Author
Information
Raut DP *, Parulekar SV**.
(* First Year Resident, ** Professor and Head, Department of Obstetrics
and Gynecology, Seth G.S. Medical College and K.E.M Hospital, Mumbai, India.)
Abstract
Vaginal
hysterectomy is much more difficult to perform than an abdominal hysterectomy. The
surgeon has to be well trained in vaginal surgery, or there can be serious
complications during the performance of the operation, including injury to the
urinary bladder. Lack of expertise and a fear of injuring the bladder can lead
to dissection in a wrong plane. Dissection into the fascia over the detrussor
and the detrussor itself is a not uncommon error. We present such a case becuse
the management of this error has not been documented well in the literature.
Introduction
The space
available for operating is limited while performing a vaginal hysterectomy.[1]
The anatomy is also a little difficult to understand, as conventional education
of human pelvic anatomy is through cadeveric dissection, which is done by the
abdominal route. Without adequate training and operative 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 is an
important step, which may be associated with a fear of injuring the bladder.
This may result in dissection in a plane that is too superficial, passing into
the fascia over the detrussor and the detrussor itself. We present such a case
and discuss methods of diagnosing the condition and managing it.
Case
Report
A 40 year
old woman, married for 20 years, multipara, presented to the outpatient
department with complaints of menorrhagia for 2 years. She has soakage of 3-4 pads per day and
passage of clots for 8 days, without any dysmenorrhea. She had come with
similar complaints 5 days back to the emergency section and was started on norethisterone
and tranexemic acid to stop the bleeding. However this treatment failed to
control the bleeding. She had undergone a rapid cervical dilatation and
endometrial curettage 1 month back for abnormal uterine bleeding. The histopathology
report was suggestive of bleeding endometrium. The patient was operated for
anal hemorrhoids 22 years ago and tubal ligation was done 6 years ago. There
was no other significant medical or surgical history. On examination her vital
parameters were stable. Speculum examination showed a hypertrophied cervix. Bimanual
pelvic examination showed bulky, retroverted, midposed uterus and free and
nontender fornices. Ultrasound examination of the pelvis showed a bulky uterus
measuring 9.4 x 4.0 x 6.6 cm and endometrial thickness of 12 mm. Malignancy was
screened for by Pap smear which showed severe inflammatory cell changes and endometrial
aspiratyub xytology which showed no malignant cells.
The patient
was posted for a vaginal hysterectomy. She was being operated on by a resident
doctor, assisted by a junior consultant. She was put in lithothotomy position
under spinal anaesthesia. After making an incision into the anterior vagina
near the portio vaginalis, anterior pouch dissection was started. Blunt
dissection was done to open the plane between
the supravaginal cervix and the bladder. There was a significant amount of
bleeding. The uterovesical fold could not be identified. At this stage we were
called for help.
The
findings are shown in figure 1. The detrussor was torn in the midline and the
bladder mucosa was seen pouting throgh it. The plane between the bladder and
the supravaginal cervix was identified after dividing the fibers of
pubovesicocervical fascia between the two. It was a smooth, white surface which
had no bleeding from its surface. The bladder was retracted with Landon’s
retractor.Dissection was continued upward in this plane until the uterovesical
fold of peritoneum was reached. It was held with two hemostats and cut.
Subsequent hysterectomy was carried out by the conventional technique. The
detrussor injury was repaired with a continuous suture of No. 3-0 polyglactin.
The patient made an uneventful recovery and was discharged after 5 days.
Figure 1. Cut edges of detrussor are shown by arrows.
Figure 2. The
cut edges of the supravaginal cervix (yellow arrows) are held with two Allis’
forceps. The correct plane of dissection is shown by white arrow.
Discussion
Abdominal
hysterectomy permits visualization of the pelvic structures clearly prior to performing
any pelvic surgery, unless the anatomy has been distorted by pelvic adhesions
or tumors. The uterovesical fold of peritoneum can be held easily, confirmed to
be the uterovesical fold by its looseness over the supravaginal cervix and isthmus,
and then cut with scissors. It is quite different in a vaginal hysterectomy.[1]
After making an incision in 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 fascial fibers which stand out as the divided vaginal
edge is elevated held by two Allis’ forceps have to be identified. The
peritoneal fold can be reached after cutting these. It is confirmed to be the
fold by putting a finger over it and rolling it from side to side. It rolls
very easily over the smooth anterior surface of the corpus. When caught with
two hemostats, it stands out as a thin translucent fold. If the dissection is
carried out more superficially, it passes into the fascia over the bladder and
then the bladder wall. Injury to the detrussor is suspected when there is
significant bleeding during the sharp dissection. Detrussor injury is more
likely to occur when the dissection is done bluntly, with finger pressure.
Injury to the bladder wall is suspected when there is leak of watery fluid into
the operative field, hematuria, visualization of the catheter through the dissected
area, and leak of methylene blue solution into the operative field when it is
instilled into the urinary bladder through Foley’s catheter.[2,8] The
correct plane has to be found posterior to the dissected area. The correct
plane has a number of diagnostic features. The smooth, white surface of the
supravaginal cervix is seen posterior to the plane. When in doubt, a bladder
sound can be passed into the bladder to define the limits of the bladder, so
that dissection can be done beyond the bladder wall. In case all of these
methods fail, the posterior peritoneal pouch can be opened first.[2,8]
Then a finger can be passed behind and then over the top of the uterus to reach
the uterovesical fold of peritoneum from above. Then it can be opened over the
finger seen through it. But this is not possible if the uterus is large.
Passing more superficially and hence into the bladder wall is much more serious
than passing too deep into the cervical tissue. However both of these
situations must be avoided by following meticulous technique, so that morbidity
is kept low.
Conclusion
A resident
doctor or a consultant not trained in vaginal surgery may experience difficulty
while opening the uterovesical fold of peritoneum, and being afraid of injuring
the urinary bladder, may go in a wrong plane. Adequate training, experience,
and adopting the techniques described in this article should help overcome this
difficulty and fear.
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Citation
Raut DP, Parulekar SV. Vesicophobia During Vaginal
Hysterectomy – Too Superficial Dissection. JPGO 2014 Volume 1 Number 12
Available from: http://www.jpgo.org/2014/12/vesicophobia-during-vaginal_1.html