Berek and Novak's Gynecology 15th Ed.

24 Hysterectomy

Tommaso Falcone

Thomas G. Stovall

• Hysterectomy is one of the most commonly performed surgical procedures in the United States.

• Vaginal hysterectomy is the procedure of choice in parous women unless this route is contraindicated.

• Laparoscopic hysterectomy is associated with faster postoperative recovery and shorter hospital stay compared with abdominal hysterectomy.

• There are no randomized clinical trials demonstrating an advantage of robotic or single-port hysterectomy over conventional laparoscopic hysterectomy.

• There appears to be no advantage to the routine use of supracervical hysterectomy when compared with total hysterectomy.

• Salpingo-oophorectomy at the time of hysterectomy for benign disease in premenopausal women at average risk for ovarian malignancy is associated with an increase in long-term patient mortality from cardiovascular disease, and ovarian conservation should be strongly considered in these patients.

Hysterectomy is one of the most common surgical procedures performed. After cesarean delivery, it is the second most frequently performed major surgical procedure in the United States (1). According to the National Hospital Discharge survey, the rate of hysterectomy during the 5-year study period was 5.4 per 1,000 women per year in 2000 and declined to 5.1 per 1,000 per year in 2004. These data do not represent hysterectomies performed in ambulatory settings. The highest rate of hysterectomy is between the ages of 40 and 49 years with an average age of 46.1 years (1). The highest rates of hysterectomy are for women living in the southern United States and they occur at a younger age. The lowest rates are consistently in the northeastern portion of the United States. Lower socioeconomic status is associated with increased hysterectomy rates (2). Hysterectomy rates are higher for black women (3). Reports on the effect of physician gender conflict with recent data shows no overall impact (4). Bilateral salpingo-oophorectomy decreased between 2000 and 2004 from 53.8% to 49.5% (1). The frequency was the highest with abdominal hysterectomy and the lowest with vaginal hysterectomy.

Indications

The indications for hysterectomy are listed in Table 24.1. Uterine leiomyomas are consistently the leading indication for hysterectomy. As expected, the indications differ with the patient’s age (1). Hospitalization rates for hysterectomy in women between the ages of 15 and 54 years decreased from 1998 to 2005 for all indications except for menstrual disorders (5).

Table 24.1 Indications for Hysterectomy (Percentage): United States 2000–2004

Uterine leiomyoma	40.7
Endometriosis	17.7
Other	15.2
(includes cervical dysplasia and menstrual disorders)
Uterine prolapse	14.5
Cancer	9.2
Endometrial hyperplasia	2.7
From Whiteman MK, Hillis SD, Jamieson DJ, et al. Inpatient hysterectomy surveillance in the United States, 2000–2004. Obstet Gynecol 2008;34.e1–e7, with permission.

Leiomyomas

The proportion of hysterectomies performed for leiomyomas decreased over time (1) (see Chapter 15). Fertility-preserving surgical management (myomectomy) is possible in most patients with leiomyomas. The decision to perform a hysterectomy for leiomyomas is usually based on the need to treat symptoms—abnormal uterine bleeding, pelvic pain, or pelvic pressure. Other indications for intervention have included “rapid” uterine enlargement, ureteral compression, or uterine growth after menopause. There is no clearly reproducible definition of rapid growth. The concept of rapid growth was challenged because these patients did not demonstrate clearly malignant conditions (6). Refuted reasons for hysterectomy in patients with leiomyomas are size greater than 12 weeks of gestation without symptoms, inability to palpate the ovaries on bimanual examination, and increased morbidity at hysterectomy with increased uterine size. If the procedures are performed abdominally, there is no difference in surgical morbidity between patients with a 12-week-sized uterus and those with a 20-week-sized uterus (7). Therefore, hysterectomy for leiomyomas should be considered only in symptomatic patients who do not desire future fertility (7).

To reduce uterine size before hysterectomy, patients with large leiomyomas may be pretreated with a gonadotropin-releasing hormone (GnRH) agonist (8,9). In many cases, the reduction of uterine size is sufficient to permit vaginal hysterectomy when an abdominal hysterectomy would otherwise be necessary. In one prospective trial, premenopausal patients with leiomyomas the size of 14 to 18 weeks' gestation were randomized to receive either 2 months of preoperative depot GnRH agonist or no GnRH agonist (8). Treatment with a short course (8 weeks) of leuprolide acetate before surgery enabled the procedures to be converted safely from an abdominal hysterectomy to a vaginal hysterectomy (9). This preoperative regimen was associated with a rise in hematocrit before surgery and a shorter hospital stay and convalescent period because patients were more likely to have a vaginal rather than an abdominal hysterectomy.

Dysfunctional Uterine Bleeding

Excessive uterine bleeding is the indication for about 20% of hysterectomies. Dysfunctional uterine bleeding assumes abnormal bleeding without an obvious anatomic cause (see Chapter 14). Anovulatory uterine bleeding is typically associated with polycystic ovary syndrome (PCOS), a condition in which anovulatory cycles are common. The bleeding can be controlled by medical intervention with progestin, estrogen, or a combination of progestin and estrogen given as oral contraceptives. Ovulatory abnormal uterine bleeding can be controlled by nonsteroidal anti-inflammatory agents, hormonal intervention, tranexamic acid, or the levonorgestrel intrauterine device. In these patients, endometrial sampling should be performed before hysterectomy (10). Dilation and curettage is not an effective means of controlling bleeding and is not necessary before hysterectomy. Hysterectomy should be reserved for patients who do not respond to or cannot tolerate medical therapy. Alternatives to hysterectomy (e.g., endometrial ablation or resection) should be considered in selected patients because these operations may be cost-effective and have a lower morbidity rate.However, in a clinical trial that randomized endometrial ablation to hysterectomy, 29% of patients assigned to the ablation underwent hysterectomy by 60 months (11).

Intractable Dysmenorrhea

About 10% of adult women are incapacitated for up to 3 days per month as a result of dysmenorrhea (see Chapter 16) (12). Dysmenorrhea can be treated with nonsteroidal anti-inflammatory agents used alone or in combination with oral contraceptives or other hormone agents to reduce or ablate menstrual flow (12). The levonorgestrel intrauterine device effectively reduces dysmenorrhea symptoms. Hysterectomy is rarely required for the treatment of primary dysmenorrhea. In patients with secondary dysmenorrhea, the underlying condition (e.g., leiomyomas, endometriosis) should be treated primarily. Hysterectomy should be considered only if medical therapy fails or if the patient does not want to preserve fertility (12).

Pelvic Pain

In a review of 418 women in whom hysterectomy was performed for a variety of nonmalignant conditions, 18% had chronic pelvic pain. Preoperative laparoscopy was performed in only 66% of these patients. After hysterectomy, there was a significant reduction in symptoms that was associated with an improvement in the patient’s quality of life (13). In a review of 104 patients who underwent hysterectomy for chronic pelvic pain that was believed to be of uterine origin, 78% experienced improvement in their pain after follow-up for a mean of 21.6 months (14). However, 22% of patients had no improvement in or exacerbation of their pain. Hysterectomy should be performed only in those patients whose pain is of gynecologic origin and does not respond to nonsurgical treatments (12) (see Chapter 16).

Cervical Intraepithelial Neoplasia

In the past, hysterectomy was performed as primary treatment of cervical intraepithelial neoplasia. More conservative treatments, such as laser or loop electrosurgical excision procedure (LEEP), can be effective in treating the disease, making hysterectomy unnecessary in most women with these conditions (see Chapter 19). For patients with recurrent high-grade dysplasia who do not desire to preserve fertility, hysterectomy may be an appropriate treatment option. After hysterectomy, these patients are at increased risk for vaginal intraepithelial neoplasia.

Genital Prolapse

Hysterectomy for symptomatic genital prolapse accounts for about 14.5% of hysterectomies performed in the United States (1). Unless there is an associated condition requiring an abdominal incision, vaginal hysterectomy is the preferred approach for genital prolapse. Uterine prolapse typically is not an isolated event and most often is associated with a variety of pelvic support defects. Each defect must be corrected to optimize the surgical outcome and decrease the risk of developing future pelvic support defects.

Obstetric Emergency

Most emergency hysterectomies are performed because of postpartum hemorrhage resulting from uterine atony. Other indications include uterine rupture that cannot be repaired or a pelvic abscess that does not respond to medical therapy. Hysterectomy may be required for patients with placenta accreta or placenta increta.

Pelvic Inflammatory Disease

Pelvic inflammatory disease can be treated successfully with antibiotics. The uterus, tubes, and ovaries should not be removed in a patient with pelvic inflammatory disease that is refractory to intravenous antibiotic therapy (see Chapter 18). Whether one proceeds with conservative surgical management, abscess drainage, or organ removal is a subjective decision that must be based on the individual. If accessible, some pelvic abscesses may be drained successfully by percutaneous catheter drainage guided by ultrasonography or computed tomography (CT) scanning. Surgical intervention is necessary if the patient has acute abdominal findings associated with peritonitis and signs of sepsis in the presence of a ruptured tubo-ovarian abscess. For the patient who desires future fertility, consideration should be given to unilateral salpingo-oophorectomy or partial bilateral salpingo-oophorectomy without hysterectomy. For the patient in whom bilateral salpingo-oophorectomy is required, the uterus can be left in place for possible ovum donation and in vitro fertilization.

Endometriosis

Medical and conservative surgical procedures are successful for treatment of endometriosis (15). Bilateral salpingo-oophorectomy, with or without hysterectomy, should be performed only in patients who do not respond to conservative surgical (resection or ablation of endometriotic implants) or medical therapy (see Chapter 17). Most patients with endometriosis who require hysterectomy have unrelenting pelvic pain or dysmenorrhea. Other less common situations include patients who do not desire future fertility and who have endometriosis involving other pelvic organs, such as the ureter or colon. Hysterectomy with or without salpingo-oophorectomy provides significant pain relief to the majority of patients. At the time of hysterectomy for endometriosis, consideration should be given to conserving normal ovaries (16).

