.3.2A). However, in other patients, or if retroperitoneal dissection is planned,

the pelvic sidewall is opened and anatomic structures identified (Tech Fig. 8.3.2B–

E).

Tech Figure 8.3.2. Laparoscopic pelvic anatomy and right pelvic sidewall dissection. A:

Transperitoneal anatomy. B: Open the sidewall peritoneum lateral to the gonadal

vessels. C: Continued opening of sidewall peritoneum. D: Gentle blunt and sharp

dissection to expose vessels and ureter.

Tech Figure 8.3.2. (continued) E: Retroperitoneal anatomy with labels.

Takedown of the adnexal ligaments and bladder flap

■ The infundibulopevic ligaments are skeletonized, cauterized, and transected

(Tech Fig. 8.3.3A). A vessel sealing device is used for each pedicle. The round

ligaments are cauterized and incised (Tech Fig. 8.3.3B). The bladder flap is

created from lateral to medial and then taken down along the anterior vaginal wall

(Tech Fig. 8.3.3C–D).

Tech Figure 8.3.3. Left sidewall and bladder flap dissection and control of uterine

vessels. A: Left infundibulopelvic ligament is cauterized and transected. B: Left round

ligament transection. C: Start of left bladder flap dissection. D: Bladder flap dissection

continued medially at level of colpotomy cup.

Uterine vessels and cardinal ligaments

■ Uterine arteries are skeletonized, then taken down with the vessel sealing device.

■ We place a seal for back bleeding, then take the uterine artery with another

seal inferior to this (Tech Fig. 8.3.3E,F).

■ Cardinal ligaments are taken down in successive bites, each inside of the last

until the vessels are taken down below the cervicovaginal junction or lateral to the

colpotomy ring (Tech Fig. 8.3.3G–I).

Tech Figure 8.3.3. (continued) E: Medial and cephalad left lower uterine segment

transected to control back bleeding. F: Dessicate and transect right uterine artery. G:

Dessication of cardinal ligaments and vessels being taken down below colpotomy ring

(arrow). H: Dessication and transect of right uterine artery. I: Back bleeding bite along

right lower uterine segment with transection of right cardinal ligament.Colpotomy is performed

■ Circumferential colpotomy is performed.

■ See Tech Fig. 8.3.4A–D.

■ This can be performed with monopolar energy, ultrasonic shears, or a

laparoscopic scalpel. I prefer the monopolar hook, typically starting with the

posterior portion of the colpotomy first (Tech Fig. 8.3.4A,B) and then moving

circumferentially around to the anterior colpotomy (Tech Fig. 8.3.4C,D).

Specimen extraction

■ Most uteri can be removed transvaginally.

■ If the uterus is too large for vaginal extraction, it should be placed in a specimen

bag. The specimen can either be morcellated within the bag transvaginally or can

be brought out through the abdominal incision. The specimen can then be

manually morcellated and/or the incision extended enough to remove the

specimen intact within the specimen bag.

Cuff closure

■ See Tech Fig. 8.3.4.

■ Transvaginal—we currently use this technique due to reports suggesting that

there is a lower risk of vaginal cuff dehiscence when compared with laparoscopic

closure. Typically, five to six figure-of-eight sutures of 0-polyglycolic acid (or

another absorbable) suture are used.

■ Laparoscopic—closure simplest utilizing and Endo Stitch device with either a

running 2-0 barbed suture or interrupted 0-polyglycolic acid suture can be used

with either extracorporeal or intracorporeal knot tying techniques.

Vaginal irrigation and cystoscopy

■ The vagina is irrigated with normal saline and inspected for bleeding or tears.

Cystoscopy can be utilized to confirm ureteral patency. We typically inject 25 mg

of fluorescein dye intravenously then observe for strong ureteral jets.

Laparoscopic irrigation, inspection and closure

■ The pelvis is irrigated with saline, lactated ringers, or sterile water (Tech Fig.

8.3.4E,F).

■ All sites of dissection are inspected for hemostasis.

■ Instruments and access port are removed and the pneumoperitoneum is

expressed.

■ We close the fascia with interrupted 0-polyglycolic acid suture.

■ We use delayed absorbable suture for cases where the incision was extended

or when chemotherapy or radiation will be given.■ We use permanent suture if there was previous or current umbilical hernia.

Tech Figure 8.3.4. Colpotomy and closure. A: Start posterior colpotomy with monopolar

hook. B: Continued circumferential colpotomy to right side. C: Left anterolateral

colpotomy. D: Completion of anterior colpotomy on colpotomy ring. E: After transvaginal

cuff closure, pelvis is copiously irrigated and hemostasis ensured. F: Final cuff

appearance and pelvic inspection.

Table 8.3.1 Selected Reports of Single-Port Total Laparoscopic Hysterectomy—

Outcomes and Complications

PEARLS AND PITFALLS

External instrument clashing

Use flexible instruments.

Turn the handle of the grasper upside down to gain additional distance between

hands.

Use a bariatric length 30-degree or flexible-tip laparoscope.

Use bariatric-length grasper can be used with standard length vessel sealing

devices.

Difficulty seeing around the uterus

To see the left side of the uterus, place the tip of the flexible camera near the left

sidewall and flex the tip back to the right. To see the right side of the uterus, place

the camera over the fundus and get a “birds-eye” view of the dissection.

Difficulty suturing

Use of the Endo Stitch device will help get around the absence of angulation to the

vagina.

Flexible graspers or flexible Endo Stitch device can also help to overcome external

instrument clashing during suturing.

Difficulty progressing safely with surgery

Add an additional trocar if necessary.

Practice in the laboratory with a box trainer starting with ports farther apart, gradually

moving them closer together until the distance is similar to single-port device.

POSTOPERATIVE CARE

■ Postoperative care is similar to standard laparoscopic hysterectomy with

Foley to gravity drainage at least 6 to 8 hours postop. Aggressive use of

nonnarcotic analgesics such as acetaminophen and ketorolac can minimize

opioid requirements. Activity and diet are advanced as tolerated in the

immediate postoperative period. The majority of patients can be discharged

home on postoperative day 1, even with incisions that were extended for

specimen extraction or hand-assist procedures.

■ Typical recovery time is 4 weeks. The major complaint at the postoperative

visit is persistent fatigue.

■ We instruct patients to avoid: driving for 2 weeks, lifting more than 10

pounds for 4 weeks, and placing anything in the vagina for 6 weeks.

