An easy and simple technique for vaginal hysterectomy, safe and without vault prolapse

1. Vaginal Hyseterctomy: Revival
Professor Galal Lotfi, MD, MRCOG
Obstetrics & Gynecology
Suez Canal University
Egypt

2. Suez Canal University Hospital

3. Aim:
•Reviving, a Well Known
Technique for Hysterectomy.
•Implementing a Technique,
Safe Without the Tragic Vault
prolapse.

4. WHY?
• Till 80ies: Age of gynecologic surgery.
• 80-90ies: Age of abdominal surgery.
• 90ies: Age of laparoscopy.
So Vaginal surgery is losing ground

5. So?
• This is not a comparison between
vaginal and abdominal Hyst.
• This is not a comparison between
vaginal and laparoscopic Hyst.

6. Patients
• Women for hysterectomy.
• No prolapse.
• No contraindication for
vaginal hyst.

7. Indications
• Dub
• Fibroid uterus < 12w
• Adenomyosis
• Cervical SL
• Contraception

8. Our Fears
• Access, mobility.
• Dissecting off the bladder.
• Opening POD.
• Pedicles.
• Slippage of a ligature, in so restricted field.
• Postoperative vault problems.

9. Requirementsfor safe technique.
Lesson 1of safety= SELECTION
• Mobility; Especially downwards
• Uterus less than 12 weeks
• Cervix not atrophied
• Fornices adequate
• Healthy tissues
• Assessment under anesthesia, in
lithotomy

10. What we need during
Hysterectomy?
• Safe: secure pedicles at all
times.
• Avoid post operative vault
prolapse: secure pedicles to
vagina.

11. Technique
• Circumferential, don’t dissect vagina off
bladder, push them up together.
• Open POD, choose the dimple behind the
cervix. The earlier you are in, the better off
you are. Probe around with your finger.

12. First Clamp
Lesson 2 Safety
• After pushing up the bladder and opening the
pouch of Douglas (POD), 1st clamp is applied
to uterosacral ligament as close to the uterus
as possible; Confirming that the inside blade
is inside the peritoneal cavity to include the
small vessels between the peritoneum and the
base of the pelvis

13. If you are very close to uterus
• Will have a good pedicle, we need long
pedicle here as the main difficulties to
encounter is the lack of mobility of the
uterus in the early steps of the operation
thast make the field tight; with good
pedicle gives safeguard if the clamp-
have slipped.
• Will avoid damage surrounding
structures like base of the bladder that is
usually caught here.

14. Ligatures.
Lesson 3 Sefety
• First ligatures is left with long threads,
one with needle will be used to have a bite
in the lateral vaginal angle so:
– Support the vaginal vault by ligating it
to the main supporting structures of the
pelvis
– Shares in the homeostasis of that
vascular area

15. First Clamp

17. Lesson 4: Vaginal support:
Stitching First Pedicle to
Vaginal Angle
• Occlusion of the space in
between
• Closure of small vessels
• Fixing uterosacral to vagina

18. 2 Ligature, Step ladder
nd
Lesson 5: Securiy
•Almost always the 2nd bite will not reach the level of
uterine vessels and we don’t intend to do so.
• I think that if one bite is taken to the whole
uterosacral ligament, it would be a big predicle
that necessities more than one suture ligature to
control the pedicle. Too many sutures in that area
are more hazardous. Usually 2 bites are needed
to finish the whole uterosacral ligament.

19. 2nd Ligatrue……
•The short thread of the 1st bite is tied
with one of the threads of the next
ligature so the whole uterosacral was at
the end taken to the vaginal angle.

20. Uterine, Ovarian Ligatures

23. Ovarian to Ovarian, Closing
Peritoneum

25. So, At the End..
• The whole three pedicles are ligated together on
one side with marked stitch. During
peritonization, one thread from round ligament
was tied to its counterpart on the other side and
peritoneum was approximated

26. At the end, The pedicles are
sutured to the vagina:
• That vaginal angle was sutured to the
uterosacral ligaments as a first step,
giving a strong support to vaginal vault
at the end of operation, preventing vault
prolapse.