Pelvic Mass or Benign Ovarian Tumor

If a pelvic mass is palpated on pelvic examination, a transvaginal ultrasound should be performed (see Chapter 14). If the mass is suspicious, appropriate consultation with a gynecologic oncologist is recommended. Benign ovarian tumors that are persistent or symptomatic require surgical treatment. If the patient desires fertility, the uterus should be conserved. If fertility is not an issue or if the patient is perimenopausal or postmenopausal, a decision must be made regarding whether the uterus should be removed. In one study, 100 patients who underwent bilateral salpingo-oophorectomy plus hysterectomy for benign adnexal disease were compared with a group of risk-matched women who underwent bilateral salpingo-oophorectomy without hysterectomy for the same indication (17). There was a significant increase in operative morbidity, estimated blood loss, and the length of hospital stay for patients in whom hysterectomy was performed.

Preoperative Considerations

The preoperative discussion should include an informed consent that documents the options, risks, benefits, outcome, and personnel involved with the procedure. The medical record should reflect the completion of childbearing and that adequate trial of medical or nonsurgical management was offered, attempted, or refused.

Health Assessment

An assessment of a patient’s health status is important in order to obtain an optimal outcome after hysterectomy for benign disease. There are no routinely recommended tests, although individual hospitals may have their own requirements. The patient should be evaluated for risk factors associated with venous thromboembolic events (18). Age, medical history, such as inherited or acquired thrombophilias, obesity, smoking, and hormonal medication, including contraceptives or hormone therapy, may increase the risk.

It is important to assess and correct underlying anemias before surgery. Blood product use can be minimized with preoperative iron supplementation or use of GnRH agonists.

Hysterectomy versus Supracervical Hysterectomy

There is a trend toward retention of the cervix at hysterectomy because of the perception that several outcome parameters, including sexual function and pelvic support, are better after a supracervical hysterectomy. Three prospective randomized clinical trials as summarized in a Cochrane review challenge this perception (19). There was no evidence to support the concept that leaving the cervix improves sexual function or lower rates of incontinence or constipation. All of these studies included hysterectomies that were performed by laparotomy. Surgical time was decreased by approximately 11 minutes.

This decreased surgical time may be more significant for laparoscopic cases, as the most difficult part of the surgery is the detachment of the cervix from the lateral ligaments and from the vagina. This is where most ureteral injuries occur during laparoscopic hysterectomy. This advantage should be balanced with the potential risk of ongoing cyclic bleeding from the cervix that is reportedly between 5% to 20% from the randomized clinical trials and 19% from a prospective observational laparoscopic trial (20). With conservation of the cervix, the patient should be told there is a potential 1% to 2% risk for reoperation to remove the cervix and that trachelectomy is associated with a risk of intraoperative complications. Patients with suspected gynecologic cancers or cervical dysplasia are not candidates for supracervical hysterectomy.

Prophylactic Salpingo-oophorectomy

The decision to remove the ovaries and tubes should be based on assessment of risk and not the route of hysterectomy (21). Premenopausal women who are at average risk of ovarian cancer (approximate lifetime risk of 1.4%) should be considered for ovarian preservation when they are undergoing hysterectomy for benign conditions where the ovaries and fallopian tubes are healthy (22). Parous women who have used oral contraceptives may have a substantially lower risk (22). Elective removal of the ovaries and fallopian tubes has declined since 2002 (23).

Salpingo-oophorectomy is performed prophylactically to prevent ovarian cancer and to eliminate the potential for further surgery for either benign or malignant disease. Arguments against prophylactic salpingo-oophorectomy center on the need for earlier and more prolonged hormone therapy and the potential increase risk of cardiovascular disease and bone loss (24,25). There is no overall survival benefit of prophylactic salpingo-oophorectomy in women at average risk for ovarian cancer. In premenopausal women before age 50 years at average risk for ovarian cancer who underwent bilateral salpingo-oophorectomy, there was a significant increase in mortality from cardiovascular disease compared to women who had ovarian preservation (25). A Markov decision analysis model was used to estimate the best strategy for maximizing a woman’s survival when salpingo-oophorectomy is considered in women at average risk for ovarian cancer who are undergoing hysterectomy for benign disease, and in the women who had salpingo-oophorectomy before age 55 years, there was an 8.58% excess mortality by age 80 (26). Both the American College of Obstetricians and Gynecologists and the Society of Gynecologic Oncologists recommend carefully assessing risk, and consideration should be given to conservation of the ovaries in premenopausal women who are at average risk of ovarian cancer (21,22).

Although estrogen therapy is well tolerated and provides good short-term symptomatic relief, recent publications demonstrate that the increased risk of breast cancer in women taking estrogen after hysterectomy makes women reluctant to use it, and long-term compliance with posthysterectomy estrogen therapy is low (27).

In women at risk for ovarian or breast cancer, a formal evaluation with genetic counseling should be offered (see Chapter 37). Salpingo-oophorectomy is associated with a reduced risk of ovarian and breast cancer. Women with a strong family history of ovarian and breast cancer and those who carry germline mutations, BRCA1 or BRCA2 should undergo risk-reducing salpingo-oophorectomy as their lifetime risk is between 10% and 50%(21,22,28,29).

Based on the finding that many serous carcinomas arise in the fallopian tube rather than in the ovary, it was proposed that bilateral salpingectomy with ovarian conservation should be performed in patients with these high penetrance germline mutations while awaiting more definitive surgical intervention (30,31). One could consider this in women at average risk for these tumors when they undergo hysterectomy for benign disease. It is unknown whether this would substantially decrease the risk of developing these malignancies.

Although salpingo-oophorectomy can be accomplished by laparoscopy or laparotomy in virtually 100% of cases, the success rate for vaginal hysterectomy ranges from 65% to 95% for experienced vaginal surgeons (32,33).

Concurrent Surgical Procedures

Appendectomy

Appendectomy may be performed concurrently with hysterectomy to prevent appendicitis and to remove disease that may be present. The former use is of limited value because the peak incidence of appendicitis is between 20 and 40 years of age, whereas the peak age for hysterectomy is 10 to 20 years later (34). There is no increase in morbidity associated with appendectomy performed at the time of hysterectomy (35). Incidental appendectomies in all abdominal hysterectomies could reduce the morbidity of appendicitis at a later time (35). Appendectomy is performed with vaginal hysterectomy without additional intraoperative or postoperative morbidity (36).

Cholecystectomy

Gallbladder disease is about four times more common in women than men, and its highest incidence occurs between 50 and 70 years of age, when hysterectomy is most often performed. Women may require both procedures. A combined procedure does not appear to result in increased febrile morbidity or length of hospital stay (37).

Abdominoplasty

Abdominoplasty performed at the time of hysterectomy is associated with a shorter hospital stay, a shorter operating time, and a lower intraoperative blood loss than when the two operations are performed separately (38,39). Liposuction can be performed safely at the time of vaginal hysterectomy (40).

Choice of Surgical Access: Vaginal, Abdominal, or Laparoscopic Hysterectomy

From 2000 to 2004, approximately 68% of all hysterectomies were performed abdominally and 32% were performed vaginally. One-third of the vaginal cases were performed with the assistance of the laparoscope (laparoscopically assisted vaginal hysterectomy) (1). There are no specific criteria that can be used to determine the route of hysterectomy. The route chosen should be based on the individual patient, but vaginal access is preferred. An alternative access is preferred if there is a narrow pubic arch (less than 90 degrees), and a narrow vagina (narrower than two fingerbreadths, especially at the apex), or if the there is an undescended immobile uterus. The presence of an adnexal mass, cul-de-sac disease, pelvic adhesions, or the assessment of chronic pain may require the addition of laparoscopy for assessment. A previous cesarean section or nulliparity does not contraindicate a vaginal approach (41).

A Cochrane review validated the perception that vaginal hysterectomy is the surgical route of choice for hysterectomy (42). This review included 3,643 patients from 27 randomized trials. It compared abdominal hysterectomy with vaginal hysterectomy and three types of laparoscopic hysterectomies. The main observations were the shorter length of hospital stay, faster postoperative recovery, and decreased febrile morbidity of vaginal and laparoscopic hysterectomy compared with abdominal hysterectomy. The report concludes that there are improved outcomes with vaginal hysterectomy, and, when vaginal access is not possible, laparoscopic hysterectomy appears to have advantages over abdominal hysterectomy. Cost-analysis trials demonstrate that laparoscopic hysterectomy can be cost-effective relative to abdominal procedure but not compared with vaginal hysterectomy (43,44). The main cost determinants are the length of hospital stay and the use of disposable surgical devices.

Risk of complication from each type of procedure provides insight into the proper options for the patient. The eVALuate study comprised two parallel randomized multicenter trials, with one comparing laparoscopic with abdominal hysterectomy and the other comparing laparoscopic with vaginal hysterectomy for nonmalignant disease (45). Patients with a uterine mass less than 12-week pregnancy were included. The primary end points were assessment of complications. A total of 1,380 patients were recruited. The trial included conversion to laparotomy for the laparoscopic and vaginal groups as a major complication. If you include conversion to laparotomy as a major complication, the number treated relative to those harmed was 20 for the laparoscopic group compared with the abdominal group. If you exclude conversion to laparotomy as a complication, then the complication rates are similar between all groups. All six ureter injuries reported in this series occurred in the laparoscopic group. The overall lower urinary tract complication rate is three times higher with the laparoscopic group compared with vaginal or abdominal procedures. A minor complication, mostly postoperative fever or infection, occurred in approximately 25% of each group.