OUTCOMES

■ Data comparing single-port total laparoscopic or single-port laparoscopicassisted vaginal hysterectomy have been reported as case reports to as

many as 274 hysterectomies in one series.2 SPL has been shown to be

similar to standard multi-port laparoscopic cohort in terms of intraoperative

and postoperative complications, length of hospital stay, estimated blood

loss, and blood transfusion rates (Table 8.3.1). Operative times for the

single-port approach for hysterectomy appears to be approximately 8

minutes longer in one meta-analysis.3 Although a decrease in postoperative

pain has been one of the purported benefits of single-port laparoscopic

surgery, data have been mixed in randomized controlled trials.4–7

COMPLICATIONS

■ The most common complications are similar to that of laparoscopic

hysterectomy. Urinary tract infection and port site cellulitis are the most

common infectious complications that we have seen. Injury to visceral

organs is similar to that of standard laparoscopic hysterectomy. The

complication that is likely to have a higher risk in single-port laparoscopic

hysterectomy is umbilical hernia which occurs in 0% to 2.4% of patients.8

We have minimized this complication with attention to closure technique

using fascial closure alone with interrupted absorbable figure-of-eight

sutures for low-risk women and nonabsorbable sutures for patients at

higher risk for hernia (prior umbilical hernia, obesity, steroid use, and need

for chemotherapy or radiation).

Key References

1. Uccella S, Ceccaroni M, Cromi A, et al. Vaginal cuff dehiscence in a series of 12,398

hysterectomies: effect of different types of colpotomy and vaginal closure. Obstet

Gynecol. 2012;120(3):516–523.

2. Park JY, Kim TJ, Kang HJ, et al. Laparoendoscopic single site (LESS) surgery in

benign gynecology: perioperative and late complications of 515 cases. Eur J Obstet

Gynecol Reprod Biol. 2013;167(2):215–218.

3. Murji A, Patel VI, Leyland N, Choi M. Single-incision laparoscopy in gynecologic

surgery: a systematic review and meta-analysis. Obstet Gynecol. 2013;121(4):819–

828.

4. Yim GW, Jung YW, Paek J, et al. Transumbilical single-port access versus

conventional total laparoscopic hysterectomy: surgical outcomes. Am J Obstet

Gynecol. 2010;203:26.e1–e6.

5. Jung YW, Lee M, Yim GW, et al. A randomized prospective study of single-port and

four-port approaches for hysterectomy in terms of postoperative pain. Surg Endosc.

2011;25(8):2462–2469.

6. Eom JM, Choi JS, Choi WJ, Kim YH, Lee JH. Does single-port laparoscopic surgeryreduce postoperative pain in women with benign gynecologic disease? J

Laparoendosc Adv Surg Tech A. 2013;23(12):999–1005.

7. Fanfani F, Fagotti A, Rossitto C, et al. Laparoscopic, minilaparoscopic and single-port

hysterectomy: perioperative outcomes. Surg Endosc. 2012;26(12):3592–3596.

8. Gunderson CC, Knight J, Ybanez-Morano J, et al. The risk of umbilical hernia and

other complications with laparoendoscopic single-site surgery. J Minim Invasive

Gynecol. 2012;19(1):40–45.Chapter 8.4 Robotically Assisted Hysterectomy

Habibeh Ladan Gitiforooz

GENERAL PRINCIPLES

Definition

■ Robotic hysterectomy is a highly effective, minimally invasive approach to

removing the uterus in patients with a variety of uterine conditions.

Robotic approach can be very effective for morbidly obese patients and for

large fibroids weighing more than 500 g. It can also be a very effective tool

for patients with multiple pelvic surgeries and severe adhesions.

Differential Diagnosis

■ Sarcoma, leiomyosarcoma, large fibroid uterus, fibroma, endometrial

stromal sarcoma, adenomyosis, and endometrial carcinoma.

Anatomic Considerations

■ A large, wide, uterus can be difficult to manipulate and this can limit

visibility.

■ The blood supply to a wide cervix can be very close to the ureters.

■ Lifting the uterus to incise the uterosacral ligament posteriorly can be

challenging.

■ The ureters can be closer to the uterosacral ligament than usual.

Nonoperative Management

■ Conservative, nonoperative management can be designed depending on the

patient’s symptoms.Figure 8.4.1. MRI 3 large midline fibroids.

■ Heavy menstrual bleeding, bulk and pressure symptoms, and mild

hydronephrosis may respond well to uterine artery embolization.

■ Heavy bleeding may respond to oral contraceptive pills, progestins, or an

IUD.

IMAGING AND OTHER DIAGNOSTICS

■ See Figures 8.4.1 to 8.4.6.

PREOPERATIVE PLANNING

■ Pap and HPV testing must be up-to-date in all cases.

■ An up-to-date, in office, endometrial biopsy is a very important part of

evaluation. Some studies suggest that more than 50% of sarcoma can be

diagnosed by an office endometrial biopsy.

■ Early evaluation of hemoglobin and bleeding.

■ Gonadotropin releasing hormone and IV or oral iron therapy can prevent

unnecessary blood transfusions.

■ An examination under anesthesia is performed to assess the height and

width of the uterus to plan the position of the midline port (Fig. 8.4.7).

■ Cystoscopy is indicated in all cases. Administer intraoperative fluorescein

or use dextrose 10% as the distending hysteroscopic fluid to evaluate

ureteral integrity.

■ Oral/nasal gastric tubes are important to avoid injury to a distended

stomach.Figure 8.4.2. MRI-2 large midline mass of fibroids above umbilicus.

Figure 8.4.3. MRI 1 bilobed fibroid.

SURGICAL MANAGEMENT

■ Indication of using the robotic approach may include:

■ patients with endometriosis and previous surgery with adhesions (Fig.

8.4.8),

■ other pelvic surgeries such as history of colon resection or multiple

cesarean sections (see Fig. 8.4.8),Figure 8.4.4. 3D ultrasound picture of fibroid uterus.

Figure 8.4.5. Degenerative fibroids.

■ patients with a history of failed myomectomy and uterine artery

embolization.

Positioning■ Proper chest wrap is important to prevent obese patients from moving up

the operating table in Trendelenburg position. Keeping in mind ventilation,

IV lines, and the blood pressure cuff and pulse oximeter (Fig. 8.4.9).

■ Perineal access to the uterus is an important part of operative positioning

for manipulation and morcellation (Fig. 8.4.10).

Figure 8.4.6. SIS picture showing 4 cm fibroid. The majority of the fibroid is located

within the muscularis and is not approachable through the endometrium.

