Author
Information
Tanksale
SJ*, Parulekar SV**.
(* Fourth Year Resident,
** Professor and Head, Department of Obstetrics and Gynecology, Seth GS Medical College & KEM
Hospital , Mumbai , India
Abstract
Hysterectomy is a common
gynecological operation. A vaginal hysterectomy is the preferred approach for
benign pathology. It is considered to be more difficult than an abdominal
hysterectomy, because the space is limited and the anatomy is difficult to
understand due to faulty orientation.
Fear of injuring the urinary ladder is common in residents in training.
This can lead too deep or too superficial dissection. After failure to identify
the uterovesical peritoneal pouch, alternative techniques are tried. One such
technique is to open it through posterior colpotomy, as in the case presented.
Introduction
During vaginal
hysterectomy it is very important to identify pelvic structures correctly and
get appropriate orientation of pelvic anatomy. Otherwise it is very difficult
for the operating surgeon to identify tissue planes and perform correct
dissection. The limited availability of space further adds to the difficulties
while performing vaginal hysterectomy.[1] One of the challenges that
surgeon faces is while opening uterovesical fold. The fear of injuring the
urinary bladder while opening uterovesical fold can cause error of judgment
leading to dissection which is too superficial (and hence into the bladder), too
deep (and hence into the supravaginal cervix) or laterally (and hence into the
broad ligament).[2,3,4]. In a patient with an atrophic uterus, the uterovesical
fold can opened through posterior pouch, when all efforts at opening it through
anterior vaginal incision fail.
Case
report
A 60 year old woman,
postmenopausal for 15 years, third para, presented with a third degree uterine
descent , cystocoele (central transverse defect), rectocele (left lateral
defect) and lax perineum. After investigations for fitness for anesthesia
showed normal results, she was subjected to a vaginal hysterectomy, vault
suspension anterior colporrhaphy and posterior colpoperineorrhaphy under spinal
anesthesia. The operating surgeon was a second year resident assisted by an
assistant professor and an associate professor. The anterior vagina was cut
transversely and the vaginal edges were held with Allis’ forceps. The urinary
bladder was separated from the supravaginal cervix by blunt and sharp
dissection. However the uterovesical fold of peritoneum could not be found. The
atrophic uterus added to the fear of injuring the urinary bladder while opening
uterovesical fold. The posterior pouch was opened by conventional method. The
small sized atrophic uterus was delivered through the posterior pouch by making
traction on its fundus with a finger passed through the posterior colpotomy
incision (figure 1). The urinary bladder was also seen through the posterior
colpotomy. The uterovesical fold was identified between the uterine corpus and
the urinary bladder. It was held between two curved hemostats and cut open. The
uterine corpus was reposited, and the remaining steps of the proposed operation
were performed in usual manner. There was no injury to the urinary bladder or
even hematuria due to traction on the bladder while delivering the uterine
corpus through the posterior colpotomy. The patient withstood the operation
well and made an uneventful recovery.
Figure 1. Operative picture during vaginal hysterectomy. White arrow: cervix; green arrow: inverted fundus of the uterus; yellow arrow: uterovesical fold of peritoneum held between two hemostats; blue arrow: urinary bladder; sky blue arrow: open posterior peritoneal pouch.
Discussion
The uterovesical fold of
peritoneum is identified as loosely attached fold over the supravaginal cervix
and isthmus. It is easily identified in abdominal approach as compared to
vaginal hysterectomy. Most of the times, it is easy to identify uterovesical
fold unless there are pelvic adhesions or large pelvic tumors causing distortion
of pelvic anatomy. During vaginal hysterectomy, pubovesicocervical fascia is
dissected to reach the peritoneal fold. Identification of correct plane
requires experience. An error can lead to dissection into the urinary bladder,
supravaginal cervix, or one of the broad ligaments.[1,3,4,5] The
small size of an atrophic uterus makes it difficult to palpate the uterus. This
further increases the difficulty in identifying the uterovesical fold. In case
of such difficulty, the suggested maneuvers include identification of the
bladder by palpation of Foley’s catheter in the bladder and insertion of a
bladder sound instead of the Foleys catheter and defining the lower limit of
bladder wall.[1,5] If these maneuvers fail, a third maneuver is
tried, in which the uterovesical fold is approached through the posterior
pouch.[1,5] A finger is passed behind and then hooked over the
fundus to pull it backwards and downwards. As the small, atrophic uterus gets
delivered through the posterior colpotomy, the urinary bladder also gets drawn
along with it, and the uterovesical fold is found between the two. The altered
anatomy must be kept in mind, in which the urinary bladder is seen above and
posterior to the uterine corpus. The peritoneal fold is then cut between two hemostats.
Such extreme steps are taken instead of taking the abdominal approach because a
vaginal hysterectomy has to be done in a case of a uterovaginal prolapse, if a
hysterectomy is a part of the repair process. A recent Cochrane review of
surgical approach to hysterectomy for benign gynecological disease, involving
3643 patients , concluded that vaginal approach is preferred to the abdominal
approach.[6]
Conclusion
If the operating surgeon
is not adequately trained may find opening the uterovesical fold to be
difficult. The surgeon may do dissection in the wrong plane in anticipation or
fear of injury to the urinary bladder. Training of resident doctors and
adequate clinical experience in performing vaginal surgery will help in
reducing such fear. In 1934, N. S. Heaney stated, “it is [my] purpose…to show
again how low the mortality and morbidity of vaginal hysterectomy may be with
the hope that this operation may find a place in the operative armamentarium of
every gynecologist.[4]
References
- Parulekar SV. Vaginal hysterectomy, Practical Gynecology and Obstetrics. 5th ed. Mumbai: Vora Medical publications;2011. pp 250-253.
- 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
- 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
- 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
- Kovac SR. A technique for reducing the risk of intentional cystotomy during vaginal hysterectomy. J Pelvic Surg 1999;5: 32
- Johnson N, Barlow D, Lethaby A, Tavender E, Curr E, garry R. Surgical approach to hysterectomy for benign gynecological disease. Cochrane database Syst Rev. 2006. Apr 19;(2): CD003677
Citation
Tanksale SJ, Parulekar
SV. Vesicophobia during vaginal hysterectomy- Opening Anterior Pouch Through
Posterior Colpotomy. JPGO 2015. Volume 2 No. 5. Available from: http://www.jpgo.org/2015/05/vesicophobia-during-vaginal.html