Author Information
Parulekar SV
(Professor and Head, Obstetrics and Gynecology, Seth G S Medical College & K E M Hospital, Mumbai, India.)
Abstract
Vaginal hysterectomy has to be performed in limited space and the anatomy is difficult to understand as compared to during an abdominal hysterectomy. The urinary bladder needs to be retracted forwards using a Landon's retractor and the rectum posteriorly using a vaginal speculum. This is possible only after the uterovesical and rectouterine peritoneal pouches have been opened. A curious case is presented in which the Landon's retractor was inadvertently passed in through the uterovesical peritoneal pouch and out through the rectouterine peritoneal pouch.
Introduction
The learning curve is quite steep for vaginal hysterectomy.[1,2] This is because the space available is limited and the anatomy is difficult to understand as compared to while performing an abdominal hysterectomy. Some of the instruments used are quite different than those used in conventional operations performed abdominally. It is necessary to retract the urinary bladder and the rectum away from the uterus so as to be able to operate. That can be done only when the uterovesical and rectouterine peritoneal pouches have been opened.[1,2] A case being operated on by a junior resident is presented in which the Landon's retractor was passed into the pelvic peritoneal cavity after opening the uterovesical peritoneal pouch, and out through the rectouterine peritoneal pouch which has already been opened. The reason for this occurrence is discussed. This is the first case of this type in the world literature.
Case Report
A 51 year old woman, para 4 living 4, presented to us with a complaint of something coming out per vaginum for 2 years. She had no urinary or rectal symptoms. There was no precipitating factor for genital prolapse. She had been menopausal for 5 years. Her past medical and surgical history was not contributory. Her general condition was fair and vital parameters within normal limits. Her general and systemic examination revealed no abnormality. She had a fourth degree uterine prolapse, large cystocele of central transverse type, a large rectocele of central transverse type, and deficient perineum. Her investigations for fitness for anesthesia showed normal results.
A vaginal hysterectomy with anterior colporrhaphy and posterior colpoperineorrhaphy was carried out under spinal anesthesia. The operation was being done by a junior resident, assisted by a junior consultant. After circumferential incision in the vaginal mucosa at the level of junction with the portio vaginalis, the rectouterine peritoneal pouch was opened and Soonawalla's speculum was passed between the uterus in front and the rectum behind. Uterine supports were weak and uterine corpus prolapsed out of the open rectouterine peritoneal pouch. Then the uterovesical peritoneal pouch was opened after dissecting the urinary bladder away from the front of the supravaginal cervix. Then a Landon's retractor was passed into the pelvic peritoneal cavity through the open uterovesical peritoneal pouch (figure 1). Then the cervix was held forward so that the prolapsed uterine corpus could be reposited before performing hysterectomy. That time it was noticed that the Landon's retractor had passed above the uterine fundus and out of the open rectouterine pouch, behind the prolapsed uterine corpus (figure 2). It was withdrawn, the uterine corpus was reposited and then the Landon's retractor was passed into the pelvic peritoneal cavity such that it did not pass out of the rectouterine pouch. The remaining part of the operation was carried out without any difficulty. The patient made an uneventful recovery.
Abstract
Vaginal hysterectomy has to be performed in limited space and the anatomy is difficult to understand as compared to during an abdominal hysterectomy. The urinary bladder needs to be retracted forwards using a Landon's retractor and the rectum posteriorly using a vaginal speculum. This is possible only after the uterovesical and rectouterine peritoneal pouches have been opened. A curious case is presented in which the Landon's retractor was inadvertently passed in through the uterovesical peritoneal pouch and out through the rectouterine peritoneal pouch.
Introduction
The learning curve is quite steep for vaginal hysterectomy.[1,2] This is because the space available is limited and the anatomy is difficult to understand as compared to while performing an abdominal hysterectomy. Some of the instruments used are quite different than those used in conventional operations performed abdominally. It is necessary to retract the urinary bladder and the rectum away from the uterus so as to be able to operate. That can be done only when the uterovesical and rectouterine peritoneal pouches have been opened.[1,2] A case being operated on by a junior resident is presented in which the Landon's retractor was passed into the pelvic peritoneal cavity after opening the uterovesical peritoneal pouch, and out through the rectouterine peritoneal pouch which has already been opened. The reason for this occurrence is discussed. This is the first case of this type in the world literature.
Case Report
A 51 year old woman, para 4 living 4, presented to us with a complaint of something coming out per vaginum for 2 years. She had no urinary or rectal symptoms. There was no precipitating factor for genital prolapse. She had been menopausal for 5 years. Her past medical and surgical history was not contributory. Her general condition was fair and vital parameters within normal limits. Her general and systemic examination revealed no abnormality. She had a fourth degree uterine prolapse, large cystocele of central transverse type, a large rectocele of central transverse type, and deficient perineum. Her investigations for fitness for anesthesia showed normal results.