Figure 8.4.7. EUA is performed to assess and plan the position of parts.Figure 8.4.8. This patient had four cesarean sections. Note the bladder and uterine

adhesions to the anterior abdominal wall.

Figure 8.4.9. Wrap the chest to the operating table to prevent patients from sliding

when placed in Trendelenburg position.Figure 8.4.10. Perineal access to retrieve large specimens and move the uterine

manipulator freely.Procedures and Techniques (Video 8.4)

Port placement

■ The first step is usually the midline 12-mm trocar placement. This trocar has to

be longer if the patient is morbidly obese. This will allow for easy docking of the

camera port and free movement of the camera arm (Tech Fig. 8.4.1). It has to be

placed supraumbilically and preferably 10 cm away from the fundus of the uterus

(Tech Fig. 8.4.2). To reduce the risk of stomach injuries with high trocar placement,

it is important to ensure an empty and collapsed stomach. If the patient has a

midline, upper abdominal incision or abdominal wall mesh with hernia repair, the

left upper quadrant can be the safest entry to the peritoneal cavity (Tech Figs. 8.4.3

and 8.4.4).

■ Place two 8-mm robotic trocars after insufflation of the abdomen and when the

patient is in the steep Trendelenburg position.

■ Care should be taken to keep enough space from the midline trocar and the right

sided 8-mm trocar to give free range of movement to the right-side arm. This

setup will avoid collision of the robotic arms (Tech Fig. 8.4.5). The right lower

quadrant 12-mm port position is important. The movement of a heavy uterus from

side to side and anterior to posterior can be helped with a tenaculum from this

port. The tenaculum is more useful for a large uterus than the uterine manipulator.

■ Tunneling of trocars in obese patients can cause collision of the robotic arms.Tech Figure 8.4.1. Use a long trocar in an obese patient. This allows for easy docking

of the camera port.Tech Figure 8.4.2. A supraumbilical 12 mm trocar should be placed 10 cm away from

the uterine fundus if possible.

Tech Figure 8.4.3. In an obese patient with a history of a midline upper abdominal

incision a left upper quadrant entry may be the safest entry.Tech Figure 8.4.4. Abdominal wall mesh with hernia repair in an obese patient.

Tech Figure 8.4.5. Keep enough space between the midline trocar and the right sidedtrocar to avoid arm collision.

Vessel sealer

■ It is very important to keep hemostasis well controlled, especially with a large

uterus.

■ Seal the uterine vessels of both the right and left sides before incising as there

can be a great deal of back bleeding from the uterus (Tech Figs. 8.4.6 and

8.4.7).

■ Stay as close as possible to the uterus without digging into it (Tech Fig. 8.4.8).

■ Large blood vessels between the fallopian tube, ovarian ligament, and round

ligament may exist. Seal them patiently (Tech Fig. 8.4.9).

Tech Figure 8.4.6. Seal the vessels on both sides before incising to prevent back

bleeding.Tech Figure 8.4.7. Stay as close to uterus without digging into it.

Tech Figure 8.4.8. Incise the parametria without entering the myometrium to decrease

bleeding.Tech Figure 8.4.9. Coagulate large blood vessels between the ovarian and round

ligaments.

Manipulation of the uterus

■ When using the uterine manipulator try to stay on one side. Go all the way down

to the vaginal fornix and seal all the blood supply before changing to the opposite

side. This will help save time and prevent the manipulator from breaking.

■ The assistant can move the uterus from side to side with the help of a tenaculum.

It is better to seal the vessels before using the tenaculum to prevent extra

bleeding.

Separation of cervical vaginal junction

■ Increase the abdominal CO2 pressure and CO2 flow; this will help keep the CO2

pressure up during colpotomy. This step must be performed quickly in obese

patients as ventilation may be a problem.

■ In the case of a large uterus, it is easier to perform colpotomy on the posterior

aspect first.

■ Lifting a heavy uterus will be harder after an incision is made on the

cervicovaginal junction.

Evacuation of the specimen

■ Using a Lahey clamp, pull the specimen into the vagina. Then protect the vaginal

wall with a weighted speculum posteriorly. Use side retractors and a large blade

to excise large fragments (Tech Figs. 8.4.10 and 8.4.11). The specimen can be

placed in a large bag laparoscopically. Then, deliver the neck of the bag from the

vagina and excise the specimen in the bag. This step will add to operative time.Tech Figure 8.4.10. Using a Lahey clamp, deliver the specimen into the vagina and

use a large blade to excise the specimen.Tech Figure 8.4.11. Large pieces can be excised with large blade.

Port closure

■ Fascial closure is indicated for a port site of 10 mm or larger to prevent hernia

formation.

■ Inject local anesthetic to all port sites at the end of surgery. This helps with

postoperative pain management.Pearls and Pitfalls

Use a long, midline trocar in obese patients.

Short trocars may be dislodged during the surgery and cause air leaks, poor visibility,

and tissue trauma.

Right sided robotic port placement is very important. Improper site selection will lead

to limited right sided instrument utility and robotic camera arm collision.

Tunneling of the trocars in obese patients can be prevented by proper 90 degree

port placement.

Unnecessary movement of the uterine manipulator should be avoided.

The uterine manipulator can break or become loose. This limits the ability to

complete a minimally invasive surgery.

Using interrupted sutures for vaginal closure will help drain any bleeding and prevent

blood collection.

POSTOPERATIVE CARE

■ The majority of robotic hysterectomies may be performed as outpatient

surgery.

■ Postoperative analgesia may include narcotic pain relief.

■ Scopolamine patch for 24 hours to prevent postoperative nausea.

OUTCOMES

■ The potential and risk of occult malignancy in reproductive-age women is

extremely low.

Figure 8.4.11. Vaginal cuff closure with interrupted figure of eight sutures can prevent

cuff dehiscence.■ Preoperative endometrial biopsy can identify the malignancy in two-thirds

of sarcoma.

■ Vaginal cuff dehiscence can be prevented by proper technique (Fig. 8.4.11).

COMPLICATIONS

■ Ureter injury may be recognized with routine cystoscopy.

■ Thermal spread ureteral injury can take up to two weeks to become

apparent.

■ Thermal bowel injury can happen, especially with a larger uterus, as part of

the operative field is much higher and closer to the bowel.

KEY READINGS

Gallo T, Kashani S, Patel DA, Elsawhi K, Silasi DA, Azodi M. Robotic-assisted

laparoscopic hysterectomy: outcomes in obese and morbidly obese patients. JSLS.

2012;16:421–427.

Goodrich SK, Knight J. Uterine sarcoma: ability of preoperative evaluation to identify

malignancy and correct histology. Gynecol Oncol. 2015;137(Suppl 1):97–98.

