Author Information
Parulekar SV
Professor and Head,
Department of Obstetrics and Gynecology, Seth G.S. Medical College and K.E.M
Hospital, Mumbai, India.)
Abstract
Vaginal hysterectomy is
more difficult to perform than an abdominal hysterectomy, even if there are no
complicating factors like uterine enlargement or distortion. The surgeon has to
be well trained in vaginal surgery, or there can be serious complications
during the performance of the operation. A fear of injuring the bladder can
lead to dissection in a wrong direction. Dissection into the broad ligament
lateral to the uterus is an error that has not been reported so far in world
literature. Such a case is presented here, along with discussion on its
prevention and management.
Introduction
The space available for
operating is much less during a vaginal hysterectomy as compared to an
abdominal hysterectomy.[1] The anatomy is also difficult to
understand, as conventional teaching of human pelvic anatomy is through
cadaveric dissection done by the abdominal route. Without adequate training and
clinical experience, the operating surgeon can experience difficulty in finding
correct tissue planes and performing the correct steps.[1] Finding
the uterovesical fold of peritoneum and
opening it are steps which are felt to be quite challenging by many untrained
surgeons, out of fear of injuring the bladder. The usual error is passing too
deep into the cervix or too superficially into the bladder. The case presented
here is the first case in the world literature, in which the dissection was
done on one side and the broad ligament was opened instead of the uterovesical
peritoneal fold.
Case Report
The patient was a 60
year old woman, third para, postmenopausal for fifteen years. She had a third
degree uterine prolapse, moderate cystocele, moderate rectocele, lax perineum,
and an atrophic uterus. Vaginal hysterectomy, anterior colporrhaphy, vault
suspension, and posterior colpoperineorrhaphy were being done under spinal
anesthesia. The operating surgeon was a junior consultant. The anterior vagina
was cut transversely just above the portio vaginalis. The vaginal edges were
held up with two Allis’ forceps. Sharp and blunt dissection was done to
separate the urinary bladder from the front of the supravaginal cervix.
Landon’s retractor was used to retract the urinary bladder during the
dissection. Some bleeding was encountered, but it was not alarming. The
uterovesical fold of peritoneum could not be identified. I was called for help
at that stage.
The anterior surface of
the supravaginal cervix was found to be irregularly dissected, but not bleeding
significantly. The anterior and posterior leaves of the left broad ligament were
torn, but the uterine artery and vein were not injured (figure 1). The ureter
was not seen in the vicinity of the opening. The location of the otherwise
unidentifiable uterus was demonstrated by passing a uterine sound into the
uterocervical canal and palpating over it from the outside.
Figure 1. The cut edges
of the anterior vagina are held with two Allis’ forceps (black arrows). The
medial edge of the opening in the left broad ligament is held with two
hemostats (blue arrows). A gloved finger (green arrow) is seen through the
window in the left broad ligament, passed from behind the uterus and the
ligament. The uterus (U) is on the right side of the opening. The cervix is
seen below (C).
The posterior peritoneal
pouch was opened first by the conventional method. An index finger was passed
behind the uterus and was brought forward over the fundus of the uterus. The
uterovesical fold was identified over the finger passed into it from above. It
was held with two hemostats and cut open. Subsequent hysterectomy was done by the
conventional method, followed by anterior colporrhaphy, vault suspension, and
posterior colpoperineorrhaphy. An excretory urography done postoperatively did
not reveal any injury to the left ureter. The patient made an uneventful
recovery.
Discussion
Visualization of the
pelvic structures clearly prior to making any cuts or performing any dissection
of tissues is possible while performing an abdominal hysterectomy. The
uterovesical fold is clearly identifiable unless the anatomy has been distorted
by pelvic adhesions or tumors. It is easily confirmed that it is indeed the
uterovesical fold by its looseness over the supravaginal cervix and isthmus. Then
it is cut with scissors. The situation is quite different in a vaginal
hysterectomy.[1] After cutting the anterior vagina near the portio
vaginalis, the pubovesicocevical fascia has to be dissected in the correct
plane that can be identified only with experience, and then the peritoneal fold
can be reached.[2,3,4,5,6,7] The uterus is usually identifiable by
its bulk. But in case of a postmenopausal woman with uterine atrophy, the
uterus is very small in size and thin anteroposteriorly. It may not be easily
identifiable. That adds to the difficulty of identifying the uterovesical fold.
In order to avoid an injury to the urinary bladder, the surgeon may try to
catch any thin fold of tissue and cut it. In the case described, the broad
ligament peritoneum lateral to the uterus was caught and dissected believing it
to be the uterovesical fold. Passage of a sound into the uterocervical canal
helped identify the position of the uterus. The method of opening the posterior
peritoneal pouch and passing a finger from there to the uterovesical fold is
shown in figure 2.
Figure 2. Method of
opening the uterovesical pouch by opening the posterior peritoneal pouch first
and passing a finger from there to the uterovesical pouch over the uterus. B:
urinary bladder; U: uterus; V. vagina; R: rectum. The course of the finger is
shown by the black arrow.
Opening the broad ligament
prior to clamping and dividing the uterosacral ligaments is associated with the
risk of injury to the ureter. That is so because the ureters are related to the
upper surface of the uterosacral ligaments and when the ligaments are divided,
the ureters fall away and are less likely to get injured during performance of
the remaining steps of the hysterectomy.[3] Opening the broad
ligament in this manner is also associated with the risk of hemorrhage from
injury to the uterine vessels. A blind attempt at stopping this bleeding by
application of hemostats and ligatures or electrocautery may further increase
the risk of ureteric injury.
Conclusion
Blind dissection to open
the uterovesical fold of peritoneum without first identifying it is risky. If
the broad ligament gets opened during such a procedure, there is risk of injury
to the ureter and the uterine vessels.
References
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- Parulekar SV. Vaginal Hysterectomy. In Practical Gynecology and Obstetrics. 5th ed. Mumbai: Vora Medical Publications; 2011. pp. 350-253
- Kovac SR. Vaginal Hysterectomy. In Rock JA, Jones HW III, editors. Te Linde’s Operative Gynecology. 10th ed. New Delhi: Wolters Kluwer Health – Lippincott Williams & Wilkins 2008; pp. 744-762.
- Monaghan JM, Lopes A, Naik R. Vaginal hysterectomy and radical vaginal hysterectomy (Schauta and Coelio-Schauta procedures). In Bonney’s Gynaecological Surgery. 10th ed. Malden, USA.Blackwell Science. 2004. pp 95-109.
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- M.Cosson Vaginal hysterectomy. In Vaginal Surgery. Cosson M, Querleu D, Dargent D. editors. 1st ed. Boca raton. Taylor & Francis. 2005. pp 29-55.
- L. Hoffman B. Schorge J, Schaffer JI, Halvorson L, Bradshaw KD, Cunningham FG.Vaginal Hysterectomy. In Williams Gynecology. 2nd ed. New York: McGraw Hill. 2012. pp 1051-1054.
Parulekar SV. Vesicophobia During Vaginal Hysterectomy – Too Lateral Dissection. JPGO 2014. Volume 1
Number 12. Available from: http://www.jpgo.org/2014/12/vesicophobia-during-vaginal.html