Multiple types of energy devices are available, such as PK devices (Gyrus ACMI, Southborough, Mass.), LigaSure instruments (Covidien, Mansfield, Mass.), the Enseal Super Jaw device (Ethicon Endo-Surgery, Nokesville, Va.) and Altrus devices (ConMed Electrosurgery, Centennial, Colo.). These devices can be particularly helpful in cases with narrowed introitus and large uterus. The choice of device is surgeon dependent and requires a learning curve.
Gentle traction is placed on the cervix while the device clamp is pushed up against the pedicle, taking care to avoid leaning against any adjacent tissues or retractor blades to avoid thermal injury. Bringing in a suction device quickly dissipates the hot steam that can be generated from the device.
Avoidance of bladder and ureteral injury
Once the vesicouterine space is entered, bladder pillars are gently pushed superiorly and laterally with the index finger to avoid injury during placement of the vessel-sealing clamp. It is imperative that the surgeon is aware of the location of the ureters, which are easily injured, particularly in cases with pelvic prolapse.
The ureters can be palpated with the index finger at 2 o’clock or at 10 o’clock (for the left and right ureter, respectively) against a curved Deaver retractor placed outside the peritoneal cavity on the lateral vaginal wall. Intraoperative cystoscopy should always be performed at the end of the procedure to diagnose inadvertent bladder and ureteral injury.
Courtesy Dr. Roseanne M. Kho
Serial wedging and coring of the uterus with a 10 blade facilitates decompression and better descensus until the utero-ovarian ligaments can be secured.
Removing the Large Uterus
Morcellation can be initiated after the uterine arteries have been sealed and divided on each side. Orientation of the uterus is maintained by placing two Jacobs tenaculi at the 3 o’clock and at 9 o’clock positions on the cervix. The cervix is bivalved to the level of the lower uterine segment.
If the anterior cul-de-sac has not been entered yet, the cervix should be bivalved to a centimeter below the vesicouterine peritoneal fold and morcellation started within the uterus.
Morcellation is performed with a Schroeder tenaculum (Aesculap Inc., Center Valley, Pa.) placed on the myometrium, and a wedge excision is accomplished with a 10 blade. Serial wedges are performed to decompress the uterus. Entry into the anterior cul-de-sac can now be performed easily with better uterine descensus and visualization of the peritoneal fold.
The surgeon should avoid forceful traction on the cervix during morcellation, which can cause the vascular pedicles to avulse.
Depending on the size of the uterus, morcellation can take over an hour. Use of an articulated long scalpel handle (such as the Precise CMK ergonomic knife by LaparoTools, in Metairie, La., which is rounded) can facilitate morcellation with less fatigue.
The surgeon must persist with morcellation as long as descensus of the uterus is continually achieved. An increase in bleeding is encountered when morcellation is near the fundus. At this point, the utero-ovarian pedicles can be identified and secured to finish the procedure.
Courtesy Dr. Roseanne M. Kho
Modified Deavers of varying length provide retraction of tissues to secure pedicles up in the pelvic sidewall.
Mastering the procedure
Simple techniques and new surgical devices are available to facilitate the difficult vaginal hysterectomy. Cases of narrowed introitus, multiple previous caesarean sections, and the large uteri requiring morcellation can be approached vaginally and achieved safely and efficiently with use of the above techniques.
In recognition of the vaginal approach as a minimally invasive procedure, AAGL has provided postgraduate courses in the recent past that incorporate hands-on workshops with the cadaveric model to master the procedure.
Similarly, AAGL has identified five large-volume vaginal centers throughout the country where observership programs are available to practitioners interested in learning the techniques (www.aagl.org). These opportunities allow the surgeon to advance their skills and reincorporate the vaginal hysterectomy into their armamentarium so that patients can benefit from its most minimally invasive approach.
Dr. Kho is associate professor and director of the minimally invasive gynecologic surgery (MIGS) fellowship program in the department of medical and surgical gynecology at the Mayo Clinic in Phoenix, Ariz. She reported that she has no relevant financial disclosures.