This technique converts the globular, anatomically distorted fundus into a cylinder. Be sure to make the encircling incision under direct vision to reduce the risk of injuring adjacent structures.
In most cases, coring has the advantage of leaving the endometrial cavity and serosa intact. With practice, this technique can quickly and reliably reduce a large uterus to a manageable size.
In some cases, you may have to remove the cervix before debulking
If the cervix is particularly bulky or prevents access to the fundus, perform cervicectomy prior to debulking. This type of debulking is not highly technical, and it may make the remainder of the procedure easier to accomplish. As debulking proceeds, use the endocervical canal or endometrial cavity for orientation.
When complete removal is impossible
Occasionally, it is not possible to complete vaginal removal of the large uterus. While this scenario is not ideal, no evidence exists that conversion to the abdominal or laparoscopic route endangers the patient, especially if the decision is made in a timely and judicious manner. Perform cervicectomy before converting to the abdominal or laparoscopic route. The cervical cuff may also be closed prior to conversion.
Be sure to weigh the specimen
Inform the pathologist of the reason for the morcellated specimen so that an accurate total weight can be determined. This is important because CPT codes for uteri larger than 250 g carry more relative value units than the codes for smaller uteri, based on the extra time in the OR as well as the greater technical skill required.
CASE 610-g uterus safely removed
M.G. undergoes vaginal hysterectomy with uteroreductive morcellation. Estimated blood loss is 200 cc.
The morning after her surgery, M.G. voids after removal of the urinary catheter, and is able to tolerate a regular diet. She walks without difficulty and is discharged home. Seven days after her surgery, she returns to work. Her job allows her the freedom to define her own responsibilities, and she has no manual duties.
The pathology report reveals that her uterus weighed 610 g, with multiple leiomyomata. The largest myoma was 8.0×5.5×4.0 cm. No other abnormalities were present.
One year later, M.G. reports a substantially improved lifestyle and expresses satisfaction with her decision to undergo vaginal hysterectomy.