ToolBox

• Mayo scissors (long).
• Metzenbaum (dissection) scissors.
• Heany clamps (4) or Zeppelin clamps (4).
• Long needle holders (2) Heavy drivers preferred.
• Long toothed forceps.
• Delayed absorbable braided suture.
• Sterile vaginal pack.
• Cystoscope room table with padded stirrups
• 
  

Patient Preparation

INTRODUCTION

Vaginal hysterectomy is the least invasive type of hysterectomy. Therefore vaginal hysterectomy is  the recommended approach whenever indicated and feasible. The benefits of vaginal hysterectomy are its invasiveness, cost-effectiveness (compared to abdominal hysterectomy and laparoscopic hysterectomy), shorter hospital admission time and faster recovery (compared to abdominal hysterectomy)^1-4.

vNOTES

 Vaginal natural orifice transluminal endoscopic surgery (vNotes) is an innovation of vaginal hysterectomy, trying to overcome the disadvantages of vaginal hysterectomy by increasing the access to the pelvic anatomy without increasing its invasiveness, making use of the benefits of pneumoperitoneum⁵.

PATIENT SELECTION

Indications for vaginal hysterectomy are fibroids, heavy menstrual bleeding, adenomyosis and in some cases prolapse, gynaecological cancer or chronic pelvic pain syndrome. 

The choice for vaginal hysterectomy depends on the size of the uterus and adequate access to the vagina (“aperture”). Vaginal hysterectomy is preferably done in smaller uteri in order to remove the uterus ‘en bloc’, but it is even possible in cases with large uterine fibroids, bearing in mind the theoretical risk of dissemination of occult leiomyosarcoma due to morcellation or myometrial coring⁶.

Patient-related factors can also contribute in choosing a vaginal hysterectomy over an abdominal or laparoscopic hysterectomy: i.e. high advanced age, comorbidities and unavailability to undergo general anaesthesia as this procedure is possible under locoregional analgesia^1-4,6,8. 

Disadvantages of vaginal hysterectomy may be lack of visibility and reduced access to the anatomy, failure rates of bilateral salpingo-oophorectomy of 36% are reported^7,9. Nulliparity, minimal uterine descent and a previous caesarean delivery are complicating factors, but not contra-indications for vaginal hysterectomy^6,8.

Steps for Vaginal Hysterectomy of the Large Uterus

Even in the uterus greatly enlarged by leiomyomas vaginal hysterectomy can be performed, preserving the advantages  over laparoscopic or laparotomies technique. Uterine volume alone should not be a reason for avoiding vaginal hysterectomy.[Quinlan, Dubuisson, Benassi, Magos 1996, Daraï, Hwang] The steps described for the smaller uterus  may need to be adapted to the specific case, a circumstance that requires both additional training and experience.[Kala, Magos 2016, Stojko, Taylor, Paparella, Hwang, Santos-López, Nazah]

Uterine Lateralization

Instead of pulling the uterus towards the surgeon (this usually makes it easier to reach the anatomical structures), one can push it cephalic, into the abdomen while deflecting it laterally. This maneuver may increase visibility of the lateral structures on the contralateral side i.e. deflecting the uterus to the left increases visibility of and access to the right parametric. (see steps 5, 6 and 0 of the standard approach for vaginal hysterectomy). Removing the cervix may facilitate this process.[Stojko] 

Transection Using a Deschamps Needle

A Deschamps needle (see figure) can be helpful in transection (see steps 5, 6 and 7 of the standard approach to vaginal hysterectomy) when the parametrial tissues are difficult to reach and/or where there is inadequate space to use clamps. The angle and curvature of the tip of this needle facilitates these difficult steps.[Santos-López] 

Figure: Deschamps needle (source: https://www.sklarcorp.com/deschamp-needle)

Bivalving and Morcellation

Bivalving of the cervix and at least the lower uterine segment is an approach that also facilitates the process of morcellation by any of a number of techniques using one or a combination of scissors, scalpel, or RF electrosurgical instruments[Stojko, Dubuisson, Taylor, Wasson, Santos-López, Nazah, Magos 1996]. The goal is to  reduce the volume of the corpus after the uterine afteries are secured bilaterally. One technique extends the bivalving incision through to the fundal serosa, where each half of the uterus is removed separately. Alternately,  the fundus can be left intact,  scissoring the two halves allowing removal in one piece after the respective parametrical pedicles are secured.[Stojko, Santos-López, Nazah, Magos 1996]

Myometrial coring (including enucleation of fibroids) is another volume reducing technique, but the difference is the fact that the outer layer of the womb (serosa) is kept intact. A circular incision is made in the isthmus of the womb allowing the surgeon to remove the contents of the womb (including the lining (endometrium), the muscle tissue (myometrium) and fibroids which are located within the serosa of the womb).[Stojko, Nazah] This technique is also considered to be a safe technique, but there are indications that it is a more difficult technique compared to morcellation and bisection.[Nazah] 

The question of morcellation and it's impact on subsequent prognosis if malignancy was addressed by Wasson, et al. who described a series of vaginal hysterectomies with morcellation where 0,82% (5/2296) had occult uterine malignancies including two low-grade stromal sarcomas and three stage 1A, grade 1 endometrial adenocarcinomas. All of these patients remained disease free after the procedure.[Wasson]