Payne TN, Dauterive FR. A comparison of total laparoscopic hysterectomy to robotically

assisted hysterectomy: surgical outcomes in a community practice. J Minim Invasive

Gynecol. 2008;15(3):286–291.

Ricci S, Angarita A, Cholakian D, et al. Preoperative patient stratification results in low

rates of occult uterine malignancy in women undergoing uterine surgery and

morcellation. Gynecol Oncol. 2015;137(Suppl 1):

11–12.Chapter 8.5 Vaginal Hysterectomy

Cecile A. Unger

GENERAL PRINCIPLES

Definition

■ Total vaginal hysterectomy is an operation that can be performed when

removal of the uterus is indicated in cases of either benign disease or

carcinoma in situ of the cervix.

■ Vaginal hysterectomy is most often performed in cases of pelvic pain,

abnormal uterine bleeding, or uterovaginal prolapse.

PREOPERATIVE PLANNING

■ The preoperative health assessment for any hysterectomy includes a

complete history and physical examination. There is no routinely

recommended imaging, cardiopulmonary testing, or laboratory tests. This

type of testing is ordered for patients based on their medical comorbidities.

Many hospitals have their own requirements for preoperative assessments,

which are often based on the patient’s age in combination with their

medical comorbidities and frailty.

■ A normal Papanicolaou (Pap) smear should be documented before

hysterectomy. In patients who are at risk for endometrial cancer,

endometrial sampling should also be obtained. If cancer or an adnexal mass

or cyst is suspected, a transvaginal ultrasound is necessary.

■ Careful review of a patient’s medication list is important before performing

a hysterectomy. Because of the increased risk of bleeding due their

antiplatelet effects, all nonsteroidal anti-inflammatory drugs and aspirin

should be stopped at least 7 days before surgery. Multivitamins containing

vitamin E should also be discontinued 10 to 14 days before surgery.

Because of the increased risk of venous thromboembolic events, oral

contraceptive pills and hormone replacement therapies should ideally be

stopped 4 to 6 weeks before surgery. This may be challenging in women

who are on hormone therapies for abnormal bleeding, but cessation should

be considered.

■ Before proceeding with hysterectomy, assessment of a patient’s risk for

intra- or postoperative anemia and need for autologous blood products is

necessary. This is especially important for patients with abnormal uterine

bleeding and baseline anemia. These patients should also be evaluated for

preoperative iron supplementation or transfusion.■ Informed consent should be obtained in the office. Patients should be well

informed of the risks and benefits of the procedure, as well as the

alternatives to hysterectomy. Most importantly, confirmation of completion

of childbearing must be done.

■ Prior to surgery, a pregnancy test is necessary in all patients of

reproductive age.

■ Hysterectomy is a clean-contaminated procedure, and prophylactic

intravenous antibiotics should be ordered, to be administered within 60

minutes of incision time. First- or second-generation cephalosporins are

first-line antibiotics.

■ All patients undergoing hysterectomy are considered “moderate risk” and

require venous thromboembolism prophylaxis. In most patients, either lowdose unfractionated heparin, low–molecular-weight heparin, or intermittent

pneumatic compression devices are recommended. In higher-risk patients,

dual prophylaxis, and in some cases, postoperative prophylaxis may be

necessary.

■ Route of hysterectomy is dependent on the following factors: vaginal

caliber and accessibility to the uterus, uterine size and shape, uterine

mobility, cancer and extrauterine disease, surgeon skillset, available

support facilities, and surgeon and patient preference.

■ A thorough bimanual examination is necessary prior to deciding on route of

hysterectomy. Care should be taken to note the following factors to help

determine the degree of difficulty that will be present in performing the

procedure: the size, mobility, and descent of the uterus; the size and shape

of the bony pelvis (a pubic arch of less than 90 degrees may preclude a

vaginal hysterectomy whereas a wide angle will facilitate the approach);

the caliber of the introitus and the vagina.

SURGICAL MANAGEMENT

■ According to the American College of Obstetricians and Gynecologists

(ACOG),1 vaginal hysterectomy is the safest and most cost-effective method

to remove the uterus for noncancerous reasons. In general, based on current

data, vaginal hysterectomy is associated with better outcomes and fewer

complications.

■ There are few absolute contraindications to the vaginal approach for

hysterectomy; however, there are factors that generally preclude this

approach, including (1) the suspicion of malignancy; (2) the presence of

known extrauterine disease or adnexal disease; (3) a narrow pubic arch

(<90 degrees); (4) a narrow vagina (narrower than 2 fingerbreadths,

especially at the apex); and (5) a fixed, immobile uterus. In the absence of

one of these factors, vaginal hysterectomy should be the approach of choicewhenever feasible given its well-documented advantages.

■ There are some conditions and patient-specific characteristics that can make

vaginal hysterectomy technically challenging. These factors are not

contraindications to vaginal hysterectomy, but should be identified

preoperatively and anticipated at the time of surgery.

■ These conditions include the enlarged or undescended uterus, previous

cesarean sections, and uterine prolapse. These factors should be taken into

consideration during surgical planning, and while they may make the

procedure more challenging, can be overcome with a few helpful pearls

that we will review in this chapter.

Positioning

■ Patients are positioned in dorsal lithotomy position using either candy cane

stirrups (Fig. 8.5.1), or yellow fin stirrups (Fig. 8.5.2). Patients should be

positioned so that the edge of the buttocks is at the edge of the surgical

table. Care is taken not to hyperflex or extend the legs in order to avoid

postoperative neuropathies. Foam can be used to pad the bony prominences

of the limbs, and also to fill dead space in the stirrups. The arms can be left

out at the sides, and are positioned in anatomic position with care taken to

not hyperextend the limbs to avoid brachial plexus injuries.Figure 8.5.1. Dorsal lithotomy positioning using candy cane stirrups.

Figure 8.5.2. Dorsal lithotomy positioning using yellowfin stirrups.

Approach

■ The procedure is performed transvaginally.Procedures and Techniques (Video 8.5)

Preparation

■ Once the patient is positioned, the vulva and vagina are fully prepped with

betadine or a surgical soap solution.

■ The patient is draped in a sterile fashion.

■ A Foley catheter is placed and can be left to continuous drainage for the case, or

it can be clamped off and intermittently emptied throughout the case.

Tenaculum placement and injection

■ A short-weighted retractor is placed in the vagina, exposing the cervix.

