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  Tips to do a good vaginal hysterectomy

Shobhana Mohandas:  TOGS bulletin , Vol 1 No9 November  2005.

 

 

   Tips to do a good vaginal hysterectomy

Lapaaroscopic surgery has almost taken away the practice of abdominal hysterectomy in good centres.  However, laparoscopy entails expensive instruments and the learning curve is there to climb. Patients have come to realise the advangages of minimally invasive surgery and so the average gynaecologist has to strike a balance and learn to do good vaginal surgery.  This keeps the patient happy that she has no scar on the abdomen and the doctor that she does not have to spend on expensive equipment. Vaginal hysterectomy also does away with pneumoperitoneum so anaesthetic complications are fewer.  There are many advantages for laparoscopy in that you can visualise what you do, but this article is not about which modality is better for doing a hysterectomy. It is about the nuances of doing a good job once a surgeon has decided on vaginal hysterectomy.

Preparation:

Besides washing hands thoroughly in the customary way, it is imperative that the practice of cleaning hands with alcohol be followed diligently as it is in vaginal surgery that one may inadvertently prick the finger and sometimes not realise it.  If one realises that the finger has been pricked, it is better to take that extra minute and change the glove.  Low grade infection can flare up in the late post-operative period and cause reactionary haemorrhage.  The size of the uterus or parity should not pose a problem that is impossible to solve.  The author has done vaginal hysterectomy iun a 12 year old mentally retarded girl and also for a woman with 26 weeks size uterrus.  With a little practice, it is possible to remove almost all uterii vaginally.Adequate light and good positioning of the patient is essential.  While putting the leg in lithotomy position, both the legs should be lifted simultaneously and put in identical position.  If the lithotomy rod is such that the popliteal fossa touches the metal in the stirrup, the author uses paddings on the stirrup, so that the peroneal nerve, which curves around the head of the fibnula does not rub against the metal stirrup. 

Volesllums with good grips and hysterectomy clamps with a vertical ridge are other necessary accecssories. 

Procedure:

After taking a circular cut on the vagina, the blader peritoneum is searched for and cut. This may pose a problem in patients with huge prolapse with decubitus ulcers involving the vagina.  sometimes even the cervix not be visible and so it becomes difficult to locate the tiny menopausal uterus .In non descent hysterectomy, patients with anterior wall fibroids pose a problem as the bladder goes high up.  Patients with previous LSCS may have bladder adhesions and one has to be careful.  In all cases , putting a urethral dilator or some metal cannaula into the bladder will help delineate the lower end of the bladder. In cases of previous caesarian section, sharp cuts should be made on the vesicovaginal fascia which will present immediately below the vagina.  The cuts should be made keeping the scissor perpendicular to the cervical axis.  Blunt dissection with gauze should be done only when there is an easy plane of cleavage.  Sometimes it is easier to find the peritoneum in the side rather than in the center. In such cases, the peritoeum should be nicked wherever it is visible, and the rest of the bladder peritoneum cut with scissor.   In patients with prolapse, the peritoneum is within visible distance.  But in patients with previous caesarian section and in patients with large uterus, it is difficult to find the bladder peritoneum.  In such patients, it is better to separate the bladder as much as possible  and then start clampinmg the mackenrodt’s ligaments.  Once the ligaments are cut and tied, the uterus will descend, making it easier to visualise the bladder peritoneum. 

Cutting the posterior peritneum is usually easier, but if vaginal hysterectomy is attempted without initially visualising laparoscopically whether there are adhesions, one might find difficulties.  By and large, if one adhers to the principle of cutting perpendicularly into the uterus and resorting to blunt dissection when the plane of cleavage is clear, there is usually no problem.  Intestinal adhesions can be seen clearly with adequate exposure and good lighting. It is just a matter of spending a few extra minutes to have the assistant hold the instruments in such a way, that the tissue which is going to be nicked is clearly visible.  This way, the author has been able to separate certain adhesions in the pouch of douglas vaginally, even when they seemed too dense to handle laparoscopically. 

Clamping the mackenrodt’s: The mackenrodt’s ligament is fan shaped and extends from the side to it’s attenuation as the uterosacral ligament behind.  It ma;y not be possible to get the whole ligament in one clamp.  After clamping the ligament laterally and tying it, the finger should be hooked around the uterosacral ligament posteriorly and it should be clamped.  After the mackenrodt’s ligaments are tied, if the peritoneal folds are not already opened, it should be done now.  While clamping the mackenrodt’s ligaments, care should be taken to see that the bladder does not sag down and get included in the clamp. The bladder should be separated and kept under a retractor, specially on the lateral side. 

Uterine arteries: Once the uterine arteries are visible, they are clamped and cut.  Care should be taken to see that the ascending branch is also tied, either together with the main branch or separately. 

Once the uterine artery has been cut, one is allowed to bisect or morcellate the uterus.  However, it should be done only after the attachment of the uterus to the lateral pelvic wall is cut off as much as possible.  This will help cut off any collateral blood vessels that may come from the uterines and reduce the amount of bleeding while cutting the uterus.

Morcellating the uterus/fibroid: While bisecting/morcellating the uterus, one should make sure that two sturdy clamps are always there on some wall of the uterus proximal to the part that is being morcellated. If suddenly this grip goes off, the uterus might just slip off into the abdomen. This happened to the author some 8 -9 years ago in the early period of learning. It was a uterus with a 10cm fibroid shaped like a tennis ball and there was no way one could catch it, vaginally or even with laparoscopic assistance , the assistant trying to push it into the pelvis and the surgeon trying to hold it wihile it was pushed.  The lesson learnt was, never, give up the grip on the uterus whatever happens, while bisection/morcellation is going on. 

Once most of the connections are gone, it is important to ask the assistant not to pull on the uterus too much, otherwise, the uterus might just jump off into the surgeon’s lap, with accompaniment of spurting from the ovarian vessels. 

Till the point of cutting the uterines, the assistant pulls the cervix/uterus to the side contralateral to the ligament that is being clamped. However, after the uterine arteries are clamped, the whole mass of the huge uterus might almost fill the available space and it may be difficult to locate the lateral attachment of the uterus,  This can now be overcome by pushing the mass into the pelvis rather than by pulling it as was being done earlier in the surgery.  When the mass is pushed into the pelvis, the attachment becomes more visible and it can  now be cut. 

Once the uterus is out, the vagina is closed and it is the autor’s practice to pack the vagina. and put in a catheter.

Instilling saline into the tissues before starting surgery, is said to give a less bloody field according to one Indian report.  In messy cases, a foley’s bulb could be put into the abdomen and inflated before closing the vagina.  It could act as a drain and the pressure of the bulb could also act on very small vessels and act as a haemostatic. 

Conclusion: This article has been written in haste to fill up remaing space in the bulletin and just contains matter that came to the author’s mind from personal experience. There are many more unsaid things that have been borne out by controlled studies that could help one perform safe vaginal hysterectomies.

 

 

 

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