Perioperative Checklist

It is important to systematically go through a checklist of perioperative measures to effectively reduce potential complications (Table 24.2). If excessive blood loss is expected, intraoperative blood salvage techniques should be considered. All patients undergoing hysterectomy for benign disorders are at moderate risk for venous thromboembolism and require prophylaxis (18). Unfractionated heparin (5,000 U every 12 hours) or low molecular weight heparin (e.g., Enoxaparin, 40 mg) or intermittent pneumatic compression device is recommended. Patients on oral contraceptives up to the time of hysterectomy should be considered for pharmacologic treatment. Mechanical bowel preparation for prevention of infection complications from bowel injury is no longer recommended (46).

Table 24.2 Perioperative Checklist

1. Is the informed consent signed? 2. Is there a recent Pap test documented in the chart? 3. Has pregnancy been ruled out? 4. Are blood products available if needed? 5. Will prophylactic antibiotics be initiated within 1 hour of incision? 6. Was the appropriate antibiotic selected according to American College of Obstetricians and Gynecologists guidelines? 7. Was the appropriate prophylaxis for venous thromboembolic events chosen? 8. Document that prophylactic antibiotics will be discontinued within 24 hours after surgery.

Technique

Abdominal Hysterectomy

General Preparation

To reduce the colony count of skin bacteria, the patient is asked to shower. Hair surrounding the incision area may be removed at the time of surgery or before surgery using a depilatory agent. Hair clipping is preferable to shaving because it decreases the incidence of incisional infection, and if shaving is done, it should be performed in the operating room just prior to the surgery (34).

Patient Positioning

For most abdominal cases, the patient is placed in the dorsal supine position for the operation. After the patient is anesthetized adequately, her legs are placed in the stirrups and a pelvic examination is performed to validate the in-office pelvic examination findings. A Foley catheter is placed in the bladder, and the vagina is cleansed with an iodine solution. The patient’s legs are straightened.

Skin Preparation

Several methods for skin cleaning can be recommended, including a 5-minute iodine solution scrub followed by application of iodine solution, iodine solution scrub followed by alcohol with application of an iodine-impregnated occlusive drape, or an iodine-alcohol combination with or without application of an iodine-impregnated occlusive drape.

Surgical Technique

Incision

The choice of incision should be determined by the following considerations:

1. Simplicity of the incision

2. Need for exposure

3. Potential need for enlarging the incision

4. Strength of the healed wound

5. Cosmesis of the healed incision

6. Location of previous surgical scars>

The skin is opened with a scalpel, and the incision is carried down through the subcutaneous tissue and fascia. With traction applied to the lateral edges of the incision, the fascia is divided. The peritoneum is opened similarly. This technique minimizes the possibility of inadvertent enterotomy, entering the abdominal cavity.

Abdominal Exploration

Cytologic sampling of the peritoneal cavity, if needed, should be performed before abdominal exploration. The upper abdomen and the pelvis are explored systematically. The liver, gallbladder, stomach, kidneys, para-aortic lymph nodes, and large and small bowel should be examined and palpated.

Retractor Choice and Placement

A variety of retractors were designed for pelvic surgery. The Balfour and the O'Connor-O'Sullivan retractors are used most often. The Bookwalter retractor has a variety of adjustable blades that can be helpful, particularly in obese patients.

Elevation of the Uterus

The uterus is elevated by placing broad ligament clamps at each cornu so that it crosses the round ligament. The clamp tip may be placed close to the internal os. This placement provides uterine traction and prevents back bleeding (Fig. 24.1).

Figure 24.1 The uterus is elevated by placement of clamps across the broad ligament. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)

Round Ligament Ligation or Transection

The uterus is deviated to the patient’s left side, stretching the right round ligament. With the proximal portion held by the broad ligament clamp, the distal portion of the round ligament is ligated with a suture ligature or simply transected with Bovie cautery (Fig. 24.2). The distal portion can be grasped with forceps, and the round ligament is cut to separate the anterior and posterior leaves of the broad ligament. The anterior leaf of the broad ligament is incised with Metzenbaum scissors or electrocautery along the vesicouterine fold, separating the peritoneal reflection of the bladder from the lower uterine segment (Fig. 24.3).

Figure 24.2 The round ligament is transected and the broad ligament is incised and opened. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)

Figure 24.3 The incision in the anterior broad ligament is extended along the vesicouterine fold. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)

Ureter Identification

The retroperitoneum is entered by extending the incision cephalad on the posterior leaf of the broad ligament. Care must be taken to remain lateral to both the infundibulopelvic ligament and iliac vessels. The external iliac artery courses along the medial aspect of the psoas muscle and is identified by bluntly dissecting the loose alveolar tissue overlying it. By following the artery cephalad to the bifurcation of the common iliac artery, the ureter is identified crossing the common iliac artery. The ureter should be left attached to the medial leaf of the broad ligament to protect its blood supply (Fig. 24.4).

Figure 24.4 Identification of the ureter in the retroperitoneal space on the medial leaf of the broad ligament. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)

Utero-ovarian Vessel and Ovarian Vessel (Infundibulopelvic Ligament) Ligation

If the ovaries are to be preserved, the uterus is retracted toward the pubic symphysis and deviated to one side, placing tension on the contralateral ovarian vessels (the so-called infundibulopelvic ligament), the tube, and the ovary. With the ureter under direct visualization, a window is created in the peritoneum of the posterior leaf of the broad ligament under the utero-ovarian ligament and fallopian tube.The tube and utero-ovarian ligament are clamped on each side with a curved Heaney or Ballantine clamp, cut, and ligated with both a free-tie and a suture ligature. The medial clamp at the uterine cornu should control back bleeding; if it does not, the clamp should be repositioned to do so (Fig. 24.5).

Figure 24.5 Ligation of the utero-ovarian ligament. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)

If the ovaries are to be removed, the peritoneal opening is enlarged and extended cephalad to the ovarian vessels (infundibulopelvic ligament) and caudad to the uterine artery. This opening allows proper exposure of the uterine artery, the ovarian vessels, and the ureter. In this manner, the ureter is released from its proximity to the uterine vessels and uterine vessels.

A curved Heaney or Ballantine clamp is placed lateral to the ovary (Fig. 24.6); care is taken to ensure that the entire ovary is included in the surgical specimen. The uterine vessels on each side are doubly ligated and cut (Fig. 24.7). Alternatively, free ties can be passed around the uterine vessels, two cephalad and one caudad, before they are cut.

Figure 24.6 Ligation of the infundibulopelvic ligament. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)

Figure 24.7 Transection of the infundibulopelvic ligament. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)

Bladder Mobilization

Using Metzenbaum scissors or Bovie, the bladder is dissected from the lower uterine segment and cervix. An avascular plane, which exists between the lower uterine segment and the bladder, allows for this mobilization. Tonsil clamps may be placed on the bladder edge to provide countertraction and easier dissection (Fig. 24.8).

Figure 24.8 Dissection of the vesicouterine plane to mobilize the bladder. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)

Uterine Vessel Ligation

The uterus is retracted cephalad and deviated to one side of the pelvis, stretching the lower ligaments. The uterine vasculature is dissected or “skeletonized” from any remaining areolar tissue, and a curved Zeppelin or Heaney clamp is placed perpendicular to the uterine artery at the junction of the cervix and body of the uterus. Care is taken to place the tip of the clamp adjacent to the uterus at this anatomic narrowing. The vessels are cut, and the pedicle is ligated. The same procedure is repeated on the opposite side (Fig. 24.9).

Figure 24.9 Ligation of the uterine blood vessels. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)

Incision of Posterior Peritoneum

If the rectum is to be mobilized from the posterior cervix, the posterior peritoneum between the uterosacral ligaments just beneath the cervix and rectum may be incised (Fig. 24.10). A relatively avascular tissue plane exists in this area, allowing mobilization of the rectum inferiorly out of the operative field.

Figure 24.10 Incision of the rectouterine peritoneum and mobilization of the rectum from the posterior cervix. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)

Cardinal Ligament Ligation

The cardinal ligament is divided by placing a straight Zeppelin or Heaney clamp medial to the uterine vessel pedicle for a distance of 2 to 3 cm parallel to the uterus. The ligament is cut, and the pedicle is suture ligated. This step is repeated on each side until the junction of the cervix and vagina is reached (Fig. 24.11).

Figure 24.11 Ligation of the cardinal ligament. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)

Removal of the Uterus

The uterus is placed on traction cephalad, and the tip of the cervix is palpated. Curved Heaney clamps are placed bilaterally, incorporating the uterosacral ligament and upper vagina just below the cervix. Care should be taken to avoid foreshortening the vagina. The uterus is then removed with scalpel or curved scissors (Fig. 24.12).

Figure 24.12 Removal of the uterus by transection of the vagina. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996.)

Vaginal Cuff Closure

A figure-of-eight suture of 0 braided absorbable material is placed at the angle of the vagina for both traction and hemostasis. The pedicles are sutured with a Heaney stitch, incorporating the uterosacral and cardinal ligament at the angle of the vagina (Fig. 24.13). A running-locked suture can be used for hemostasis along the cuff edge (Fig. 24.14).

Figure 24.13 Vaginal cuff closure incorporating the uterosacral and cardinal ligaments. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)

Figure 24.14 A: Vaginal cuff left open with a running suture along the cuff. B: Peritoneum closed. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)

Irrigation and Hemostasis

The pelvis is thoroughly irrigated with saline. Meticulous hemostasis in the pelvis, particularly of the vascular pedicles, should be ensured. Ureteral position and integrity are checked to ensure that they are intact and do not appear dilated.

Peritoneal Closure

The pelvic peritoneum is not reapproximated. Research using animal models suggests that reapproximation may increase tissue trauma and promote adhesion formation (47).

Fascia Closure

The parietal peritoneum is not reapproximated as a separate layer. Fascia can be closed with an interrupted or continuous 0 or 1 monofilament absorbable suture. A prospective randomized trial did not show any advantage of interrupted versus continuous fascial closure (48). Bites should be taken about 1 cm from the cut edge of the fascia and about 1 cm apart to prevent wound dehiscence.