■ A small right-angle retractor is used to elevate the anterior vaginal wall and a

second right-angle retractor displaces one lateral vaginal wall and exposes the

cervix.

■ Two single-tooth tenacula are placed in a vertical fashion at the 3 and 9 o’clock

positions of the cervix through the full thickness of the stroma. Alternatively, two

single-tooth tenacula such as a Jacobs tenaculum can be applied to the midanterior and posterior lips of the cervix (Tech Fig. 8.5.1).

■ Gentle traction is applied to the tenacula and approximately 10 cc of local

anesthetic with a dilute vasoconstricting agent (we recommend using 0.5%

lidocaine with 1:200,000 units epinephrine) is injected circumferentially beneath

the vaginal epithelium at its junction with the cervix. This creates a

hydrodissection plane for the colpotomy and helps with hemostasis as well.Tech Figure 8.5.1. Sagittal view of the pelvic organs. Positioning of the retractors at 12

and 6 o’clock and placement of two single-tooth tenacula on the cervix at the start of a

vaginal hysterectomy. Reprinted with permission, Cleveland Clinic Center for Medical

Art & Photography © 2015, all rights reserved.

Colpotomy and entry into the posterior cul-de-sac

■ A scalpel or Bovie cautery can be used to create the colpotomy. A

circumferential incision is made in the vaginal epithelium until the cervical stroma

in reached (Tech Figs. 8.5.2 and 8.5.3). The incision should stay above the

pubovesical cervical fascia anteriorly and the perirectal fascia posteriorly. Rightangle retractors can be placed at the 3 and 9 o’clock positions to help protect the

vaginal sidewalls while the incision is made. Curved Mayo scissors are then used

to dissect the vagina off of the cervical stroma anteriorly and posteriorly. Traction

on the cervix should be maintained during this dissection to avoid injury to the

surrounding viscera and to help identify the correct dissection planes.

■ The tenacula are then pulled upwards toward the pubic bone until the posterior

peritoneum of the cul-de-sac is identified. The peritoneum is grasped and tented

away from the cervix and then entered sharply with the curved Mayo scissors

(Tech Figs. 8.5.4 and 8.5.5). Confirmation of entry is made by visualization

and/or palpation.

■ A finger is placed in the cul-de-sac, and the short-weight retractor is removed

and replaced with a long-billed weighted retractor (Tech Fig. 8.5.6).Tech Figure 8.5.2. Cervical incision; initial colpotomy. Reprinted with permission,

Cleveland Clinic Center for Medical Art & Photography © 2015, all rights reserved.

Tech Figure 8.5.3. Cervical incision; initial colpotomy.Tech Figure 8.5.4. Entry into the posterior cul-de-sac. Reprinted with permission,

Cleveland Clinic Center for Medical Art & Photography © 2015, all rights reserved.

Tech Figure 8.5.5. Entry into the posterior cul-de-sac.Tech Figure 8.5.6. Placement of a long weighted retractor into the posterior cul-de-sac.

Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography ©

2015, all rights reserved.

Suture ligation of the uterosacral ligaments

■ Many providers enter the anterior cul-de-sac before ligating the uterosacral

pedicles. We believe that suture ligation of the uterosacral ligaments prior to

anterior entry facilitates descent of the uterine specimen, making it easier to

identify the vesicouterine reflection, and decreasing the risk of injury to the

bladder at the time of anterior entry.

■ The cervix is placed on upward and lateral retraction using the tenacula. A curved

Heaney clamp is placed in the posterior cul-de-sac with one blade underneath

the uterosacral ligament and the opposite blade over the uterosacral ligament

(Tech Fig. 8.5.7). In order to prevent possible ureteral injury, it is important to place

the clamp along the uterine cervix so that some tissue of the cervix is included in

this clamp.

■ A curved Mayo scissor is used to transect the pedicle and a No. 0 polyglactin

suture is used to tie off of the pedicle before releasing the clamp. A Heaneyfixation stitch of No. 0 polyglactin is used for all pedicles (Tech Figs. 8.5.8 and

8.5.9). The uterosacral ligaments are suture ligated bilaterally using this method.

■ If there is oozing of blood at the posterior vaginal cuff, the posterior peritoneum

can be reefed to the vaginal epithelium between the uterosacral pedicles using a

No. 2-0 or 0 polyglactin suture in a running locked fashion.

Tech Figure 8.5.7. Clamping of the right uterosacral ligament.Tech Figure 8.5.8. Clamping, transection, and suture ligation of the uterosacral

ligament. Reprinted with permission, Cleveland Clinic Center for Medical Art &

Photography © 2015, all rights reserved.

Tech Figure 8.5.9. Suture ligation of the right uterosacral ligament.

Entry into the anterior cul-de-sac

■ Downward traction is applied to the cervix and the anterior vaginal epithelium and

underlying bladder are dissected off of the cervix and lower uterine segment.

■ A right-angle retractor is placed under the vaginal epithelium and is used to

elevate the bladder to help facilitate dissection (Tech Fig. 8.5.10).

■ Anterior dissection is carried all the way to the vesicouterine peritoneal reflection.

This is considered by many to be one of the most challenging steps of the

vaginal hysterectomy. However, if dissection is not carried up to the vesicouterine

fold, entry into the anterior cul-de-sac will be very challenging, and there is an

increased risk of injury to the bladder. The right-angle retractor can then be

placed underneath the bladder to better visualize the vesicouterine fold, which

appears like a thin white transverse line across the lower uterine segment.

■ With downward traction on the cervix, the vesicouterine fold is tented upwards

with pickup forceps and it is entered using the curved Mayo scissors (Tech Figs.

8.5.11 and 8.5.12).

■ A finger is immediately placed in the incised hole and explored to ensure that

there is no injury to the bladder. The bladder can be identified by palpating the

bulb of the Foley catheter. A right-angle retractor is then placed beneath the

finger and passed into the anterior cul-de-sac (Tech Figs. 8.5.13 and 8.5.14).Tech Figure 8.5.10. Dissection of the bladder off of the anterior cervix. Reprinted with

permission, Cleveland Clinic Center for Medical Art & Photography © 2015, all rights

reserved.Tech Figure 8.5.11. Entry into the anterior cul-de-sac. Reprinted with permission,

Cleveland Clinic Center for Medical Art & Photography © 2015, all rights reserved.

Tech Figure 8.5.12. Entry into the anterior cul-de-sac.Tech Figure 8.5.13. Placement of a right-angle retractor into the anterior cul-de-sac.

Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography ©

2015, all rights reserved.

Tech Figure 8.5.14. Placement of a right-angle retractor into the anterior cul-de-sac.

Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography ©2015, all rights reserved.

Suture ligation of the cardinal ligaments and uterine vessels

■ Upward and lateral traction is applied to the cervix and staying as close to the

cervix as possible, a Heaney clamp is applied to the cardinal ligament (Tech Fig.

8.5.15), which is transected with the curved Mayo scissor and then suture ligated

(Tech Fig. 8.5.16). This procedure is performed bilaterally.

■ The remaining portion of the broad ligament attached to the lower uterine

segment containing the uterine artery is clamped adjacent to the cervix and

suture ligated bilaterally. A Heaney fixation suture can be performed on this

pedicle, but caution should be taken to avoid placing the needle directly through

the vascular portion of the pedicle, which can create a hematoma. In addition,

great care should be taken to hug the cervix and lower uterine segment to avoid

lateral placement of the clamps and possible injury to the ureters.

Tech Figure 8.5.15. Clamping of the left cardinal ligament.Tech Figure 8.5.16. Clamping, transection, and suture ligation of the cardinal ligament.

Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography ©

2015, all rights reserved.

Suture ligation of the utero-ovarian pedicles

■ Once all of the pedicles are suture ligated, and the cornua of the uterus are

reached, the cervix is retracted upwards and tenacula or towel clamps are

sequentially placed in a “hand over hand” fashion on the uterine segment until the

fundus of the uterus can be delivered posteriorly (Tech Figs. 8.5.17 and 8.5.18).

■ Caution should be taken in applying too much traction at this stage of the

procedure, as the remaining utero-ovarian pedicles can easily be avulsed.

■ A finger is placed under the utero-ovarian pedicle and round ligament and a

Heaney clamp is then passed along the path of the finger and used to clamp the

pedicle. A second Heaney clamp is then placed alongside the first, and the

pedicle is double suture ligated (Tech Figs. 8.5.19 to 8.5.21).

■ The uterus and cervix are then removed from the peritoneal cavity and can be

passed off the surgical field.Tech Figure 8.5.17. Fundus of the uterus delivered posteriorly. Reprinted with

permission, Cleveland Clinic Center for Medical Art & Photography © 2015, all rights

reserved.Tech Figure 8.5.18. Fundus of the uterus delivered posteriorly.

Tech Figure 8.5.19. Right utero-ovarian ligament clamped.

Tech Figure 8.5.20. Right utero-ovarian ligament suture ligated.Tech Figure 8.5.21. Clamping, transection, and suture ligation of the utero-ovarian

ligaments. Reprinted with permission, Cleveland Clinic Center for Medical Art &

Photography © 2015, all rights reserved.

Salpingo-oophorectomy

■ Removal of the fallopian tubes and ovaries is not always performed at the time of

vaginal hysterectomy, but is sometimes indicated. There are two techniques

commonly used to perform this procedure. Both techniques can be done once

the uterus has been removed.

■ First, the small bowel is packed with a tagged moist laparotomy sponge. A

sponge stick can also be used, but can sometimes get in the way of the

operative field. Vaginal retractors are placed at 12 and 6 o’clock to facilitate

visualization. A third retractor is placed at either 3 or 9 o’clock, depending on

which ovary is the target, in order to retract the contralateral ovary and tube out of

the way.

■ The first technique involves placing downward traction on the fallopian tube and

ovary using an Allis or Babcock clamp in order to identify the infundibulopelvic

ligament. Once this is done, one or two Heaney clamps are passed around the

ovarian blood supply and the pedicle is transected. This pedicle is then ligated

using a free tie followed by a suture. In some cases, a vessel sealing device

such as the Ligasure (Valleylab, Boulder, CO) can be used to ligate and seal thepedicle.

■ A second technique can be used to isolate the ovarian blood supply by

dissecting between the round ligament and the infundibulopelvic ligament. This

technique can be done once the uterus is removed, but it can also be done with

one side of the uterus separated from the adnexa, and the other remaining

attached via the utero-ovarian ligament, which is what we will describe in this

section. The technique is similar to what is usually done abdominally to perform

an oophorectomy, but requires a good grasp of anatomy when it is performed

transvaginally. The round ligament is clamped, cut, and suture ligated, and the

pedicle is retracted laterally. The broad ligament and mesosalpinx are then

sharply dissected laterally and cephalad until the infundibulopelvic ligament is

isolated and the ovarian vessels can be clamped close to the ovary using a

Heaney or long Kelly clamp. These are cut and suture ligated. Of note, the Bovie

cautery can be used to open the round ligament and perform the dissection of

the mesosalpinx. This is sometimes helpful in maintaining hemostasis as these

tissues are often very delicate and friable. With this in mind, gentle handling of

the tissues is very important. Once the infundibulopelvic ligament pedicle is

ligated, the specimen (containing the uterus and cervix and one of the fallopian

tubes and ovaries) can be passed off. With exposure and isolation of the

contralateral round ligament, the contralateral ovary is removed in the same

manner.

Closure of the vaginal cuff

■ The vaginal cuff is sutured with either a running locked stitch or with figure-ofeight stitches using No. 0 or 2-0 polyglactin suture. To maintain vaginal length, a

transverse closure is usually preferable (Tech Fig. 8.5.22).Tech Figure 8.5.22. Transverse closure of the vaginal cuff. Reprinted with permission,

Cleveland Clinic Center for Medical Art & Photography © 2015, all rights reserved.Pearls and Pitfalls2,3

Obese patients

Position the patient properly to maximize access. The buttocks should be positioned

well beyond the edge of the operating table; this brings the operating field closer to

the surgeon and makes it easier to use long-handled retractors posteriorly.

Adequate surgical assistance is important; if possible, use two surgical assistants,

one on each side. Candy cane stirrups should be used to allow better access for the

assistants.

Minimize Trendelenburg position as it will cause the patient to slide up the bed and

make posterior entry more difficult.

Enlarged uterus (fibroid uterus)

The hysterectomy is performed in the standard fashion. Once the uterine pedicles

are ligated, one of the following techniques can be used to remove the specimen

and gain access to the remaining pedicles: bivalving or hemisection (Fig. 8.5.3),

intramyometrial coring (Fig. 8.5.4), wedge morcellation, myomectomy (Fig. 8.5.5).

When using the above techniques, be sure to keep the serosa of the uterus intact to

maintain orientation. Orient your scalpel blade so that you are always cutting toward

the center of the specimen. Use traction–countertraction while coring or

morcellating; certain clamps like the Lahey thyroid (triple hook) clamp can be useful.

