Vaginal Hysterectomy: Techniques Vaginal Hysterectomy: Techniques and Tips and Tips

Mickey Karram M.D.Mickey Karram M.D.

Director of UrogynecologyDirector of Urogynecology

The Christ HospitalThe Christ Hospital

Clinical Professor of Ob/Gyn & UrologyClinical Professor of Ob/Gyn & Urology

University of Cincinnati University of Cincinnati

ObjectivesObjectives

Describe the important factors in choosing Describe the important factors in choosing the best route of hysterectomy the best route of hysterectomy

Review some ways to optimize hysterectomy Review some ways to optimize hysterectomy outcomesoutcomes

Discuss and show videos of techniques to Discuss and show videos of techniques to perform vaginal hysterectomy perform vaginal hysterectomy

Vaginal HysterectomyVaginal Hysterectomy

““If you are going to have your tonsils If you are going to have your tonsils

removed, would you prefer they be removed, would you prefer they be

taken out through your throat or taken out through your throat or

through an incision in the side of through an incision in the side of

your neck?”your neck?”

- Chassar Moir- Chassar Moir

Minimize Bleeding During Minimize Bleeding During Vaginal SurgeryVaginal Surgery

Preoperative assessmentPreoperative assessment

Discontinue NSAIDS, ASA 2 weeks pre-opDiscontinue NSAIDS, ASA 2 weeks pre-op

Bleeding diathesisBleeding diathesis

Careful entry into proper tissue planesCareful entry into proper tissue planes

Normal saline injectionNormal saline injection

Lidocaine 1% with epinephrine 1:200,000Lidocaine 1% with epinephrine 1:200,000

PitressinPitressin

Difficult Entry into Posterior Difficult Entry into Posterior Cul-de-Sac can be caused by:Cul-de-Sac can be caused by:

Shallow Pouch of DouglasShallow Pouch of Douglas

Long cervixLong cervix

EndometriosisEndometriosis

Posterior cervical or lower uterine Posterior cervical or lower uterine segment myomassegment myomas

Pelvic adhesionsPelvic adhesions

Difficult Entry into Posterior Difficult Entry into Posterior Cul-de-SacCul-de-Sac

Traction-countertractionTraction-countertraction

Sharp dissectionSharp dissection

Digital rectal examDigital rectal exam

Extraperitoneal pedicle ligationExtraperitoneal pedicle ligation

Palpation of cul-de-sac via anterior colpotomyPalpation of cul-de-sac via anterior colpotomy

Division of posterior cervixDivision of posterior cervix

Difficult Entry into Anterior Difficult Entry into Anterior Cul-de-SacCul-de-Sac

Try to Try to seesee the peritoneum before cutting the peritoneum before cutting

Traction-countertractionTraction-countertraction

Sharp dissectionSharp dissection

Extraperitoneal pedicle ligationExtraperitoneal pedicle ligation

Digital palpation of anterior reflection via the Digital palpation of anterior reflection via the posterior cul-de-sacposterior cul-de-sac

Uterine sound in bladder; retrograde bladder fillUterine sound in bladder; retrograde bladder fill

TractionTraction and and

Counter-traction Counter-traction

help to increase the help to increase the

distance between distance between

the clamps and the the clamps and the

ureter, thus ureter, thus

minimizing the risk minimizing the risk

of ureteral injury of ureteral injury

during vaginal during vaginal

hysterectomyhysterectomy

Clamp and ligate the pedicles in continuity to help avoid bleeding

Route of Hysterectomy Route of Hysterectomy

May the vaginal hysterectomy May the vaginal hysterectomy

never be to gynecology what never be to gynecology what

breech delivery has become to breech delivery has become to

obstetrics.obstetrics.

- George Morley- George Morley