Skin Closure

The subcutaneous tissue should be irrigated, with careful hemostasis. Wound disruption seems to be decreased with closure of the subcutaneous fat layer in women with 2 cm or more fat (49). Skin staples or subcuticular sutures are used to reapproximate the skin edges. A dressing is applied and left in place for about 24 hours.

Intraoperative Complications

Every surgeon must be prepared to recognize and repair operative injuries, because despite a high level of attention to detail, injuries and complications, recognized and unrecognized, can still occur.

Ureteral Injuries

Injury to the pelvic ureter is one of the most formidable complications of hysterectomy (50). It is always essential to be aware of the proximity of the ureter to the other pelvic structures. Most ureteral injuries can be avoided by opening the retroperitoneum and directly identifying the ureter. The use of ureteral catheters as a substitute for direct visualization is often of little help in patients with extensive fibrosis or scarring resulting from endometriosis, pelvic inflammatory disease, or ovarian cancer. In these instances, a false sense of security may increase an already high risk for ureteral injury. The use of ureteral catheters are associated with hematuria and acute urinary retention, although their complications are usually transitory in nature.

Direct visualization is accomplished by opening the retroperitoneum lateral to the external iliac artery. Blunt dissection of the loose areolar tissue is performed to visualize the artery directly. The artery may be traced cephalad to the bifurcation of the internal and external iliac arteries. The ureter crosses the common iliac artery at its bifurcation and may be followed throughout its course in the pelvis.

Despite these precautions, ureteral injuries may occur. Prompt consultation is necessary if the surgeon is not trained in ureteral repair. If a ureteral obstruction is suspected, confirmation may be obtained by intravenous injection of 1 ampule of indigo carmine dye and performance of a cystoscopic evaluation. The integrity of the ureters should be confirmed by the presence or absence of bilateral spill of tinted urine.

Bladder Injury

Because of the close anatomic relationship of the bladder, uterus, and upper vagina, the bladder is the segment of the lower urinary tract that is most vulnerable to injury. Bladder injury may occur on opening the peritoneum or, more frequently, during the dissection of the bladder off the cervix and upper vagina. Unless there is involvement of the bladder trigone, a bladder laceration is easily repaired. In the nonirradiated bladder, a one- or two-layer closure with a small-caliber braided absorbable suture such as a 3-0 polyglycolic acid is adequate. The bladder should be drained postoperatively. The length of time that drainage is required is controversial. If the bladder is not compromised, drainage should be continued at least until gross hematuria clears, which may occur as soon as 48 hours postoperatively. A more conservative practice is to continue drainage for 3 to 14 days depending on the type of injury (50). Elective incision into the dome of the bladder is performed in the same manner. If the trigone is involved, a surgeon trained in complicated urologic repair should be consulted, because reimplantation of the ureter may be necessary.

Bowel Injury

Small bowel injuries are the most common intestinal injuries in gynecologic surgery. Small defects of the serosa or muscularis may be repaired using a single layer of continuous or interrupted 3-0 braided absorbable suture. Although single-layer closure of the small bowel has proved adequate, it is safer to close defects involving the lumen in two layers using a 3-0 braided absorbable suture. The defect should be closed in a direction perpendicular to the intestinal lumen. If a large area is injured, resection with reanastomosis may be necessary. Because the bacterial flora of the ascending colon is similar to that of the small bowel, injuries can be repaired in a similar manner. The transverse colon rarely is injured in normal gynecologic procedures because it is well outside the operative field. However, the descending colon and the rectosigmoid colon are intimately involved with the pelvic structures and are at significant risk for injury during gynecologic surgery. Injuries not involving the mucosa may be repaired with a single running layer of 2-0 or 3-0 braided absorbable suture. If the laceration involves the mucosa, it may be closed as with small bowel injuries.

Hemorrhage

Significant arterial bleeding usually arises from the uterine arteries or the ovarian vessels near the insertion of the infundibulopelvic ligaments. Blind clamping of these vessels presents a risk for ureteral injury; therefore, the ureters should be identified in the retroperitoneal space and traced to the area of bleeding to avoid inadvertent ligation. It is best to apply a pressure pack to tamponade the bleeding and slowly remove the pack in an effort to visualize, isolate, and individually clamp the bleeding vessels. Mass ligatures should be avoided. The use of surgical clips may be helpful. Venous bleeding is less dramatic but often is more difficult to manage, particularly in the presence of extensive adhesions and fibroids. This type of bleeding can be controlled with pressure alone or with suture ligation. Bleeding from peritoneal edges or denuded surfaces may be controlled with pressure, application of topical agents such as thrombin or collagen, or Bovie cautery. A variety of laser techniques are used to control bleeding, such as the use of the Argon beam laser.

Postoperative Management

Bladder Drainage

Overdistention of the bladder resulting from bladder trauma or the patient’s reluctance to initiate the voluntary phase of voiding is one of the most common complications after abdominal hysterectomy. An indwelling bladder catheter should be used for the first few postoperative hours until the patient is able to ambulate and urinate.

If retropubic urethropexy was performed, a suprapubic catheter, which allows postvoid residual levels to be checked without repetitive catheterizations, can be considered. This catheter may be removed when satisfactory postvoid residual levels of less than 100 mL are obtained.

Diet

As soon as the patient is alert, diet is resumed, offering solid foods as tolerated with return of appetite. This dietary regimen assumes minimal intraoperative bowel manipulation and dissection. Early postoperative feeding was shown to be safe and to speed return of bowel function and recovery. In patients who had pelvic and para-aortic lymphadenectomy, bowel surgery, or other extensive dissections, a slower return to normal bowel function may occur, so the diet is administered as tolerated when the patient’s appetite returns.

Activity

Early ambulation decreases the incidence of thrombophlebitis and pneumonia. Patients are encouraged to begin ambulation on their first postoperative day if possible and to increase their time out of bed progressively as their strength improves. On discharge, the patient is instructed to avoid lifting more than 20 pounds for 6 weeks, thereby minimizing stress on fascia to allow full healing. Sexual intercourse is not recommended until 6 weeks after surgery, when the vaginal cuff is fully healed. Patients are instructed to avoid driving until full mobility returns because postoperative pain and tenderness may hinder sudden braking or steering maneuvers in emergency situations. With these exceptions, the patient is encouraged to return to normal activities as soon as she feels comfortable doing so.

Wound Care

The abdominal incision normally requires little attention, except for ordinary hygienic measures. The wound is kept covered with a sterile dressing for the first 24 hours after surgery, by which time the incision has sealed. After the dressing is removed, the incision should be cleaned daily with mild soap and water and kept dry.

Vaginal Hysterectomy

Preoperative Evaluation

Evaluation of Pelvic Support

The most important observation in determining the feasibility of a vaginal hysterectomy is the demonstration of uterine mobility (51). A vaginal approach should be chosen only if the uterus is freely mobile. Pelvic support structures are elevated at the initial pelvic examination. In patients with no apparent prolapse, poor pelvic support can often be demonstrated by observing descent of the uterus with a series of Valsalva maneuvers. Although vaginal hysterectomy is easier to perform when the uterine supporting ligaments are lax, it is not an absolute requirement. The practice of applying traction to the cervix with a tenaculum to demonstrate descent of an apparently well-supported uterus is not recommended. Some gynecologists advocate the application of a tenaculum to the anterior cervical lip, with subsequent traction applied as the patient bears down. This exercise may give some indication of uterine mobility, but it is uncomfortable and not necessarily predictive of the success of vaginal hysterectomy.

Evaluation of the Pelvis

After assessment of pelvic support, the bony pelvis should be evaluated. Ideally, the angle of the pubic arch should be 90 degrees or greater, the vaginal canal should be ample, and the posterior vaginal fornix should be wide and deep. The surgeon may use a closed fist to approximate the bituberous diameter, which should exceed 10 cm. The size and shape of the female pelvis contributes to increased exposure. The importance of a wide pubic arch was underscored by the result of a study of 25 failed vaginal hysterectomies that were compared with 50 successful vaginal hysterectomies. Risk factors, such as age, parity, body weight, surgical indication, uterine size, presence of leiomyomata in the anterior lower uterine segment, previous pelvic surgeries, adhesions, location and length of the cervix, and narrow pubic arch (less than 90 degrees), were examined. In the study, only the presence of a narrow pubic arch increased the risk of vaginal hysterectomy (52).

Surgical Considerations

Patient Positioning

When the patient is in the dorsal lithotomy position, the buttocks should be positioned just over the table’s edge. Several stirrup types are available, including those that support the entire leg and those that suspend the legs in straps. To avoid nerve injury, adequate padding should be used; marked flexion of the thigh and pressure points should be avoided. Trendelenburg (10- to 15-degree) positioning aids in the intravaginal visualization needed during surgery.

Vaginal Preparation

A povidone-iodine solution is applied to the vagina, the bladder is drained, and the catheter is removed. Several methods for draping are proposed, including individual or single-piece drapes; the method chosen is at the surgeon’s discretion. There is usually no need to shave or clip the pubic hair. Individual drapes with an adhesive barrier should be used to hold them in place and prevent the pubic hair from compromising the field.

Instruments

Instruments specific to and useful in performing a vaginal hysterectomy include right-angled retractors, narrow Deaver retractors, weighted specula, Heaney needle holders, and an assortment of Breisky–Navratil vaginal retractors. Heaney and Heaney–Ballantine hysterectomy clamps are preferable. Several other clamps are commonly used, including the Masterson clamp.

Lighting

Overhead high-intensity lamps should be used and positioned to direct light over the operator’s shoulder. The surgeon may use a headlight, which can be worn to provide direct horizontal lighting. A fiberoptic-lighted irrigating suction system can provide additional light and transilluminate tissue planes.

Suture Material

Various suture materials are advocated for gynecologic surgery. The type of suture material chosen is based on the surgeon’s preference. A synthetic delayed absorbable polyglactin or polyglycolic acid suture and atraumatic needles are preferable.