Be sure to replace the scalpel periodically to ensure it remains sharp and work

systematically to remove as much of the central tissue as possible.

Lack of uterine descent

The initial cervical incision can be challenging; the Bovie cautery can be used with

the tip bent at 45 degrees to make the incision easier.

The posterior colpotomy and suture ligation of the uterosacral ligaments should be

done before the anterior colpotomy in order to facilitate some descensus of the

uterus, making anterior access safer and easier.

Once the uterine vessels are ligated, techniques used for the enlarged uterus (see

above) can be used to further access the remaining pedicles.

Consider using a vessel sealing device rather than clamping and suturing. It is

sometimes difficult to place sutures in a tight, poorly illuminated space, so using a

vessel sealer above the uterosacral ligaments is sometimes helpful. Choose a

device that is shaped like a Heaney clamp. There are devices that exist that are

specifically made for vaginal hysterectomy.

If suturing, always use a Heaney needle driver, with the suture loaded in the center

of the needle curve.

Use a disposable fiber-optic lighted suction irrigator to retract redundant tissue away

from the course of the needle when suturing high up in the pelvis.Narrow vaginal opening

A small mediolateral incision can be made starting just above the hymen through the

perineal structures. To reduce blood loss, start by injecting local anesthetic with a

dilute vasoconstricting agent and use the Bovie cautery to make the incision; avoid

injury to the anus and rectum.

Figure 8.5.3. Bivalving the cervix and uterus.

Figure 8.5.4. Intramyometrial coring.Figure 8.5.5. Myomectomy.

In cases of extreme narrowing, a more extensive Schuchardt incision can be

performed: the mediolateral incision is carried into the ischiorectal fossa and into the

upper part of the vagina.

Avoid over-using sidewall retractors; they can sometimes get in the way and narrow

the surgical field. The tip of the suction catheter can sometimes be used to retract

the vaginal side wall while the surgeon is working.

Difficult anterior entry (previous cesarean section)

Be patient, you do not need to enter anteriorly right away to successfully perform the

procedure.

Enter the posterior cul-de-sac and perform the procedure extraperitoneally; as long

as the bladder is protected, several pedicles can be suture ligated before entering

anteriorly.

Use sharp dissection anteriorly; blunt dissection has a much higher risk of causing

injury/entry into the bladder; never enter anteriorly in a blind fashion, the

vesicouterine space should be well developed and the peritoneum visualized before

entry.

The bladder can be back-filled through the catheter to demarcate the edge of the

bladder and the vesicouterine peritoneal fold. A uterine sound can also be bent and

passed through the urethra and into the bladder to help demarcate the lower

boundary of the bladder.

You can also utilize your posterior access to identify the anterior peritoneal fold. This

is usually possible when the uterus is small and there is descensus; the surgeon’s

fingers can reach around the fundus and identify the peritoneum. In cases of no

descensus, a uterine sound can be bent and passed posteriorly, up and around the

fundus in order to identify the fold.

Difficult posterior entry (endometriosis, cervical fibroid)

Use sharp dissection with good traction–countertraction and clamp pediclesextraperitoneally until safe access is possible. Keep dissection close to the uterus

and use retractors to protect the rectum.

Enter the anterior cul-de-sac if possible and if the uterus is small, deliver the fundus

anteriorly or access the posterior cul-de-sac digitally through the anterior peritoneal

incision.

If a posterior cervical fibroid is obstructing access, attempt intramyometrial coring and

myomectomy to decompress the bulk posteriorly.

Transcervical access to the posterior cul-de-sac is also an option. A tenaculum is

placed on the posterior cervix and traction is applied anteriorly. A retractor is placed

at 6 o’clock over the posterior vagina. A hemostatic agent is injected into the

posterior cervix. A scalpel or curved Mayo scissors are used to perform a fullthickness division of the posterior cervix in the midline starting at the external os and

moving downward until the posterior peritoneum is encountered and can be entered.

Elongated cervix

The biggest challenge in these cases is usually anterior and posterior entries.

Careful examination under anesthesia is necessary. Identification of the area of

transition between the cervix and fundus at the lower uterine segment is important.

The anterior peritoneal fold is usually located at or above this location. The posterior

peritoneal fold is usually more distal. Identification of the distal edge of the bladder is

also important. Sometimes, a vaginal crease is seen. If this is not the case, backfill of

the bladder can be done to identify the demarcation line. A rectal examination can be

done to identify the distal demarcation of the rectum. Once the distal edges of the

rectum and bladder are noted, the circumferential cervical incision can be made,

high enough to avoid extensive dissection on the cervix, but low enough to avoid

injury to viscera.

The above-mentioned techniques can also be used to help gain access into the

anterior and posterior cul-de-sacs.

Uterovaginal prolapse

The biggest challenge with prolapse is that there is often distortion of the anatomy.

The bladder reflection is often very distal on the cervix. Therefore, the initial cervical

incision should be made distally, with care taken to not amputate the cervix.

In cases of severe prolapse, the bladder trigone is often everted which displaces the

ureteral orifices distally, so that they are close to the distal bladder reflection. Careful

dissection of the bladder off of the cervix is key.

The posterior cul-de-sac is often easier to enter in prolapse cases because it lies

behind the upper half or so of the posterior vaginal wall while the distal rectum lies

behind it. The posterior peritoneal incision can be used to access the anterior

peritoneum as described by the techniques above. This can be helpful in avoiding

bladder and ureteral injuries.POSTOPERATIVE CARE

■ Patients may be discharged from the hospital the same day of surgery or

after overnight observation depending upon how quickly they meet their

postoperative milestones, which include the ability to tolerate an oral diet,

good pain control, ability to ambulate and void.

■ In some cases, vaginal packing may be used to decrease the risk of

hematoma formation. This is often done after concurrent prolapse repairs.

Packing must be removed within 24 hours of surgery and before a trial of

void is performed.

■ A Foley catheter may be left in place after surgery and removed once the

patient is ambulating. If the patient is destined to be discharged home the

day of surgery, the catheter may be removed in the operating room or once

the patient is brought to the recovery room.

■ Patients are cautioned against heavy lifting and vigorous activity for 6

weeks. They should also be placed on pelvic rest with nothing in the vagina

for those weeks. They should be examined at that time and allowed to

return to their normal activities as long as the vaginal cuff appears well

healed and intact. In cases of granulation tissue formation or bleeding from

the vaginal cuff, silver nitrate can be applied to help with healing.

OUTCOMES

■ Removal of the uterus results in the cessation of menstrual flow and causes

sterility. In addition, it eliminates any existing cervical or uterine disease.

