Vaginal Hysterectomy

Anatomy and Physiology

Hysterectomy can be performed in more than a few different ways. Some of the generally performed routes of hysterectomy are vaginal, abdominal, laparoscopic, and robotic-assisted. Vaginal hysterectomy is considered one of the least and minimally invasive types of hysterectomies, and it has better outcomes and fewer complications compared to other types. It should be regarded as the preferred route of hysterectomy, whenever possible. The advantages of vaginal hysterectomy include less pain, rapid recovery, faster return to work, lower costs, and lower morbidity. It is usually performed for benign conditions. 

Indications

Hysterectomy is one of the most frequently performed surgeries in the world, and some of the most common indications for hysterectomy include:[1]

• Pelvic relaxation
• Fibroid uterus
• Abnormal uterine bleeding
• Pelvic pain associated with endometriosis
• Pelvic organ prolapse
• Benign ovarian mass
• Gynecological cancer
• Adenomyosis

Contraindications

There are no absolute contraindications, but some of the relative contraindications to vaginal hysterectomy are:[2]

• Pelvic radiation
• Large uterus
• Prior pelvic surgeries
• Suspected severe pelvic adhesion and anatomical distortion from PID (pelvic inflammatory disease) or endometriosis.
• Morbid obesity
• Nulliparity
• Lack of uterine descent

Equipment

The instruments required for vaginal hysterectomy are the following:

• Long, heavy Mayo scissors
• Short and long weighted vaginal speculums with an extra-long blade
• Heaney right-angle retractors
• Jorgenson scissors
• Long Allis clamps
• Deaver retractors.
• A long needle holder
• Heany clamps
• Single tooth tenaculum
• Single-tooth tenaculum
• Bovie extender,
• Suction apparatus
• A neurosurgery headlight 

Personnel

• Gynecologist
• Urogynecologists
• Anesthesiologist
• Anesthetic technologist
• Nurses
• Surgical assistants

Preparation

Preparation of the patient includes the following:

• Proper patient positioning- Vaginal hysterectomy is typically performed with the patient positioned in dorsal lithotomy with the help of either candy cane or boot-type stirrups.
• Application of sequential compression devices or administration of anticoagulants for venous thromboembolism prophylaxis
• Antibiotic prophylaxis- We typically use cefazolin 1 to 2 gm IV, administered within 60 min of the incision.
• Time out (pre-procedure verification checklist) is always performed before the commencement of surgery to confirm the correct patient, type of the operation, equipment used, and the surgeon performing the procedure, as per the standard hospital protocol.
• The patient is examined under anesthesia for the evaluation of size, shape, mobility of the uterus, assessment of the adnexa, and other pelvic structures. The degree of descent of the uterus, vaginal wall caliber, and pelvic organ prolapse, cystocele, and rectocele are assessed.
• Betadine scrub is used for vaginal preparation before the procedure.[3]
• A sterile surgical drape is used to cover the patient to ensure the aseptic environment of the entire procedure.

Technique or Treatment

Urinary bladder and ureteral injuries are the most common preventable complications that can occur during the hysterectomy. The technique for performing a hysterectomy is as follows:

1. Decompression of the bladder -A Foley catheter is used to drain urine.
2. Injecting vasoconstricting agents- Dilute vasopressin (20 units in 100 ml of normal saline) is circumferentially injected into the proper planes of the cervicovaginal junction. The purpose of this is for hemostasis and hydrodissection.
3. A circumferential incision is made around the cervix at the cervicovaginal intersection by using a scalpel or diathermy.
4. Dissection and deflection of the bladder, anterior colpotomy- After the circumferential incision is made, the anterior aspect of the vaginal mucosa is grasped and tented up, sharp and blunt dissection is done to separate the vaginal mucosa from the cervical stroma. The peritoneum is identified, and the peritoneal cavity is entered sharply. A right angle or Deaver retractor is then placed into the peritoneal cavity, and the bladder is protected. 
5. Posterior cul-de-sac entry- Posterior vaginal epithelium is grasped at the previous circumferential incision with a pair of Allis clamps and tended up. The peritoneum is identified and sharply entered with Mayo scissors. Once the peritoneal cavity is opened, the vaginal mucosa is stretched or incised laterally, and a long-weighted vaginal speculum is reinserted into the peritoneal cavity.
6. Uterosacral and cardinal ligament complex-Uterosacral ligaments are felt by examining with the index finger. The right-angle retractor is placed in the medial aspect of the vagina for proper exposure of this ligament, which is then clamped with Heaney clamp and cut. It is then sutured, and the tail of the suture is clamped and saved for future McCall's culdoplasty. Similarly, the cardinal ligaments are identified, clamped, cut, and suture ligated. Care must be taken during clamping as the ureters are very close to the uterosacral ligaments. Clamps must be placed very close to the cervical stump. All clamps must incorporate both anterior and posterior peritoneum to prevent bleeding from collateral blood vessels.
7. Uterine vessels- The Heaney clamp is widely opened and slide off the cervix, making sure all the vasculature is incorporated into the clamp, uterine vessels are cut, and suture ligated. The author does not recommend Heaney stitch as it can cause unnecessary injury to the vascular pedicle and cause bleeding. A significant uterine descent is seen after the uterine vessel's dissection.
8. Broad ligament- This is an avascular ligament primarily composed of peritoneum and minor blood vessels. This ligament is clamped medially, cut, and sutured.
9. Utero-ovarian, round ligament complex, and cornual end of the Fallopian tube- The upper and the final pedicle can be clamped all together or separately. If the pedicles are too large, the round ligament can be clamped individually. As this is a large pedicle, the author recommends doubly clamping this pedicle, and two sutures are placed. First, suture tie followed by suture ligation medial to the first. Once all ligaments and vessels are cut, ligated, and secured, the uterus is delivered.
10. Evaluate all pedicles in a clockwise fashion for adequate hemostasis.
11. Closure of the cuff and McCall's culdoplasty- As the vaginal apex is the most common site of bleeding during vaginal hysterectomy, we usually close it in the running and locking fashion to control bleeding from the vaginal edges.[4] The author typically horizontally closes the cuff unless there is a concern for the vaginal length, in which the wound is closed in a vertical fashion.[5]

Incorporate the uterosacral ligaments into the angle of the vaginal cuff at the time of cuff closure for the suspensory support of the vagina. This maneuver prevents future vaginal wall prolapse.