Procedure

The patient is examined while anesthetized to confirm prior findings and to assess uterine mobility and descent. The decision whether to proceed vaginally or abdominally is made.

Grasping and Circumscribing the Cervix

The anterior and posterior lips of the cervix are grasped with a single- or double-toothed tenaculum. With downward traction applied on the cervix, a circumferential incision is made in the vaginal epithelium at the junction of the cervix (Fig. 24.15).

Figure 24.15 Circumferential incision in the vagina to infiltrate a vaginal hysterectomy. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)

Dissection of Vaginal Mucosa

After the initial incision is made with a scalpel or a Bovie, the vaginal epithelium may be dissected sharply from the underlying tissue or pushed bluntly with an open sponge (Fig. 24.16). If the initial incision is made too close to the external cervical os, a greater amount of dissection is required and causes associated bleeding. This circumscribing incision should be made just below the bladder reflection. It is important to continue the dissection in the correct cleavage plane to minimize blood loss.

Figure 24.16 Dissection of the vaginal mucosa. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)

Posterior Cul-de-Sac Entry

The peritoneal reflection of the posterior cul-de-sac (cul-de-sac of Douglas) can be identified by stretching the vaginal mucosa and underlying connective tissue with forceps (Fig. 24.17). If difficulty is encountered (e.g., if the cervix is elongated and the peritoneum is not evident), the vaginal mucosa may be incised vertically to the point at which the cul-de-sac becomes more apparent.

Figure 24.17 Entry into the posterior cul-de-sac. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)

If the vaginal mucosa is dissected in the wrong plane, the hysterectomy may begin extraperitoneally by clamping and cutting the uterosacral and cardinal ligaments close to the cervix. The posterior cul-de-sac will be readily identifiable. If the peritoneal reflection of the posterior cul-de-sac cannot be identified, entry into the anterior peritoneum is attempted, and a finger is hooked into the posterior cul-de-sac to place tension on the peritoneum. The peritoneum is opened with Mayo scissors. An interrupted suture is placed to approximate the peritoneum and vaginal cuff and provide hemostasis (Fig. 24.18). The posterior pelvic cavity is examined for pathologic alterations of the uterus or adhesive disease of the cul-de-sac. The weighted speculum is placed into the posterior cul-de-sac.

Figure 24.18 Interrupted suture is placed on posterior vaginal cuff and peritoneum for hemostasis. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)

Uterosacral Ligament Ligation

With retraction of the lateral vaginal wall and countertraction on the cervix, the uterosacral ligaments are clamped with the tip of the clamp incorporating the lower portion of the cardinal ligaments (Fig. 24.19). The clamp is placed perpendicular to the uterine axis, and the pedicle is cut and sutured close to the clamp. A small pedicle (0.5 cm) distal to the clamp is optimal because a larger pedicle becomes necrotic and the tissue sloughs, which may become a culture medium for micro-organisms. The pedicle should be incised no more than one-half to three-fourths of the way around the tip of the clamp. Limiting the incision prevents the next pedicle, which may be vascular, from being cut.

Figure 24.19 Ligation of the uterosacral ligaments. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)

When suturing any pedicle, the needle point is placed at the tip of the clamp, and the needle is passed through the tissue by a rolling motion of the operator’s wrist. Once ligated, the uterosacral ligaments may be transfixed to the posterolateral vaginal mucosa (Fig. 24.20). This suture may lend additional support to the vagina and provide hemostasis at this point on the vaginal mucosa. This suture is held with a hemostat to facilitate location of any bleeding at the completion of the procedure and to aid in the closure of vaginal mucosa.

Figure 24.20 Transfixion of the uterosacral ligament to the posterolateral vaginal mucosa. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)

Entry versus Nonentry into the Vesicovaginal Space (Cul-de-Sac)

Downward traction is placed on the cervix. Using either Mayo scissors, with the points directed toward the uterus, or an open moistened 4 × 4 gauze sponge, the bladder is advanced. If the vesicovaginal peritoneal reflection is easily identified at this point, the vesicovaginal space may be entered. Otherwise, it may be preferable to delay entry. There is no danger in delaying entry so long as the operator ascertains that the bladder was advanced.

After the bladder is advanced, a curved Deaver or Heaney retractor is placed in the midline, holding the bladder out of the operative field. This process precedes each step of the vaginal hysterectomy until the vesicovaginal space is entered.

Cardinal Ligament Ligation

With traction on the cervix continued, the cardinal ligaments are identified, clamped, and cut. The suture is ligated (Fig. 24.21).

Figure 24.21 Ligation of the cardinal ligament. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)

Advancement of Bladder

The bladder again is advanced out of the operative field. A blunt dissection technique may be used; sharp dissection may be helpful if the patient had previous surgery, such as cesarean delivery, which may have scarred the bladder reflection.

Uterine Artery Ligation

Contralateral and downward traction are placed on the cervix. With an effort to incorporate the anterior and posterior leaves of the visceral peritoneum, the uterine vessels are identified, clamped, and cut, and the pedicle is suture ligated (Fig. 24.22). A single suture and single clamp technique is adequate and decreases the potential risk for ureteral injury. When the uterus is large or when a fibroid distorts the anatomic relationships, a second suture may be required to ligate any remaining branches of the uterine artery.

Figure 24.22 Ligation of the uterine artery. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996.)

Entry into the Vesicovaginal Space

The anterior peritoneal fold can be identified just before or after clamping and suture ligation of the uterine arteries. The anterior peritoneal cavity should not be opened blindly because of the increased risk of bladder injury (Fig. 24.23). The peritoneum is grasped with forceps, tented, and opened using scissors with the tips pointed toward the uterus. A Heaney or Deaver retractor is placed, and the peritoneal contents are identified. This retractor serves to keep the bladder out of the operative field.

Figure 24.23 Entry into the vesicovaginal space. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)

Delivery of the Uterus

A tenaculum is placed onto the uterine fundus in a successive fashion to deliver the fundus posteriorly (Fig. 24.24). The operator’s index finger is used to identify the utero-ovarian ligament and aid in clamp placement.

Figure 24.24 Delivery of the uterine fundus posteriorly. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)

Utero-ovarian and Round Ligament Ligation

With the posterior and anterior peritoneum opened, the remainder of the broad ligament and utero-ovarian ligaments are clamped, cut, and ligated (Fig. 24.25). The utero-ovarian and round ligament complexes are double ligated with a suture tie followed by a ligature medial to the first suture. A hemostat is placed on the second suture to aid in the identification of any bleeding and to assist with peritoneal closure. A hemostat should not be placed on the first suture or any other vascular pedicle to avoid the risk for loosening the tie.

Figure 24.25 Ligation of the utero-ovarian and round ligaments. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)

Removal of the Ovaries

During the removal of the adnexa, the round ligaments should be removed separately from the adnexal pedicles. Traction is placed on the utero-ovarian pedicle. The ovary is drawn into the operative field by grasping it with a Babcock clamp. A Heaney clamp is placed across the ovarian vessels (infundibulopelvic ligament), and the ovary and tube are excised (Fig. 24.26). A transfixion tie and suture ligature are placed on the ovarian vessels. The surgeon should not be reluctant to remove the fallopian tube separately from the ovary if taking them together risks loss of the tissue pedicle or injury to the ureter or nearby blood vessels.

Figure 24.26 Removal of the ovaries and fallopian tubes by clamping across the ovarian vessels (infundibulopelvic ligament). (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)

Hemostasis

A retractor or tagged sponge is placed into the peritoneal cavity, and each of the pedicles is visualized and inspected for hemostasis. If additional sutures are required, they should be placed precisely, with care to avoid the ureter or bladder.

Peritoneal Closure

Because the pelvic peritoneum does not provide support and re-forms within 24 hours after surgery, the peritoneum need not be reapproximated routinely. If it is important, the anterior peritoneal edge is identified and grasped with forceps. A continuous absorbable 0 suture is begun at the 12-o'clock position. The suture is continued in a purse-string fashion and incorporates the distal portion of the left upper pedicle and the left uterosacral ligament (Fig. 24.27). At the beginning of the procedure tension is applied to the suture that incorporates the posterior peritoneum and vaginal mucosa. This allows for high posterior reperitonealization, which shortens the cul-de-sac and helps prevent future enterocele formation. The right uterosacral ligament and the distal portion of the right upper pedicle are incorporated, and this continuous suture ends at the point on the anterior peritoneum where it began.

Figure 24.27 Closure of the peritoneum. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)

Vaginal Mucosa Closure

The vaginal mucosa can be reapproximated in a vertical or horizontal manner, using either interrupted or continuous sutures (Fig. 24.28). The vaginal mucosa is, in this case, reapproximated horizontally with interrupted absorbable sutures. The sutures are placed through the entire thickness of the vaginal epithelium, with care taken to avoid entering the bladder anteriorly. These sutures will obliterate the underlying dead space and produce an anatomic approximation of the vaginal epithelium, thereby decreasing the postoperative formation of granulation tissue.

Figure 24.28 Closure of the vaginal mucosa. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)

Bladder Drainage

After completion of the procedure, the bladder is drained. Unless an anterior or posterior colporrhaphy or other reconstructive procedure is performed, neither bladder catheter nor vaginal packing is mandatory.

Surgical Techniques for Selected Patients

Injection of Vaginal Mucosa

The use of paracervical and submucosal injection of 20 to 30 mL of 0.5% lidocaine with 1:200,000 epinephrine before incision of the vaginal mucosa may decrease postoperative pain and facilitate identification of surgical planes. There is no need to inject the cervix. Areas to be injected include the bladder pillars, lower portion of the cardinal ligament, uterosacral ligaments, and paracervical tissue. The incidence of cuff cellulitis and cuff abscess formation is increased when epinephrine is injected into the cervicovaginal mucosa.

