Vaginal Hysterectomy: How to Accomplish

Abstract

Vaginal hysterectomy should be the hysterectomy of choice for women with uterovaginal descent, provided there is no adnexal mass, cervical or broad ligament leiomyoma, or malignancy. Vaginal hysterectomy is associated with lower incidence of ureteric injuries and is cosmetically the most superior type of hysterectomy since it does not result in a scar on the abdomen. A non-descent vaginal hysterectomy can be done safely, and the size of the uterus is by itself not a contraindication. The fallopian tubes and ovaries can also be removed vaginally. The main steps for performing a successful vaginal hysterectomy are

• Successful opening of the anterior and posterior pouches

• Applying clamps always medial to the previous pedicle and as close to the specimen as possible

• Bisection and morcellation of the specimen after ligation of uterine arteries to facilitate descent and to obtain more space

• Intermittent emptying of bladder to keep the bladder empty and to facilitate descent; this also helps in the prompt recognition of bladder injury which may have occurred

The challenges that a gynecologist faces during vaginal hysterectomy are inability to open the pouches especially where there has been a previous caesarean delivery and inability to proceed further due to lack of descent. Other problem that one encounters during vaginal hysterectomy is bleeding due to slippage of clamps or sutures. It is better to complete the surgery by laparotomy than compromise with patient safety; bladder and ureteric injuries and internal bleeding requiring exploration later are better avoided. However, there are certain techniques by which a vaginal hysterectomy and even salpingo-oophorectomy by the vaginal route can be successfully accomplished even in difficult cases.