A vaginal hysterectomy with anterior colporrhaphy and posterior colpoperineorrhaphy was carried out under spinal anesthesia. The operation was being done by a junior resident, assisted by a junior consultant. After circumferential incision in the vaginal mucosa at the level of junction with the portio vaginalis, the rectouterine peritoneal pouch was opened and Soonawalla's speculum was passed between the uterus in front and the rectum behind. Uterine supports were weak and uterine corpus prolapsed out of the open rectouterine peritoneal pouch. Then the uterovesical peritoneal pouch was opened after dissecting the urinary bladder away from the front of the supravaginal cervix. Then a Landon's retractor was passed into the pelvic peritoneal cavity through the open uterovesical peritoneal pouch (figure 1). Then the cervix was held forward so that the prolapsed uterine corpus could be reposited before performing hysterectomy. That time it was noticed that the Landon's retractor had passed above the uterine fundus and out of the open rectouterine pouch, behind the prolapsed uterine corpus (figure 2). It was withdrawn, the uterine corpus was reposited and then the Landon's retractor was passed into the pelvic peritoneal cavity such that it did not pass out of the rectouterine pouch. The remaining part of the operation was carried out without any difficulty. The patient made an uneventful recovery.
Figure 1. Landon's retractor has been passed through open uterovesical
peritoneal pouch. Prolapsed uterine corpus is shown by black arrow.
Figure
2. The blade of the Landon's retractor is seen to have exited through
open rectouterine peritoneal pouch, behind the prolapsed uterine corpus.
Discussion
The
space available in the lower pelvis for performing a vaginal
hysterectomy is quite limited because the vaginal space is small and it
is largely occupied by the uterus, rectum and urinary bladder.[3] The
instruments used to retract the urinary bladder (Landon's retractor) and
the rectum (Soonawalla's speculum) usually pass between the urinary
bladder and uterus in case of Landon's retractor and between the uterus
and the rectum in case of the Soonawalla's speculum. This is because
these instruments are crowded in the limited space by the pelvic
organs.[4,5] However in case of a massive uterovaginal prolapse, the
urinary bladder, uterus and rectum are outside the pelvic outlet and the
restraint of space does not apply. The levator hiatus is also likely to
be very large due to separation of the two levatores from each other.
The uterus of a postmenopausal woman is often small due to atrophy,
which results from loss of estrogen. Such a small size of the uterus,
combined with poor supports, tends to prolapse out through open
rectouterine peritoneal pouch, as happened in the case presented. That
increased the space available between the pelvic organs further. Owing
to misdirection of the Landon's retractor during its passage between the
urinary bladder and the uterus, the blade of the retractor passed more
posteriorly, above the prolapsed uterine corpus and behind it, and then
out through the open rectouterine peritoneal pouch.
The
occurrence was not serious, because it could be corrected very easily,
and no operative mishap could have occurred as further operative steps
could not haven been taken without correcting its position first. It is
reported only because it was quite curious. Its awareness should help
junior surgeons in training, to operate better.
Acknowledment
I thank Dr. Sana Bijapur for taking operative photographs.
References
- Zimmerman CW. vaginal Hysterectomy. In: Jones HW, Rock JA editors. TeLinde's Operative Gynecology. 11th ed. Philadelphia: Wolters Kluwer 2014. p.716-737.
- Lentz GM. Anatomic defects of the abdominal wall and pelvic floor. In: Katz VL, Lentz GM, Lobo RA, Gershensen DM editors. Comprehensive Gynecology. Philadelphia: Elsevier 2016. p. 500-536.
- Brummer TH, Jalkanen J, Fraser J, Heikkinen AM, Kauko M, Mäkinen J, et al. FINHYST, a prospective study of 5279 hysterectomies: complications and their risk factors. Hum Reprod 2011;26:1741.
- Fatania K, Vithayathil M, Newbold P, Yoong W. Vaginal versus abdominal hysterectomy for the enlarged non-prolapsed uterus: a retrospective cohort study. Eur J Obstet Gynecol Reprod Biol 2014; 174:111.
- Johnson N, Barlow D, Lethaby A, Tavender E, Curr E, Garry R. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2006;(19):CD003677.
Citation
Parulekar SV. Transperitoneal Passage Of Landon's Retractor During Vaginal Hysterectomy For Procidentia. JPGO 2018. Vol 5 No. 11. Available from: https://www.jpgo.org/2018/11/transperitoneal-passage-of-landons.html
Parulekar SV. Transperitoneal Passage Of Landon's Retractor During Vaginal Hysterectomy For Procidentia. JPGO 2018. Vol 5 No. 11. Available from: https://www.jpgo.org/2018/11/transperitoneal-passage-of-landons.html