Vaginal Hysterectomy

Background

In the United States, hysterectomy is one of the most frequently performed surgical procedures. Even with the increased use of conservative therapies, approximately 600,000 hysterectomies are performed each year. ^[1]

Hysterectomy may be performed vaginally, abdominally, laparoscopically, or with robotic assistance, with the route depending primarily on physician choice. Factors to be considered in choosing the route for hysterectomy should include safety, cost-effectiveness, and the medical needs of the patient. ^[2]  A large body mass index (BMI)  may also play a role in the route chosen.

In a review that evaluated the outcomes of abdominal hysterectomy, laparoscopic hysterectomy, and vaginal hysterectomy in 2232 very obese and morbidly obese patients (BMI ≥35 kg/m²), investigators found that abdominal hysterectomy was associated with more postoperative complications such as wound dehiscence and wound infections and longer length of hospital stay in this patient population than were seen with the other two procedures. ^[3]

Most of the literature supports the view that vaginal hysterectomy, when feasible, is the safest and most cost-effective procedure for removal of the uterus. ^{[4, 5]}  Nevertheless, the abdominal route is the one most commonly chosen: 66% of hysterectomies are performed abdominally, 22% are performed vaginally, and 12% are performed laparoscopically. ^[6]

Indications

The most common indications for hysterectomy are symptomatic uterine leiomyomas, endometriosis, and uterine prolapse. ^{[1, 7]}

Contraindications

There are very few absolute contraindications for vaginal hysterectomy (eg, pregnancy, cancer). However, there are some factors that may influence the surgeon's choice of a route for hysterectomy, including the following:

• Surgeon training and experience

• Accessibility of the uterus

• Extent of extrauterine disease

• Size and shape of the uterus

• Need for concurrent procedures

• Patient preference

There are some relative contraindications to vaginal hysterectomy, such as the following:

• Enlarged uterus

• Nulliparity

• Narrow vagina

• Narrow pubic arch (< 90º)

• Immobile uterus

Other possible concerns that may militate against vaginal hysterectomy include extrauterine disease (eg, adnexal pathology), severe endometriosis, adhesions, and an indication for salpingo-oophorectomy. When these concerns arise, many surgeons choose to visualize the pelvis laparoscopically before deciding on the route for hysterectomy. The decision to perform a salpingo-oophorectomy should not be influenced by the chosen route for hysterectomy and is not a contraindication for vaginal hysterectomy. ^[4]

The American College of Obstetricians and Gynecologists made the following recommendations on choosing the route of hysterectomy for benign disease ^[8] :

• Vaginal hysterectomy is the approach of choice whenever feasible.

• Laparoscopic hysterectomy is a preferable alternative to open abdominal hysterectomy for those patients in whom a vaginal hysterectomy is not indicated or feasible.

• The surgeon should account for clinical factors to determine the best route of hysterectomy for each individual patient.

• The size and shape of the vagina and uterus; accessibility to the uterus (eg, descensus, pelvic adhesions); extent of extrauterine disease; the need for concurrent procedures; surgeon training and experience; average case volume; available hospital technology, devices, and support; whether the case is emergent or scheduled, and patient preference can all influence the route of hysterectomy.

• A discussion with the patient should take place on the route of hysterectomy and advantages and disadvantages of each approach.

• Opportunistic salpingectomy usually can be safely accomplished at the time of vaginal hysterectomy.

• The role of robotic assistance for execution of laparoscopic hysterectomy has not been clearly determined and more studies are needed to determine clinical use.

An algorithm has been proposed by Kovac et al that aids the clinician in choosing the route by which hysterectomy will be performed (see the image below). ^[9]

In practice, most vaginal surgeons individualize the choice of a hysterectomy route. Many nulliparous women and many women who have undergone cesarean delivery do in fact have sufficient vaginal capacity to allow a vaginal hysterectomy. As long as the surgeon can obtain adequate access for division of the uterosacral and cardinal ligaments, the uterus can be mobilized sufficiently to allow vaginal extraction.

Even when the uterus is enlarged, vaginal hysterectomy often can be accomplished safely by means of morcellation, uterine bisection, wedge debulking, or intramyometrial coring (see Technique). ^[4]

Outcomes

A Cochrane review found that the vaginal route, compared with all other routes for hysterectomy, yields better outcomes and fewer complications (see the image below). ^[10] The authors also noted that when vaginal hysterectomy is not possible, laparoscopic vaginal hysterectomy has advantages over abdominal hysterectomy (eg, faster return to normal activity, shorter hospital stay, reduced intraoperative blood loss, and fewer wound infections) but also disadvantages (eg, longer operating time and higher rate of urinary tract injury).

Vaginal hysterectomy

Once the patient has been properly positioned, a weighted speculum is placed into the posterior vagina, and a right-angle retractor is positioned anterior to the cervix while the anterior and posterior lips of the cervix are grasped with a single- or double-toothed tenaculum. Some surgeons inject vasopressin (10-20 U in 50 mL of saline) or lidocaine 0.5% into the cervical, paracervical, and submucosal tissues to help identify tissue planes and reduce blood loss, but these agents are not required.