Morcellation of the Large Uterus

Uterine morcellation is a well-known but underutilized surgical procedure whereby the uterus is removed piecemeal. Several methods of uterine morcellation were described, including hemisection or bivalving, wedge or “V” incisions, and intramyometrial coring (53). Before beginning any morcellation procedure, the uterine vessels must be ligated, and the peritoneal cavity must be entered. When uterine hemisection or bivalving is performed, the cervix is split at the midline, and the uterus is cut into halves, which are removed separately (53). This method seems best suited for fundal, midline leiomyomas.

Wedge morcellation is best suited for anterior or posterior fibroids or for fibroids in the other broad ligaments (i.e., when the fibroids are away from the midline). The cervix is amputated, and the myometrium is grasped with clamps. Wedge-shaped portions of myometrium are removed from the anterior or posterior uterine wall. The apex of the wedge is kept in the midline, thereby reducing the bulk of the myometrium. This process is repeated until the uterus can be removed or until a pseudocapsule of a fibroid can be grasped with a Leahy clamp or towel clip. Traction is applied, and a “myomectomy” is performed.

When the intramyometrial coring technique is used, the myometrium above the site of the ligated vessels is incised parallel to the axis of the uterine cavity and serosa of the uterus. This incision is continued around the full circumference of the myometrium in a symmetrical fashion beneath the uterine serosa. Traction is maintained on the cervix, and the avascular myometrium is cut to allow the undisturbed endometrial cavity, with a thick layer of myometrium, to be delivered with the cervix. As a result, the inside of the uterus with its unopened endometrial cavity is brought closer to the operator. Incision of the lateral portions of the myometrium medial to the remaining attachment of the broad ligament results in considerable additional descent of the uterus and greatly increases the mobility of the uterine fundus. The uterus is converted from a globular to an elongated tissue mass. The cored uterus is removed by clamping the utero-ovarian pedicle and fallopian tubes.

In a retrospective comparison of 383 patients undergoing abdominal hysterectomy or vaginal hysterectomy with uterine morcellation, length of stay and perioperative complications were significantly increased with abdominal hysterectomy. It appears that vaginal hysterectomy with uterine morcellation is safe and allows an increased number of women to undergo vaginal hysterectomy (54).

McCall Culdoplasty

Although McCall culdoplasty is thought to help decrease future enterocele formation, the accuracy of this belief remains open to debate. An absorbable suture is placed through the full thickness of the posterior vaginal wall at the point of the highest portion of the vaginal vault. The patient’s left uterosacral ligament pedicle is grasped and sutured. The suture incorporates the posterior peritoneum, between the uterosacral ligaments and the right uterosacral ligament. The suture is completed by passing the needle from the inside to the outside at the same point at which it was begun. The suture is tied, thereby approximating the uterosacral ligaments and the posterior peritoneum.

Schuchardt Incision

When vaginal exposure is difficult, the Schuchardt incision may be used. If the surgeon is right handed, the incision is made on the patient’s left side. To decrease blood loss, the area can be infiltrated with lidocaine-containing epinephrine. The incision follows a curved line from the 4-o'clock position at the hymenal margin to a point halfway between the anus and the ischial tuberosity. The incision may be continued into the vaginal vault as high as necessary to gain exposure. The depth of the incision is the medial portion of the pubococcygeus muscle, which may be divided in extreme cases. The incision must be closed in layers at the completion of the procedure.

Intraoperative Complications

Bladder Injury

Injury to the urinary bladder is one of the most common intraoperative complications associated with hysterectomy. If the bladder is inadvertently entered, repair should be performed when the injury is discovered and not delayed until completion of surgery. When bladder injury is recognized, the edges of the wound should be mobilized to assess the full extent of the injury and allow repair without tension. This assessment should include visualization of the trigone to exclude injury to that area. The bladder may be repaired with a single- or double-layered closure with a small-caliber absorbable suture. Methylene blue, indigo carmine, or a dye of sterile milk formula can be instilled into the bladder to ensure that the repair is adequate.

Bowel Injury

Because patients with suspected pelvic adhesions or obvious pelvic disease are excluded as candidates for vaginal hysterectomy, bowel injuries do not occur often. Bowel injuries are associated with the performance of a posterior colporrhaphy and are usually confined to the rectum.

If the rectum is entered, the injury is repaired with a single- or double-layer closure using a small-caliber absorbable suture, followed by copious irrigation. Postoperatively, the patient should be given a stool softener and a low-residue diet.

Hemorrhage

Intraoperative hemorrhage invariably is the result of failure to ligate securely a significant blood vessel, bleeding from the vaginal cuff, slippage of a previously placed ligature, or avulsion of tissue before clamping. Most intraoperative bleeding can be avoided with adequate exposure and good surgical technique. Using square knots with attention to proper knot-tying mechanisms will prevent bleeding in most cases. The use of Heaney-type sutures may minimize ligature slippage and subsequent bleeding from bulky pedicles. When bleeding does occur, blind clamping, which may endanger the ureter, should be avoided. The bleeding vessel should be identified and precisely ligated, with visualization of the ureter if necessary. If the location of the ureter is in question, it should be visualized before suturing a bleeding vessel.

Perioperative Care

Bladder Drainage

Postoperative bladder drainage should be employed after any procedure in which spontaneous, complete voiding is not anticipated. Reasons to consider closed bladder drainage include significant local pain, additional vaginal reparative procedures, surgery for stress incontinence, the use of a vaginal pack, and patient anxiety.

After vaginal hysterectomy without additional repair, most patients can void spontaneously, and catheter drainage is not required. The relative amount of pain after a vaginal hysterectomy is less than with abdominal hysterectomy and, in the absence of additional repairs or a pack, no obstructive effect should be present.

If the patient does not tolerate pain well postoperatively or is extremely anxious, the transurethral insertion of a 16-Fr. catheter after completing surgery is warranted. This catheter may be inserted postoperatively if the patient is unable to void spontaneously on two attempts. Closed-catheter drainage after vaginal hysterectomy usually is not necessary for longer than 24 hours. The catheter is removed without clamping, and there is no need to obtain a urine specimen for culture and sensitivity.

Diet

Although little manipulation of the bowel occurs during vaginal hysterectomy, there is some slowing of gastrointestinal motility. This slowing rarely occurs to a degree that limits some form of oral intake soon after surgery. Most patients experience some degree of nausea after surgery, which, combined with drowsiness from analgesics, usually makes them disinterested in food on the evening after surgery. A clear liquid diet is suitable during the first night after surgery, and on the first full postoperative day, a regular diet can usually be consumed. The patient is often the best judge of what she can tolerate as her appetite returns.

Laparoscopic Hysterectomy

Preoperative Preparation

The main limitations to a laparoscopic approach are medical or anesthetic disorders that do not allow adequate pneuomperitoneum or proper ventilation (34). Extensive and dense pelvic abdominal adhesions from previous surgery and very large uterine size are relative contraindications, although this decision can be made after assessing the peritoneal cavity (see Chapter 23). If the uterine size limits access to the uterine vessels, laparoscopic hysterectomy may not be possible. Obesity is not a contraindication to laparoscopic hysterectomy. The increased morbidity from laparotomy in patients with high body mass (BMI) can be minimized with laparoscopy.

Different classifications were proposed for the types of laparoscopic hysterectomy. Laparoscopic hysterectomy is defined as a laparoscopic-assisted vaginal hysterectomy (LAVH) if the uterine vessels are occluded vaginally. The Cochrane review authors recommended that if the vessels are occluded laparoscopically, or if part of the operation is performed vaginally, the procedure be called laparoscopic hysterectomy, and, if no component is performed vaginally, the procedure should be called a total laparoscopic hysterectomy (41).

Patient Positioning

The patient is placed in dorsal lithotomy position with legs placed in Allen or Yellowfin stirrups (Allen Medical Systems, Acton, MA). Attention to proper leg placement will avoid nerve injury. Hyperflexion of the hips should be avoided because this may cause femoral nerve palsy. The patient should be placed on an egg crate mattress or beanbag cushion to limit patient movement in the Trendelenburg position. The arms are tucked on the patients' side and protected with egg crate–type material. No shaving or clipping is necessary. Shoulder braces should not be used as they are associated with brachial plexus injury.

The steps to follow before introducing the first trocar are:

• Perform an examination under anesthesia.

• Place a Foley catheter to drain the bladder.

• Introduce a uterine manipulator (e.g., Koh colpotomizer [Cooper Surgical Inc., Trumbull, CT] or VCare [Conmed Corp., Utica NY]).

• Place an oral gastric tube.

Instrumentation

The most important instrument is the one used to occlude blood vessels. A multitude of energy forms exist, including electrosurgery, lasers, and ultrasonic scalpel (see Chapter 23). Some surgeons use stapling devices, although the cost of these stapling devices is high, and an energy-occluding device is needed to access areas that a stapler cannot. The versatility of the devices with energy makes them the method of choice to occlude vessels. There are no valid clinical data showing that one instrument is safer than another. The preferred one involves bipolar energy because gynecologists are experienced with this form of energy.

Surgical Technique of Laparoscopic Hysterectomy

Peritoneal Access

The most important technical consideration for all laparoscopic surgery is port placement (see Chapter 23). The umbilical site typically is used in patients without a previous history of surgery or intra-abdominal infection. In cases of previous surgery where there was a midline incision or a history of a pelvic-abdominal incision, an open laparoscopy is done or an alternative site is chosen to introduce the primary cannula. The open laparoscopy is essentially a mini-laparotomy at the umbilicus. The alternative site is the left upper quadrant. The standard closed technique involves the use of pneumoperitoneum needle (Verres needle), insufflation, and primary trocar insertion. An alternative technique is the direct trocar insertion (no insufflation prior to trocar insertion). A meta-analysis showed no advantage of one technique over the other (24). Gynecologists should use the approach with which they have most experience.

