Vaginal Hysterectomy - Indications and Complications

Indications

 * 1) Uterovaginal Prolapse
 * 2) Dysfunctional uterine bleeding/Abnormal uterine bleeding(mechanical/anatomic)
 * 3) Fibroids
 * 4) Persistent dysplasia/CIS
 * 5) Atypical Endometrial Hyperplasia
 * 6) Failed permanent sterilization
 * 7) Dysmenorrhea and central pelvic pain or CPP with previous negative laparoscopy
 * 8) Grade 1 endometrial adenocarcinoma in obese patients

Criteria for successful procedure

 * 1) Decensus (Grade 1 or greater)
 * 2) Uterine size (operator dependent)
 * 3) Parity or adequate pelvic working space based on an appropriate distance between ischial tuberosities (operator dependent) and sufficient infrapubic arch angle
 * 4) Previous CS or other pelvic surgery (scarring may require conversion to LAVH)

Complications

 * 1) Bladder injury
 * 2) Cystotomy with urine leakage
 * 3) Fistula formation – vescovaginal, vesicoabdominal
 * 4) Ureteral injury
 * 5) Obstruction
 * 6) Ureteral leakage vaginally, abdominally
 * 7) Ureterovaginal fistula, ureteroabdominal fistula
 * 8) Postoperative bleeding
 * 9) Generalized
 * 10) Ovarian vessels
 * 11) Cuff
 * 12) Need for abdominal conversion
 * 13) Post procedure vaginal vault prolapse
 * 14) Pelvic cuff abscess
 * 15) Bowel injury
 * 16) Nerve injury
 * 17) Burn injuries

Complication Prevention

 * 1) Bladder injury
 * 2) Cystotomy entering anterior cul-de-sac
 * 3) Inject saline solution or pitressin/saline solution at junction of vagina and cervix to hydrodissect along the pubovesical cerivical fascia
 * 4) Keep field clean to aid in clearly identifying pubovesical fascia when making anterior incision
 * 5) Dissect plane with blunt dissection (rather than sharp dissection)
 * 6) Dissect to above the internal os of the cervix
 * 7) Cut peritoneum below retractor and pick-up with scissors pointed toward cervix and away from the bladder
 * 8) Vesicovaginal fistula
 * 9) Recognize injury by leaving urine in bladder to identify damage
 * 10) Instill sterile milk or indigo carmine if unsure of damage
 * 11) Ureteral injury
 * 12) Maintain downward traction of cervix
 * 13) Roll clamps off of the cervix and uterine corpus
 * 14) Keep vaginal cuff sutures as superficial as possible
 * 15) Diagnose any injury using indigocarmine and cystoscopy
 * 16) Postoperative bleeding
 * 17) Generalized
 * 18) Discontinue ASA (5 days), Plavix (3 days) and other anti-clotting meds prior to surgery
 * 19) Ovarian vessels
 * 20) Double-ligate, with first tie being an anchor stitch, then a free tie
 * 21) Avoid unnecessary tension on first throw of suture (use surgeon's knot)
 * 22) Cuff
 * 23) Run and lock posterior cuff
 * 24) Identify bleeding before closure
 * 25) Run and lock cuff closure (as opposed to interrupted sutures)
 * 26) Abdominal conversion
 * 27) Make sure uterus is mobile
 * 28) Check bituberous distance to be >10 cm
 * 29) Check infrapubic arch to be >75 deg
 * 30) Check uterine size to be < 12 weeks gestation (or your preference)
 * 31) Be familiar with coring, bivalving morcellation techniques to reduce uterine mass
 * 32) Be familiar with inverting the uterus to gain exposure
 * 33) Post procedure vaginal vault prolapse
 * 34) Identify uterosacrals and incorporate the intact uterosacral ligaments into the vaginal cuff (uterosacral vault suspension, modified McCall’s culdoplasty, using Ethibond suture or other permanent suture)
 * 35) Pelvic cuff abscess
 * 36) Avoid using epinephrine injection (Pitressin preferable)
 * 37) Avoid use of cautery to incise vaginal mucosa/muscularis around cervix
 * 38) Good hemostasis of cuff
 * 39) Use prophylactic antibiotics, at least 30 minutes before incision
 * 40) Screen and treat patients for BV or consider repeating antibiotics (up to three doses) for affected or higher risk patients
 * 41) Bowel injury
 * 42) During EUA, check that posterior cuff is free from cul-de-sac endometriosis
 * 43) In posterior dissection, avoid being too posterior and angle Mayo scissors parallel to the cervix to avoid damaging sigmoid
 * 44) Use minilap packs to avoid small bowel injury (can tie sutures to blue string to aid in place entire pack in pelvis)
 * 45) Use Trendelenberg position
 * 46) 	Check for adhesions of bowel to fundus upon enteringNerve injury
 * 47) Nerve injury
 * 48) To prevent femoral nerve injury from tension to inguinal ligaments, use Allen’s (Yellow fin) stirrups
 * 49) Avoid candy cane stirrups
 * 50) Burn injury
 * 51) Avoid accidental electrocauterization of weighted speculum, retractors or hemostats