Vaginal incision and opening of posterior peritoneum

The initial vaginal incision is made circumferentially, beginning at the level of the vaginal rugae through the full thickness of the vagina, just below the bladder reflection—not on the cervix (see the image below). If an incidental cystotomy occurs, the vaginal hysterectomy should be completed before the bladder is repaired. The vaginal epithelium is dissected bluntly or sharply to the underlying tissue with an open sponge over the index finger and Mayo scissors.

The posterior peritoneum is then identified where rugae are not present and where the uterosacral ligaments join the cervix. The peritoneum is grasped with tissue forceps and incised with Mayo scissors in a generous bite (see the image below), and a Steiner-Anvard weighted speculum is inserted into the posterior cul-de-sac.

Division and ligation of uterosacral ligaments

The uterosacral ligaments are identified and clamped, with the tip of the clamp incorporating the lower portion of the cardinal ligaments. The clamp is placed perpendicular to the uterine axis, and the pedicle is cut so that approximately 0.5 cm of tissue is distal to the clamp. A transfixion suture is placed at the tip of the clamp and tied. This suture may be held with a hemostat to facilitate location of any bleeding at the completion of the procedure and to aid in vaginal closure.

Opening of anterior peritoneum

Attention is then directed to opening the anterior peritoneum. The anterior peritoneal fold appears as a crescent-shaped line. The peritoneal reflection is grasped with tissue forceps, tented, and opened with scissors that have their tips pointed toward the uterus (see the image below). A Heaney or Deaver retractor is placed into this space to protect the bladder and to facilitate visualization of the abdominal contents.

If the peritoneal reflection is not readily identified, one can wait to make the entry, as long as the bladder has been safely advanced cranially. A Deaver or Heaney retractor is placed in the midline to keep the bladder out of the operative field. Blunt or sharp advancement of the bladder should continue before each clamp placement until the vesicovaginal space is entered. Once this space is entered, the Heaney or Deaver retractor is placed into the peritoneal cavity.

Division and ligation of cardinal ligaments

Next, the cardinal ligaments are identified, clamped, cut, and suture-ligated in a manner similar to that previously described for the uterosacral ligaments. Alternatively, newer electrocauterization devices (eg, LigaSure; Covidien, Boulder, CO) can be used in vessels up to 7 mm in diameter to accomplish the same task.

The uterine vessels are then clamped in such a way as to incorporate the anterior and posterior leaves of the visceral peritoneum (an important step). A single-clamp technique reduces the risk of ureteral injury (see the image below).

Delivery of surgical specimen

The uterine fundus is delivered posteriorly by placing a tenaculum or towel clip on the uterine fundus in successive bites. The utero-ovarian ligament is identified with the surgeon's finger, then clamped and cut. The pedicles are double-ligated, first with a suture tie and then with a suture ligature medial to the first tie. A hemostat is placed on the second suture to assist in the identification of any bleeding.

If the adnexa are to be removed, ^[11] traction is placed on the ovary by grasping it with a Babcock clamp. A Heaney clamp is placed across the infundibulopelvic ligament, and the ovary and tube are excised. Both a suture tie and a transfixion suture ligature are placed on this pedicle (see the image below).

Management of enlarged uterus

For enlarged uteri, the following techniques may be employed to facilitate removal of the uterus: morcellation, intramyometrial coring, uterine bisection, and wedge debulking.

Morcellation can be used in cases involving uterine enlargement, uterine fixation, or limited vaginal exposure. It should not be performed if the uterine arteries cannot be secured or if malignancy is suspected.

Intramyometrial coring (see the image below) is accomplished by circumferentially incising the outer myometrium beneath the uterine serosa with a scalpel while placing the cervix on traction. The incision should be kept as close to the uterine serosa as possible. The enlarged uterus is delivered as an elongated mass inverting the uterine fundus.

Uterine bisection is performed by cutting the cervix and the uterine fundus in the sagittal plane. This technique is often combined with myomectomy or wedge morcellation to reduce the bulk of the uterine halves so that the tubo-ovarian vessels can be ligated. ^[12]

Completion and closure

A sponge-stick or laparotomy pad is placed into the peritoneal cavity to allow the surgeon to visualize each of the pedicles and confirm that hemostasis is adequate. If any bleeding points are identified, a suture is used to ligate the bleeding vessel under direct vision. The pelvic peritoneum is left open.

Finally, the vaginal epithelium is reapproximated either vertically or horizontally with either a continuous suture or a series of interrupted sutures. These sutures are placed through the full thickness of the vaginal epithelium, with care taken to ensure that the bladder is not entered.

