Scenario
A 46-year-old, para 2 woman, who has a long history of benign heavy menstrual bleeding seeking definitive treatment
after medical therapy (including MIRENA coil) fails to alleviate her bleeding.
Pelvic examination reveals a uterus of 14 weeks’ size that descends to 1.5cm above vaginal orifice with no significant
cystocele or rectocele. Her first child was delivered normally and the second by an uncomplicated caesarean section.
After you have discussed the routes of hysterectomy with her, she opts and insists for a vaginal hysterectomy.
You have 15 minutes to complete this station by answering the questions asked by the examiner related to this case
scenario of difficult vaginal hysterectomy. You can use the models provided to you as to explain the procedures if
needed.
1) Mention the conditions that are generally accepted as rather absolute contraindications to vaginal
hysterectomy
1. Advanced pelvic malignancy,
2. Advanced uterine size
3. Severe endometriosis,
4. Fixed uterus severe adhesions
5. Adnexal mass – Tubo-ovarian mass
6. History of
i. Fistula repair as recto-vaginal or vesico-vaginal (RVF, VVF)
ii. Perineal tear repair
iii. Suspension operations such as sling.
iv. Vaginal procedures as Brachytherapy
2) How would you evaluate her for vaginal hysterectomy?
History
1. General history of any current problems- e.g. pelvic pain, secondary dysmenorrhea,
dyspareunia, stress incontinence
2. A detailed obstetric history
3. Gynecologic history including treatment taken
i. Past history of repeated Lower Reproductive Tract Infections
ii. Pelvic inflammatory disease (PID),
iii. Pelvic or genital TB,
iv. Septic abortions
4. Medical history- as they may affect the surgery or post operative healing.
I. DM,
II. HT,
III. pulmonary TB,
IV. Coagulopathies
V. UTI etc.
5. Surgical history
i. Abdominal, pelvic, or vaginal surgeries in past
ii. Check for the findings/notes for presence of fibrous adhesions
6. Family history of gynecologic, gastrointestinal tract, or breast malignancies.
7. Sexual history- Any reports of dyspareunia
Examination
1. General abdominal examinations-Scars, masses, distention, hernia
2. Pelvic examination
Speculum examination
I. Dimple sign on Posterior or lateral fornix suggestive of thick dense adhesions
II. Pull the cervix downward with vulsellum:- at least 1 cm decent is normal , but in
pathological situations (as fixity, huge size, adnexal mass) it may not be possible.
III. Pain or suprapubic abdominal depression (Cervico-fundal sign) on pulling may suggest the
possibility of adhesions with anterior abdominal wall
Bimanual examination
I. Uterus (size, shape, contour, consistency, pathology)
II. Mobility (free, limited, restricted, frozen pelvis)
III. Adnexal masses, uterosacral tenderness, nodularity of the uterosacral ligaments and any
areas of pelvic pain during the examination
IV. Available space (vaginal capacity, distensibility, pubic arch)
Imaging
I. Measure the size of uterus
II. Map out the locations of fibroids if any
III. Adnexal masses
3) In the absence of contraindications you mentioned earlier, what other factors in this patient may suggest a
difficult vaginal hysterectomy?
I. Markedly retroverted uterus, suggesting obliterated posterior cul de sac
II. Hypertrophied and/or very narrow cervix
III. Inability to reach lateral cervico-uterine junction (uterine vessels)
IV. Reduced patient hip/leg mobility
V. Obese patient with a deep vagina
VI. Prominent buttocks
VII. Previous caesarean section
VIII. Narrow pubic arch
4) What could be done intraoperatively when the space appears to be rather inadequate due to her prominent
buttocks and slightly narrow pubic arch?
I. Proper patient positioning in dorsal lithotomy with the buttocks at the edge of the
operating table, thighs flexed and abducted, and the knees flexed and externally rotated
II. Use larger or wider vaginal retractors or self-retaining vaginal retractor.
III. Have assistants with knowledge of the procedure and anatomy during the procedure.
IV. A Schuchardt incision avoid injuring injure the anal sphincter.
5) How would you enter anterior cul-de sac in this patient?
I. Apply traction on the cervix to expose area
II. Identify the vesico-uterine peritoneum with subfascial yellow fatty layer as the land mark
III. No Blunt dissection using finger or the gauze on instrument at utero-vesicle junction.
IV. Use sharp dissection at utero-vesicle junction and keep the tip of scissors towards the cervix.
V. Keeping the bladder somewhat distended to identify the bladder location and clearly identify
any cystotomy if it occurs.
VI. If adhered, the posterior entry approach can help to identify the anterior bladder reflection
by inserting the index finger into the posterior cul de sac and wrapping it around the uterus
onto the anterior uterine surface.
VII. Developing a lateral “window” through the broad ligament to the bladder dissection may be
helpful when there are dense midline adhesions.
VIII. Placement of a bent uterine sound in the posterior cul-de-sac and it is then brought around to
the anterior cul-de-sac to identify the vesico-uterine peritoneal fold
6) Having tied both uterine arteries after entering anterior and posterior cul de sacs, you are having trouble in
accessing the top pedicle due to uterine size. What techniques would you consider to remove the uterus as
to complete the procedure? Explain the key points of the techniques you mentioned.
I. Uterine morcellation
1. Traction is placed on the part of the uterus to be removed using a tenaculum or Kocher
clamp and parts of the uterus are then removed piece-meal with a scalpel
2. it is repeated until satisfactory debulking completed
II. Hemisection with or without morcellation or myomectomy
1. Begin by cutting the cervix and extend upward to the uterine fundus in the sagittal
plane while applying traction.
2. It is often combined with myomectomy or wedge morcellation to reduce the bulk
III. Intramyometrial coring
1. Keep dissection closer to the uterine serosa
2. Done up to a “critical” point of Well suited for removal of a diffusely enlarged uterine
fundus
3. Begin with a circumferential incision into the lower fundus near the point where it
begins to expand.
4. The incise with heavy Mayo scissors or knife is continued circumferentially and
cephalad through the myometrium while constant traction is applied to the cervix.
5. Keep the dissection the uterine fundus and the utero-ovarian pedicle is then clamped
as usual
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