Author
Information
Manjrekar VM*, 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 a lot more difficult to perform than an abdominal hysterectomy.
Unless the gynecologist is well trained in vaginal surgery, there can be serious
complications during the performance of the operation, including injury to the
urinary bladder. A fear of injuring the bladder can lead to dissection in a
wrong plane. Dissection into the front of the supravaginal cervix is a common
error. We present such a case because the management of this error has not been
documented well in the literature.
Introduction
The space
available for operating is limited during performance of a vaginal
hysterectomy.[1] The anatomy is also a little difficult to
understand, because conventional education of human pelvic anatomy is through cadaveric
dissection, which is 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 is an important step, of which many untrained surgeons are afraid
out of fear of injuring the bladder. This may result in dissection in a plane
that is too deep, passing into the supravaginal cervix. We present such a case
and discuss methods of diagnosing the condition and managing it.
Case
Report
A 45 year
old woman, married for 28 years, multipara, presented to the outpatient
department with complaints of menorrhagia for 2 years. There was soakage of 3-4
pads per day and passage of clots. She also complained of something coming out
per vaginum for 2 years, which was aggravated by straining and required digital
manipulation for reposition. She had 3 normal deliveries and 1 intrauterine
fetal demise. She had a history of lifting heavy objects at home on a regular
basis. There was no other significant contributory factor like history of
chronic cough, constipation, urinary retention or medical or surgical illness.
On examination her vital parameters were stable. A speculum examination revealed
hypertrophied cervix, a second degree uterovesical descent, moderate cystocoele
and rectocoele. The vagina was healthy. On per vaginal examination the uterus
was normal sized, retroverted, firm and mobile. Her PAP smear showed severe inflammatory
cell changes and endometrial aspirate showed no malignant cells. Her
investigations for fitness for anesthesia showed normal values.
She was posted for Vaginal hysterectomy with
anterior colporrhaphy and posterior colpoperineorrhaphy. The operating surgeon
was a resident doctor being assisted by a junior consultant. The patient was
put in lithothotomy position under spinal anaesthesia. Anterior pouch
dissection was started after making infiltration of normal saline under the
anterior vaginal mucosa and incision into the vaginal mucosa just above the portio
vaginalis. Dissection was attempted between the cervix and the bladder, but the
correct plane could not be found. We were called at that stage.
Figure 1. The cut edges of the supravaginal cervix (yellow
arrows) are held with two Allis’ forceps.
Figure 2. The black arrow indicates the place where the
supravaginal cervix had been cut into. The green arrow indicates the beginning
of the plane between the supravaginal cervix and the urinary bladder.
Figure 3. The plane is being dissected by placing closed
blades of a curved hemostat at the lower end of the plane and opening the
blades widely.
Figure 4.
The blue arrow indicates the uterovesical fold of peritoneum.
It was
found that the incision had passed into the supravaginal cervix. The upper cut
edge of the cervix was identified on the bladder wall. It was held with two
Allis’ forceps and drawn down. The pubovesicocervical fascia was cut between
the cervical edge and the bladder, and the correct plane was indentified
between the bladder and the cervix. The plane was developed further by putting
closed blades of a curved hemostat there and opening the blades in the
transverse plane. The bladder was retracted with Landon’s retractor. The
uterovesical fold of peritoneum was identified deep inside this plane. It was
held with two hemostats and cut. Subsequent hysterectomy was carried out by the
conventional technique. The patient made an uneventful recovery and was
discharged after 5days.
Discussion
Abdominal
hysterectomy permits visualization of the pelvic structures clearly prior to
making any cuts or performing any dissection of tissues. The uterus, the
urinary bladder, and the uterovesical fold are clearly identifiable unless the
anatomy has been distorted by pelvic adhesions or tumors. It is easy to hold
the uterovesical fold of peritoneum, confirm that it is indeed the uterovesical
fold by its looseness over the supravaginal cervix and isthmus, and cut it 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] An experienced surgeon identifies the fascial fibers which
stand out as the divided vaginal edge is elevated held by two Allis’ forceps.
After cutting these, the peritoneal fold can be reached. It is confirmed to be
the fold by putting a finger over it and rolling it from side to side. It rolls
very easily. On catching with two hemostats, it stands out as a thin
translucent fold. In case of any doubt, the urinary bladder and the bladder
neck can be identified by palpation of the inflated balloon of the Foley’s
catheter in the bladder.[2,8] In case it does not help, the catheter
can be substituted for with a bladder sound. The tip of the sound is directed
backwards. It defines the lower limits of the bladder wall, so that dissection
can be carried out away from it.[2,8] If the peritoneal fold is high
in situation and cannot be reached, the uterosacral ligaments can be clamped,
cut and ligated first. The uterus then descends and the peritoneal fold becomes
accessible. It can be opened then.[2] 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.
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.
References
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Citation
Manjrekar VM, Parulekar SV. Vesicophobia During
Vaginal Hysterectomy – Too Deep Dissection. JPGO 2014. Vol 1 No. 12: Available from: http://www.jpgo.org/2014/12/vesicophobia-during-vaginal_30.html