Culdoplasty for prevention of enterocele

A culdoplasty is generally recommended to reduce the risk of subsequent enterocele formation and potential vaginal vault prolapse. The 2 methods commonly described are the Moschcowitz repair (ie, closing the cul-de-sac and bringing the uterosacral-cardinal complex together in the midline) and the McCall culdoplasty (ie, obliterating the cul-de-sac, plicating the uterosacral-cardinal complex, and elevating any redundant posterior vaginal apex). There is some evidence to suggest that the McCall procedure is superior in preventing enterocele. ^[13]

In this procedure, an absorbable suture is placed through the full thickness of the posterior vaginal wall at the apex of what will be the vaginal vault. This suture is passed through the left uterosacral ligament pedicle, the posterior peritoneum, and the right uterosacral ligament and completed by being passed from the inside to the outside at the same point where it was begun. The suture is then tied, thus approximating the uterosacral ligaments and the posterior peritoneum. It is not necessary to use a vaginal pack or leave a bladder catheter in place.

Complications of procedure

The primary intraoperative complications are visceral injury and hemorrhage. Reported rates of hemorrhage range from 1.4% to 2.6%, whereas reported rates of ureteral and bladder injury are 0.88% and 1.76%, respectively. ^[12]

The most common postoperative complication is pelvic infection. Febrile morbidity occurs in approximately 15% of women who undergo vaginal hysterectomy and can be reduced by means of prophylactic antibiotics. Infections after vaginal hysterectomy include vaginal cuff cellulitis, pelvic cellulitis, and pelvic abscess. These infections occur in approximately 4% of women. ^[14]

Preprocedural planning

For optimal surgical outcome, a preoperative health/risk assessment is critical. This assessment should always include a complete history and physical examination. Although no preoperative laboratory tests are routinely recommended, screening laboratory tests should be ordered as indicated by the patient's underlying medical problem (eg, electrocardiography [ECG] in a patient with a history of heart disease).

Any nonprescription drugs (eg, nonsteroidal anti-inflammatory drugs [NSAIDs] and aspirin) that the patient may be taking should be discontinued at least 7 days before the procedure to reduce the risk of bleeding. Ovarian cancer has the highest mortality rate of all gynecologic cancers. Therefore, informed consent should include discussion of prophylactic salpingectomy for the possible prevention of ovarian cancer. In addition, clinicians should discuss with patients oophorectomy and sexual function following surgery. ^[15]

Perioperative care includes the following:

• Prophylactic antibiotics within 1 hour before incision

• First- or second-generation cephalosporins ^[16]  or  clindamycin plus gentamicin or a quinolone or aztreonam or metronidazole plus gentamicin or a quinolone

• Discontinuance of antibiotics within 24 hours after surgery

• Discontinuance of indwelling catheters within 24 hours after surgery

• Prophylaxis for venous thromboembolism - Unfractionated heparin (5,000 U every 12 hours, beginning 2 hours before incision) or low-molecular-weight heparin (eg, enoxaparin 40 mg or dalteparin 2500 U, beginning 2 hours before incision) or intermittent pneumatic compression devices before incision

Patient preparation

Vaginal hysterectomy can be performed with either general anesthesia or regional anesthesia.

Placing the patient in the dorsal lithotomy position is critical for obtaining optimal exposure. Allen or "candy cane" stirrups may be used. Regardless of the type of stirrup used, the surgeon must be careful to protect the vulnerable neurologic, vascular, and bony points of the lower extremities. The buttocks should be positioned at the end of the table, with the table level with the floor. Hyperflexion of the hips should be avoided because it can cause femoral neuropathy. Padding should be used at all potential pressure points.

Once the patient has been properly positioned and appropriate anesthesia has been provided, a bimanual pelvic examination should be performed to assess uterine mobility and descent, to confirm the findings of the office examination, and to determine whether unsuspected adnexal pathology is present. This step affords the surgeon a final opportunity to decide whether to proceed with a vaginal or an abdominal approach.

The patient is then prepared and draped, with the stirrups positioned so that assistants can place themselves inside them to visualize the operative field. A bladder catheter may be inserted, but the author prefers to drain the bladder with a straight catheter. Alternatively, some surgeons believe that a distended bladder facilitates recognition of urogenital injuries and therefore do not drain the bladder at all.

International Society for Gynecologic Endoscopy

In 2020, the International Society for Gynecologic Endoscopy (ISGE) published their recommendations for vaginal hysterectomy for a non-prolapsed uterus. ^[17]

Vaginal hysterectomy is the route preferred by the ISGE for the removal of a non-prolapsed uterus. The ISGE recommendations for the successful performance of this procedure are as follows:

• A circular incision at the level of the cervicovaginal junction is recommended.
• The posterior peritoneum should be opened first.
• Clamping and cutting the uterosacral and cardinal ligaments before or after obtaining access into the anterior peritoneum is recommended.
• Routine closure of the peritoneum during vaginal hysterectomy is not recommended.
• Vertical or horizontal closure of the vaginal vault following vaginal hysterectomy is recommended.
• The insertion of a vaginal plug after vaginal hysterectomy is not recommended.