If the left upper quadrant is used, the surgeon should be aware of the closest anatomic structures to the left costal margin (see Chapter 23, Fig. 23.3). Typically the cannula is introduced below the left costal margin in the midclavicular line. The closest structures to this area are the stomach and the left lobe of the liver. Therefore, an oral gastric tube should be introduced to empty the stomach before starting the procedure.

The patient is kept in a horizontal (not Trendelenburg) position until proper peritoneal access is confirmed. The angle of insertion of the primary trocar will depend on the size of the patient. Typically for nonobese or overweight patients a 45-degree angle from the horizontal is used and with obese patients a 60- to 80-degree angle or open technique is used.

Proper placement of accessory ports is critical to allow the steps of a laparoscopic hysterectomy. The authors typically use three lateral accessory ports and do not use a suprapubic port. Lateral ports offer the surgeon an ergonomic approach in which both hands can be used comfortably. The most important step when placing lateral ports is to avoid the inferior epigastric vessels, which are branches of the external iliac artery and vein. (see Chapter 23, Fig. 23.3). Direct visualization is best. These vessels (typically two veins and an artery) are seen through the peritoneum medial to the insertion of the round ligament in the deep inguinal ring. They cannot be transilluminated. Ports are placed approximately 8 cm from the midline and 8 cm above the pubic symphysis.

Laparoscopic hysterectomy requires traction and countertraction to identify the vascular pedicles and the ureter, which is accomplished with the uterine manipulator. In the case of a large uterus, a laparoscopic tenaculum is required. The procedure starts with coagulating and transecting the round ligament (Fig. 24.29). The incision is carried anteriorly to create a bladder peritoneal flap by sharp dissection of the loose areolar cervicovesical tissue. The retroperitoneal space is opened and the ureter identified on the medial leaf of the broad ligament (Fig. 24.30). The ovarian vessels (infundibulopelvic ligament) or the utero-ovarian ligaments are coagulated and transected, depending on whether the ovaries will be removed (Fig. 24.31). The surgeon can proceed vaginally (LAVH), but there will not be any improved uterine descent because the transected tissue has no major role in uterine support.

Figure 24.29 The right round ligament is grasped and desiccated with a bipolar device.

Figure 24.30 The round ligament has been transected and the right ureter is identified in the retroperitoneal space.

Figure 24.31 The right infundibulopelvic ligament is grasped with a bipolar device, desiccated and cut.

The uterus is then torqued away from the uterine artery to be occluded. The uterine artery is skeletonized by cutting the posterior peritoneum up to the uterosacral ligament, coagulated, and transected. The procedure is carried out on the other side. This area of occlusion is approximately the level of the internal os. If a supracervical hysterectomy was performed, the uterus can now be amputated. When this is done, the remaining endocervical canal should be cauterized.

The anterior dissection should be completed so that the bladder is completely off the anterior fornix area of the vagina (Fig. 24.32). Using a vaginal device such as the Koh, the surgeon can identify this area. Ensuring that no CO₂escapes from the vagina, and an incision is made on the vagina circumferentially around the cervix (Fig. 24.33). The uterus can be pulled out though the vagina or can be morcellated first, and then removed either vaginally or laparoscopically, whichever is easier.

Figure 24.32 After the bladder peritoneum is sharply dissected down to the level of the cervix, the uterine vessels are grasped with the bipolar devise and desiccated.

Figure 24.33 The vagina over the anterior fornix is identified and incision is made.

The vaginal cuff is closed laparoscopically or vaginally with interrupted or continuous delayed absorbable suture (2-0 on CT-1 needle). To give added pelvic support, the uterosacral ligaments are reattached to the vagina (McCall’s culdoplasty) with delayed absorbable suture. Intravenous indigo carmine is given and the integrity of the bladder and ureters confirmed with cystoscopy, if desired, by the surgeon.

At the end of the procedure, the secondary ports should be removed under direct visualization to ensure that there is no bleeding. The fascia should be closed at port sites that are 8 mm or greater and smaller ports that have prolonged manipulation to avoid possible herniation.

The patient is kept in the short stay unit and discharged within 24 hours if there are no complications. A regular diet as tolerated is given on the same day as the surgery. Ambulation is encouraged as soon as possible. Median time to return to work is 3 to 4 weeks (42).

Robotic-Assisted Laparoscopic Hysterectomy

A surgical robot consists of a surgeon’s console with the instrument manipulators and view screen, a robot tower with telerobotic arms that are attached to the patient, and the computer interface equipment, which is housed in a separate tower (see Chapter 25 for a more complete discussion). Robotic assistance at laparoscopy has some advantages, including a three-dimensional view, instruments with articulating tips that offer seven[MB1] degrees of movement, scaling of movement, and more precise movements. The disadvantages are the bulky device around the patient that limits the assistant’s movements, the lack of haptic feedback, and the high cost of the robot. The robot device uses a 12-mm laparoscope and 8-mm instruments.

The robotic tower can be docked between the legs or on the patient’s side (side docked). Side docking allows access to the perineum and vagina so that the assistant can comfortably manipulate the uterus. A robot-assisted hysterectomy goes through the same steps as a laparoscopic hysterectomy. A right-handed surgeon should have the monopolar scissors or harmonic scalpel through a right robotic port and a vessel-sealing device such as a bipolar instrument through a left-sided robotic port. If a fourth robotic arm is used, the additional port is placed on the right side for right-handed surgeons.

Observational studies showed that outcomes for robotic-assisted hysterectomy can be similar to laparoscopic hysterectomy but with less blood loss and possibly fewer conversions to laparotomy (55,56). The learning curve to stabilize operative times for skilled laparoscopic surgeons is about 50 cases (57). Although these case series demonstrated equivalent operative times, an analysis of the Premier hospital database of over 36,000 laparoscopic or robotic hysterectomies demonstrated longer surgical times and higher costs with the robot-assisted procedures compared with conventional laparoscopy with little difference in perioperative and postoperative outcomes (58). Robotic-assisted laparoscopic hysterectomy is associated with delayed vaginal cuff dehiscence around 7 to 8 weeks after hysterectomy, although one case series showed an increased frequency with conventional laparoscopy (59,60). The frequency of other complications is similar to conventional laparoscopy. A more complete discussion of this subject is in Chapter 25.

Laparoendoscopic Single-Site Surgery

Another modification of laparoscopic hysterectomy is the introduction of laparoendoscopic single-site surgery or single-port surgery. Because some surgeons use one of the multiple ports at one site, laparoendoscopic single-site surgery is probably the best term. The role of single-site access to hysterectomy is unclear, and there are only case reports (61). Specifically designed umbilical port systems that admit multiple instrument access have enabled the development of this technique. The availability of flexible instruments and flexible tip laparoscopes allows the surgeon to perform a hysterectomy by reducing instrument crowding and clashing at the umbilicus. The basic hysterectomy steps are the same.

Intraoperative Complications: Laparoscopic Hysterectomy

The intraoperative complications of a laparoscopic hysterectomy are similar to an open hysterectomy. These are injury to the ureter, bladder, and bowel and hemorrhage. Recognition and management are similar. Because there is an increased frequency of injury to the ureter and bladder, a cystoscopic evaluation after injection of intravenous indigo carmine dye is recommended (62).

Intraoperative bleeding during a laparoscopic procedure is handled by use of a bipolar instrument. The same principles apply as with an open case. Cautery should not be used without proper localization of the ureters. If it is not apparent where the bleeding is occurring, the procedure should be converted to an open one.

Perioperative Care

Many surgeons remove the bladder catheter at the end of the laparoscopic hysterectomy. Patients can resume a regular diet the same day as the surgery. Transition to oral analgesics can be made the same day.

Postoperative Complications of Hysterectomy

A comprehensive discussion of postoperative complications after gynecologic surgery is presented in Chapter 22.

Wound Infections

Wound infections occur after 4% to 6% of abdominal hysterectomies (33). Measures believed to reduce the incidence of wound infections include a preoperative shower, no removal of hair, or if hair removal is necessary, removal of hair with clippers in the operating room, use of adhesive drapes and prophylactic antibiotics, and delayed primary closure (see Chapter 22).

Incisional Pain

Incisional pain can occur at trocar sites, especially if located in the region of the ilioinguinal or iliohypogastric nerves. Pfannenstiel incisions can be a source of chronic pain at the incision site as a result of nerve entrapment (63).

Hemorrhage

Immediately after hysterectomy, hemorrhage may become apparent in one of two ways. Bleeding from the vagina may first be noted by the nursing staff or physician within the first few hours after surgery. Second, the patient may be noted to have little bleeding from the vagina but deteriorating vital signs manifested by low blood pressure and rapid pulse, falling hematocrit level, and flank or abdominal pain. The first presentation is in the form of bleeding from the vaginal cuff or one of the pedicles. The second presentation may be a retroperitoneal hemorrhage. Each situation is approached differently in its evaluation and treatment, but both involve the same general principles of rapid diagnosis, stabilization of vital signs, appropriate fluid and blood replacement, and constant surveillance of the patient’s overall condition.

After vital signs are assessed, attention should be directed to the amount of bleeding. A small amount of bleeding is expected after any vaginal hysterectomy. Steady bleeding 2 to 3 hours after surgery suggests lack of hemostasis.The patient should be taken promptly to the examining room, where the operative site is viewed using a large speculum and good lighting. If bleeding is not excessive, the vaginal cuff can be inspected, and in many instances, bleeding from the cuff edge will be found. Hemostasis can easily be achieved with one or two sutures placed through the mucosa.

If bleeding is excessive or appears to be coming from above the cuff, or if the patient is too uncomfortable to tolerate adequate examination, she should be taken to the operating room. General anesthesia should be administered and the vaginal operative site should be thoroughly explored. Any bleeding point may be sutured or ligated. Bleeding that is coming from above the cuff or is extremely heavy usually cannot be controlled through the vaginal route. An exploratory laparotomy is necessary to examine the pelvic floor, identify and isolate the bleeding vessel, and achieve hemostasis. The ovarian vessels and uterine arteries should be thoroughly inspected because they often are the source of excessive vaginal bleeding. If it is difficult to localize bleeding to a specific pelvic vessel, or if these maneuvers do not work, ligation of the hypogastric artery may be performed.