The vagina is not usually packed as it has not been shown to improve bleeding or any other outcomes.

A Foley catheter is left in place until the patient is ambulatory. 

Diet is advanced as tolerated.

Complications

A. Intraoperative Complications

1. Bleeding - The most common sites of bleeding during vaginal hysterectomy are uterine vessels, Utero-ovarian ligament, and vaginal cuff.[4]
2. Ureteral injury- The incidence of ureteral injury is about 0.5 percent.[6]
3. Bladder injury- The prevalence of bladder injury during vaginal hysterectomy is up to 1.2 percent. It increases with risk factors like prior pelvic surgeries and concomitant bladder surgery.[7]
4. Bowel injury- The risk is approximately 0.4 percent.
5. Nerve injuries- Most commonly, the femoral nerve, peroneal, and tibial nerves are affected by the retractors or by malposition of the legs on the stirrups.
6. Conversion to laparotomy- Instances like unexpected large pelvic masses, adhesions, and hemorrhage unable to identify and control can increase the chances of conversion to abdominal hysterectomy.
7. Adverse reactions to anesthetics

B. Postoperative Complications

1. Ileus 
2. Bowel obstruction
3. Vaginal cuff dehiscence 
4. Infections like vaginal cuff cellulitis and pelvic abscess
5. Fistulas-vesicovaginal, ureterovaginal, and rectovaginal fistulas
6. Prolapse of the pelvic structures like a Fallopian tube

Ureteral injuries during a hysterectomy most commonly occur at the following sites:[8]

1. Clamping and cutting the infundibulopelvic ligament.
2. Separating the uterine vessels.
3. Separating the uterosacral-cardinal ligament complex and during the closure of vaginal apex.

N.B. The details of the management of complications of hysterectomy are outside the scope of this article.

Clinical Significance

Vaginal hysterectomy is considered one of the minimally invasive forms of hysterectomies with better outcomes and fewer complications. It should be viewed as the preferred mode of hysterectomy whenever possible. The advantages of vaginal hysterectomy include less pain, rapid recovery, faster return to work, lower costs, and lower morbidity. It is usually performed for benign reasons.[9] 

Hysterectomy can majorly impact a patient's quality of life and have long-term physical, psychological, and mental health effects. Healthcare practitioners should thoroughly counsel patients before hysterectomy so that they can make informed decisions about their treatment.

Enhancing Healthcare Team Outcomes

Vaginal hysterectomy (VH) is a very common gynecological procedure used to treat a wide range of gynecological pathologies. A vaginal hysterectomy procedure incorporates the coordinated collaboration among the members of the interprofessional team. The nurse has a crucial role before, during, and after the VH procedure. Before the procedure, the nurse should assist the clinician in providing the woman and her family with the necessary information leaflets about the procedure, its benefits, and risks. The nurse should assist the clinician in the preoperative preparation of patients and ensuring that all preoperative investigations are readily available before the scheduled VH procedure. During the procedure, the nurse should assist the clinician in handling the necessary tools and ensuring the proper lighting to obtain the maximum visualization of the surgical field. The nurse must ensure that the diathermy equipment is connected and the patient is correctly insulated. The nurse has a paramount role in counting the instruments and towels used during the procedure and documenting the intraoperative blood loss. After the procedure, the nurse should monitor the vital signs of the woman and ensure that the woman's general and hemodynamic status is stable. The nurse should report any untoward changes in the vital signs of the patient to the clinician. Effective and clear communication among the members of the interprofessional team is mandatory to optimize patient outcomes. The interprofessional team needs to ensure patient safety at all times. Patient education is a key to successful vaginal hysterectomy procedures. The nurse should ensure that the woman is well-informed about the procedure and her concerns are addressed appropriately. The only way to achieve the best standard outcome for women undergoing vaginal hysterectomy and their families is through coordinated care among the interprofessional team members. [Level 5]

Nursing, Allied Health, and Interprofessional Team Interventions

Interprofessional teamwork is essential during and after hysterectomy. The goal of the nursing intervention is prevention or minimization of complications, pain management, support, and help optimum recovery. Nursing care is essential from the day of admission to discharge. The primary responsibilities include but are not limited to 1. preoperative preparation, 2. intraoperative coordination of the surgery, as well as 3. postoperative pain management, diet advancement, bladder and bowel care, mobility and physical therapy, breathing exercises, wound care, personal hygiene, and monitoring of the vaginal bleeding. Nursing actions and interventions are one of the essential aspects of hysterectomy procedures. 

Simulation-based training is a very effective method to advance the knowledge and skills of the providers. The simulation model has shown promise for teaching vaginal, uterine morcellation skills. Providers have commented that the simulation is a good starting point for residents in training and provided a good overall approximation of vaginal morcellation.[10]

Nursing, Allied Health, and Interprofessional Team Monitoring

• Vital signs
• Wound hygiene
• Any symptoms or signs of wound infection
• Ambulation level
• General status of the patient
• The emotional and mental condition of the woman