27. Vaginal to Vaginal, Closing Vag

28. Why Approximating Pedicles:
Lesson 6
• The marker stitch can help in pulling down any
part of any pedicle when bleeding has to be
secured.
• Ligaturing the pedicles together will occlude the
small vessels in between making good hemostasis.
• These structures give good support to the vagina
preventing posthysterectomy vaginal vault
prolapse.

29. Results.
• Median opertive time 60min.
• Post operative analgesics
33%.
• Hospital stay 2.1 days.

30. Complications:
• Post op bleed 4%
• One day fever 3%
• Post op fever 2%
• UTI 1%
• Post op vault 0%
• Stress Incont 1%
• Det. Inst 1%

31. Cost.
• In 1998, the average charge for a laparoscopically-
assisted vaginal hysterectomy in USA was $14,500;
An abdominal hysterectomy was $12,500: that for a
vaginal hysterectomy was $10,380.
• In Egypt Hospital cost is the least for vaginal
hysterectomy.
• Vaginal hysterectomy resulted in better quality-of-
life outcomes and lower costs compared with
laparoscopically assisted vaginal or abdominal
hysterectomy (van den Eeden 1998).

32. Discussion

33. Step Ladder
• Easy access to all pedicles at any time.
• Good inspection of the pedicles at the
conclusion of surgery.
• Minimizing oozing vessels in-between
pedicles.

34. Advantages of Technique:
• Minimize well known postoperative vault
prolapse, good support to vaginal vault.
• Minimize intraoperative bleeding.
• Minimize postoperative hematoma.
• Easy and versatile access to ligature.

35. Advantages of Vaginal Approach
• Time of operation
• Exposure and
Traumatization
• Good for high risk patients
• Post operative stay
• Cost

36. Vaginal Approach…
• The long thread of the 1st bite is tied with one of the
threads of the next ligature so the whole
uterosacral was at the end taken to the vaginal
angle.
• These ligaments afford the main support of the
uterus and upper vagina ( Howkins & Bourne
1976). For that reason the proposed modifications
entails suturing of the cardinal ligament and
lateral vaginal wall together to create adhesive
forces that help holding the vagina.

38. Story of vault prolapse
• It should be noticed that the vagina lies parallel to the levator ani in a
horizontal position. With increased intrabdominal pressure, the
levator ani and cardinal ligament hold the cervix and upper vagina in
their proper position. Distortion of vaginal axis due to weak support
places the vaginal apex in an unsupported position over the
uterovaginal hiatus i.e. the vagina cannot rest upon the levator plate
resulting in prolapse. This illustrates the importance of normal;
vaginal axis in the integrity of the vaginal support (Richter 1967, fun
et al 1978).
• In the technique described, round ligament was attached to the
cardinal ligament. Some authors used, round ligament as part of
vaginal fixation (Symmond’s et al 1982, Randall & Nichols 1971) to
prevent posthysterectomy vaginal vault prolapse. I feel that the
round ligament in that issue is trivial, however the used technique of
attaching the round ligament to the cardinal ligament help to make
peritonozation easier. This conclude that vaginal hysterectomy
should be taken as an opportunity to prevent posthysterectomy
vaginal vault prolapse by meticulous care of supporting ligaments.

39. Conclusion..
• Vaginal hysterectomy should be considered
whether there is associated prolapse or not.
• With proper selection, continued training,
its rate will increase in front of abdominal
or laparoscopic route.
• Good access and assessment of uterosacrals.
• Good support to the vagina.
• Always follow the rules:

40. Rules to follow:
• Opening the POD in proper plane
• Don’t dissect the bladder from fascia
• In clamping uterosacral, inner blade includes the
peritoneum
• Clamping the pedicle in two steps is better than a
big sizeable pedicle
• First pedicle to be fixed to vaginal angle
• Keep your clamps adjacent to the uterus
• Step ladder procedure

41. Epilog
• Abdominal route: Surgery
• Laparoscopic: Technological costly
surgery
• Vaginal: Art surgery

42. • If your only too; is a hammer you will see
every problem as a nail.

43. Thank You