In the patient with little vaginal bleeding in whom vital signs have deteriorated, retroperitoneal hemorrhage should be suspected. Input and output should be monitored. Hematocrit assessment, along with cross-matching of packed red blood cells, should be performed immediately. Examination may reveal tenderness and dullness in the flank. In cases of intraperitoneal bleeding, abdominal distention may occur. Diagnostic radiologic studies can be used to confirm the presence of retroperitoneal or intra-abdominal bleeding. Ultrasonography is one option for viewing low pelvic hematomas; CT provides better visualization of retroperitoneal spaces and can delineate a hematoma.

If the patient’s condition stabilizes rapidly with intravenous fluids, one of two approaches may be used for continued care. The first is to give the patient a transfusion and follow serial hematocrit assessments and vital signs. In many instances, retroperitoneal bleeding will tamponade and stop, forming a hematoma that may eventually be resorbed. The risk with this approach is that the hematoma will become infected, necessitating surgical drainage. In some instances when the patient’s condition is stable, radiologic embolization may be considered.

Another option is to perform abdominal exploratory surgery while the patient’s condition is stable. This approach adds the morbidity of a second procedure but avoids the possibility of the patient’s condition deteriorating with continued delay or the formation of a pelvic abscess. Once adequate exposure is obtained, the peritoneum over the hematoma should be opened and the blood evacuated. All bleeding vessels should be identified and ligated. If bleeding is difficult to control, consideration should be given to unilateral or bilateral ligation of the anterior division of the internal iliac artery. Once hemostasis is achieved, the pelvis should be drained using a closed system.

Urinary Tract Complications

Urinary Retention

Urinary retention after hysterectomy is an uncommon occurrence. If the urethra is unobstructed and retention occurs, it is usually the result of either pain or bladder atony resulting from anesthesia. Both are temporary effects.

If a catheter was not placed after surgery, retention can be relieved initially with the insertion of a Foley catheter for 12 to 24 hours. Most patients are able to void after the catheter is removed 1 day later. If the patient still has trouble voiding and urethral spasm is suspected, success can be achieved with a skeletal muscle relaxant such as diazepam (2 mg twice a day). In most cases, waiting is the best course, and voiding usually occurs spontaneously.

Ureteral Injury

In patients who develop flank pain soon after vaginal hysterectomy, ureteral obstruction should be suspected. The incidence of ureteral injury is lower with vaginal hysterectomy than with abdominal hysterectomy(41,44). One risk factor for its occurrence is total uterine prolapse, in which the ureters are drawn outside the bony pelvis.

In a patient with flank pain in whom ureteral obstruction is suspected, a CT urogram and a urinalysis should be performed. If obstruction is noted on CT scan, it is usually present near the ureterovesical junction. The immediate step is attempted passage of a catheter through the ureter under cystoscopic guidance. If a catheter can be passed through the ureter, it should be left in place for at least 4 to 6 weeks, allowing sutures to absorb and the obstruction or kinking to release. If the catheter cannot be passed through the ureter, the best course is to perform abdominal exploratory surgery and repair the ureter at the site of obstruction.

Vesicovaginal Fistula

Vesicovaginal fistulas occur most often after total abdominal hysterectomy for benign gynecologic disease (50). Intraoperative steps to avoid the formation of a vesicovaginal fistula include correct identification of the proper plane between the bladder and cervix, sharp rather than blunt dissection of the bladder, and care in clamping and suturing the vaginal cuff. The development of a postoperative vesicovaginal fistula after hysterectomy is rare; the incidence is as low as 0.2%.

Patients who have a postoperative vesicovaginal fistula develop a watery vaginal discharge 10 to 14 days after surgery. Some fistulas resulting from surgery are noted as early as the first 48 to 72 hours after surgery. After vaginal examination with a speculum, the diagnosis can usually be confirmed with the insertion of a cotton tampon into the vagina followed by the instillation of methylene blue or indigo carmine dye through a transurethral catheter. If the tampon stains blue, a vesicovaginal fistula is present. If no staining occurs, the presence of a ureterovaginal fistula must be ruled out by the intravenous injection of 5 mL of indigo carmine dye. Within 20 minutes, the tampon should stain blue if a ureterovaginal fistula is present. A CT urogram should be performed to rule out ureteral obstruction.

If a vesicovaginal fistula is diagnosed, a Foley catheter should be inserted for prolonged drainage. Up to 15% of fistulas close spontaneously with 4 to 6 weeks of continuous bladder drainage. If closure has not occurred by 6 weeks, operative correction is necessary. Waiting 3 to 4 months from the time of diagnosis before operative repair is recommended to allow reduction of inflammation and to improve vascular supply. After vaginal hysterectomy, the fistula site is above the bladder trigone and away from the ureters. Vaginal repair can be anticipated in most patients. The surgical correction is undertaken in a four-layered closure: the bladder mucosa, the seromuscular layer, the endopelvic fascia, and the vaginal epithelium.

Incidental cystotomy at the time of hysterectomy is more common than vesicovaginal fistula. When identified and repaired correctly, cystotomy rarely results in the development of a fistula.

Prolapse of the Fallopian Tube

Posthysterectomy prolapse of the fallopian tube is a rare event and can be confused with granulation tissue at the vaginal apex. Predisposing factors for the development of fallopian tube prolapse include development of a hematoma and an abscess at the vaginal apex. Approximately one-half of patients undergoing vaginal hysterectomy form some granulation tissue at the vaginal vault. In patients in whom granulation tissue persists after attempts to cauterize it or pain is experienced with attempts to remove it, fallopian tube prolapse should be suspected. A biopsy of the area is warranted and usually reveals tubal epithelium if a fallopian tube is present.

If fallopian tube prolapse is diagnosed, it should be repaired with surgery. The surrounding vaginal mucosa should be opened and undermined widely. The tube is ligated high and removed, followed by closure of the vaginal mucosa.

Discharge Instructions

Before discharging the patient, instructions should be reviewed. Printed postoperative instructions are helpful to the patient and a suggested set of instructions are as follows:

1. Avoid strenuous activity for the first 2 weeks, and increase activity level gradually.

2. Avoid heavy lifting, douching, or sexual intercourse until instructed by the physician.

3. Bathe as needed using shower or tub baths.

4. Follow a regular diet.

5. Avoid straining for a bowel movement or urination. For constipation, use Milk of Magnesia or Metamucil (1 tsp in juice).

6. Call the physician if excessive vaginal bleeding or fever occurs.

7. Schedule a return appointment at the time specified by the physician.

The physician should provide telephone numbers for emergencies both during and after office hours. Typically, the first postoperative visit is scheduled about 4 weeks after discharge from the hospital. At the time of that visit, the patient should be ambulating well, and vaginal discharge or bleeding should be minimal. Speculum examination of the cuff should be gentle and cursory, but the patient should be assured that the healing process is proceeding normally. Finally, the patient’s questions should be answered and advice given on increasing her activity level, including sexual activity, work, and normal household activity.

General Pelvic Symptoms and Quality of Life

Patient satisfaction after hysterectomy is related to the initial indication for surgery and patient expectation. The Maine Women’s Health Study evaluated the effect of hysterectomy for nonmalignant disorders on quality of life (13). They documented a marked improvement in pelvic pain, urinary symptoms, and psychological and sexual symptoms at 1 year in the majority of patients. In the Maryland Women’s Health Study patients were followed for up to 2 years after hysterectomy for nonmalignant conditions (64). Symptoms related to the underlying indication for surgery, and associated symptoms of depression and anxiety and quality of life, improved after hysterectomy. Each study reported that about 8% of patients had new symptoms, such as depression and lack of interest in sex or lack of improvement in quality of life. Although women with pelvic pain and depression did not show the same level of improvement as other groups, there was significant improvement over baseline. Patient satisfaction is very high after hysterectomy (64).

Sexual Function

There is considerable debate in the lay literature about the effect of hysterectomy on sexual function, although evidence consistently suggests that the majority of women have unchanged or improved sexual function 1 to 2 years after hysterectomy (13,64). Few women who had a hysterectomy had a measurable worsening in sexual function during this time period. The long-term effects of hysterectomy on sexual function remain largely unknown. Studies have addressed the short-term effects of hysterectomy on dyspareunia, frequency of intercourse, orgasm, libido or sexual interest, vaginal dryness, and overall sexual function. The Maine Women’s Health Study demonstrated a significant decrease in the number of women who reported dyspareunia 12 and 24 months after hysterectomy compared to the preoperative period (13). Eighty-one percent of the women who experienced dyspareunia preoperatively had an improvement in this symptom at 24 months after hysterectomy, while only 1.9% of women without preoperative dyspareunia developed it by 24 months after surgery. In this study, 39% of women reported dyspareunia preoperatively, and only 8% had this complaint 12 months after hysterectomy. Women who were managed nonsurgically showed no decline in the mean frequency of dyspareunia (13).

Most studies report that hysterectomy has little impact on the frequency of intercourse, libido, and sexual interest. Orgasmic function before and after hysterectomy is somewhat more controversial, but the largest study by Carlson et al. reported a slight increase in the proportion of women who experienced orgasms after a hysterectomy (13). It is plausible that removal of the uterus and/or cervix (especially if the ovaries are also removed) may adversely affect sexual function in some women, but this may be offset by the improvement in sexual function that could result from cessation of abnormal or heavy vaginal bleeding, dysmenorrhea, or symptoms of prolapse. It is likely that vaginal dryness is not affected by hysterectomy and depends more on age and postoperative hormonal status. Body image and sexual function are improved after vaginal, abdominal, and laparoscopic hysterectomy, but no differences were found between the three routes (13,63).

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