■ The most significant health benefit of prophylactic oophorectomy is

reduced ovarian cancer risk. It is estimated that approximately 1,000 cases

of ovarian cancer could be prevented each year in the United States if all

women undergoing hysterectomy at 40 years or older had elective salpingooophorectomy performed.4 The level of cancer risk reduction associated

with prophylactic oophorectomy is thought to range from 80% to 95%.

■ While there is well-documented significant reduction in the risk of breast

cancer in women with known hereditary breast cancer syndromes such as

BRCA, it is unclear what the benefit is for nonhereditary breast cancers.

■ Unlike the gradual decline in hormonal function seen with natural

menopause that occurs over years, surgical menopause results in an abrupt

cessation of all ovarian hormone production. It is important to give

thoughtful consideration to this when counseling pre- or perimenopausal

women about prophylactic oophorectomy at the time of vaginal

hysterectomy. Studies show that premature menopause is associated with

an increased risk of cognitive impairment, heart disease, bone fractures,

and shorter long-term survival (not related to cancer). A study by Parker et

al.5 used a Markov decision-analysis model to determine whether theovaries of women aged 40 years or older should be removed during a

hysterectomy for benign disease. The authors found that ovarian

conservation demonstrated a net benefit in overall survival probability (as

defined by reduced heart disease and hip fracture) at age 80, offsetting any

adverse effects of new cases of ovarian and breast cancer. Their survival

curves comparing women with and without ovaries imply that ovarian

conservation up to age 65 in women without a strong personal or family

history of ovarian–breast cancer syndromes may be beneficial.

COMPLICATIONS

■ Complications that occur at the time of or after vaginal hysterectomy can

be directly related to the surgical technique used, associated with

anesthesia, or a result of the patient’s medical comorbidities.

■ Rates of complications vary by route of hysterectomy. Vaginal

hysterectomy is associated with the lowest complication rates, unless

additional surgeries such as prolapse repair are performed concurrently.

The eVALuate trial6 was a multicenter study that compared laparoscopic

and abdominal hysterectomy as well as laparoscopic and vaginal

hysterectomy performed for benign disease. The overall urinary injury rate

(bladder and ureter) was higher in the laparoscopic group; however, the

overall complication rate between the three modes of surgery appeared

similar. The study did show that both laparoscopic and vaginal

hysterectomy (compared to abdominal hysterectomy) were associated with

a quicker recovery time, less pain, improved short-term quality of life, and

shorter hospital stay. However, not surprisingly, laparoscopic hysterectomy

was associated with longer operating room time and cost.

■ Perioperative complications associated with vaginal hysterectomy are rare,

but include the following: hemorrhage, hematoma, bowel injury, lower

urinary tract injury (ureteral and bladder), infection, abscess, vaginal cuff

evisceration, vesicovaginal fistula, complications with anesthesia.

■ Bladder injury (cystotomy) can occur in up to 2% of vaginal hysterectomy

cases and there are some data that show that the risk of this type of injury

is higher with concurrent prolapse procedures.7 Previous cesarean section is

associated with adhesions between the cervix and bladder and can

significantly increase the risk of cystotomy. In these patients, careful

dissection is required. Surgeons should consider using mostly sharp

technique to dissect the bladder off of the cervix as blunt dissection such as

the use of a gloved finger or gauze decreases tactile sensation over the

tissues, increasing the risk of entry into the bladder. Immediate recognition

and repair of a bladder injury is necessary. Closure should be tension-free,

water-tight, and performed in two layers using a No. 2-0 or 3-0 delayedabsorbable suture. The bladder is placed to continuous drainage for 7 to 14

days (depending on size and location of the injury). A cystogram of the

bladder should be performed prior to catheter removal in cases of large

injuries to ensure that there is no leak and that the bladder has been

adequately repaired.

■ The risk of ureteral injury after vaginal hysterectomy (without concurrent

prolapse repair) has been reported to be as high as 0.9%.7 The distal ureter

is the most at risk for injury and the common sites of injury include its

passage under the uterine artery as it travels through the cardinal ligament

complex to enter the bladder, at the level of the infundibulopelvic ligament,

and along the pelvic side wall just above the uterosacral ligament. Ureteral

injury is a rare adverse event and can often be detected intraoperatively if

proper precautions are taken. Failure to detect an injury can lead to

permanent upper urinary tract damage including loss of renal function and

complex genitourinary fistula. Intraoperative cystoscopy is an effective

method of detecting an intraoperative injury, and we recommend routine

cystoscopy after vaginal hysterectomy. Administration of a dye that

changes the color of the urine is often useful to visualize ureteral jets at the

time of cystoscopy. This is not always necessary, as urine jets can be seen

without dye. But if the risk of ureteral injury is high, a dye may be useful

to confirm patency. For a long time, intravenous administration of indigo

carmine was a safe and commonly used technique to visualize ureteral flow.

There has recently been a shortage of this dye, and alternatives have been

used. These include intravenous administration of fluorescein, preoperative

oral administration of phenazopyridine, and bladder instillation with a

hyperosmolar solution such 50% dextrose. In cases where ureteral injury is

suspected, intraoperative urology consultation should be obtained. In most

cases, the ureteral injury occurs in the distal 4 to 5 cm of the ureter, and

this type of injury can usually be repaired with reimplantation of the ureter

into the bladder (ureteroneocystostomy). A ureteral stent is usually left in

place and the bladder is placed on continuous drainage with a Foley

catheter for 10 to 14 days. The stent is removed later and an intravenous

urogram is performed to ensure that there is no stenosis, stricture, or fistula

at the site of the repair.

■ Vesicovaginal fistulae are very rare complications. Patients usually present

with early onset constitutional symptoms and eventually develop watery

drainage from the vagina 10 to 14 days after surgery. If a fistula tract

cannot be visualized on speculum examination or with cystoscopy, a

tampon dye test may be performed. This is done by instilling methylene

blue dye into the bladder and inserting a tampon inside of the vagina. If the

blue dye is noted on the proximal tampon, a bladder fistula is suspected. If

there is no dye noted, a uterovaginal fistula should be ruled out, which canalso be done with a tampon in the vagina using intravenous indigo carmine

or oral phenazopyridine. Alternatively, an intravenous pyelogram or CT

urogram can be done to help diagnose a fistula. If the fistula is small, it

may heal spontaneously with the bladder to continuous drainage for 6 to 12

weeks. Fistulae that do not heal spontaneously, or are complex or large,

will require surgical repair.

KEY REFERENCES