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Vaginal hysterectomy is the least invasive method of removal of uterus. Most of hysterectomies can be performed vaginally. The lower rate of vaginal hysterectomy is not only due to the relative contraindications to the vaginal route of hysterectomy but also due to the technical barriers in the mind of most surgeons to deal with inadequate accessibility, poor visibility and effective hemostasis even after considerable experiences. That is why they prefer a more obvious and widely visible abdominal or laparoscopic route of hysterectomy even for a moderate size uterus that could otherwise have been removed vaginally by another surgeon keeping the abdominal wall intact. Our goal should be to perform the vast majority of hysterectomies for benign disease via the vaginal route.

Only detachment of the lateral attachments to remove uterus is possible in majority cases (86.45%) while only13.55% cases required assistance of volume reduction manoeuvres when Purohit technique was used as a method to remove consecutive benign uteri with out prolapse up to 20 weeks size including cases with relative contraindications (excluding endometriosis). Combining with the techniques of volume reduction maneuver vaginal hysterectomy is possible in more than 99% cases by Purohit technique. No other selection guidelines are required. Failure is very rare.

Techniques dealing with the detachment of the lateral attachment try to meet the challenges of poor accessibility, poor visibility and achievement of effective hemostasis.

Techniques dealing with reduction of bulk of uterus try to minimize or remove the central obstruction (Bulk of uterus) safely.

To be a successful vaginal hysterectomy surgeon, one has to learn both groups of technique side by side.

How to achieve adequate visibility

Enhancement of visibility increases the feasibility, safety, efficiency and satisfaction of the surgeon. We feel enhancement of visibility is more important then the type of speculum, retractors used. We feel the operating room light with a back up of 10mm telescope with light source or a pelvic illuminator is enough to increase the visibility of vaginal canal and lateral pelvic wall up to the level of infundibulo- pelvic ligament and up to the completion of salpingo -oophorectomy. A 10mm telescope offers the advantages of long (16 inches) rigid thin torch that can be focused to a deeper and darker part of pelvic cavity precisely from a required angle. It is handled by either left or right assistant. However a telescope with light source is required in about 10% cases of hysterectomy but more frequently when salpingo oophorectomy is desired. It is of distinct advantage in visualizing and localizing precisely the bleeder from the lateral wall after removal of uterus. We believe a surgeon equipped with operative laparoscopic set up can expand the limit of feasibility of vaginal hysterectomy.

We have devised a special pelvic illuminator(Dr R K Purohit pelvic illuminator) consists of a 10mm rigid tube containing only optical fibres.It has a handle at one end. Length about 18 inches. It does not contain any lens system thus it is cheaper.

Incision of anterior vaginal wall

Incision on the anterior vaginal wall is given by a frequent gentle stroke sufficient to expose the wall of cervix. A deeper incision will incise the superficial part of myometrium and will go beyond the line of cleavage. It will resemble a strong band of adhesion in the midline and will cause dissection problem. Little superficial incision on the other hand will fall short of reaching line of cleavage. Forceful dissection through this wrong plane will hit the bladder wall and will result in penetration of lumen of bladder.

When the incision falls short of line of cleavage there the anterior margin of incision is lifted by an Allis forceps. The stretched taught tissue between the cut margins (Supravaginal septum or vesicovaginal septum) is gently incised by a curved scissors directing its curvature against the anterior wall of cervix to get the cleavage to enter to the vesicocervical space.

When the incision goes beyond the line of cleavage the adhered superficial layer of cervix to anterior incision is treated as a strong band of adhesion and dissected later on by lateral approach. Moreover the complex anatomy around the uterine cervix needs a systematic approach to prevent most complications.

Dissection of vesicocervical space and separation of bladder from cervix.

Vesicocervical space is bounded anteriorly by bladder, posteriorly by uterus and cervix, laterally by bladder pillars, below by supravaginal septum and above by vesicouterine peritoneum. It contains loose fascia... Normally bladder is peeled easily and quickly from the cervix by finger dissection. If adhesions are sensed by finger during dissection they are divided by sharp dissection. Dissection is stopped on sensing a strong band of adhesion. No strong force is applied to detach it.

Usually these bands are thin and found in the lower boarder of vesicovaginal space. The space above the scar is soft and can be easily pushed by finger. By a lateral approach index finger is pushed lateral to the scar band to reach the upper part of the vesicocervical space. The upper space is dissected by medially bend index finger and the band is isolated. It is then ‘hooked’ by the finger. We prefer to ‘hook’ it by the bend of a right angle forceps (Photo No 17)

Photo no 17

It is then divided at its base very close to the cervical wall. Very thick and wide band of adhesion covering the whole width of the anterior wall of cervix between bladder pillars is detached later on simultaneously with the vesicocervical- cardinal- uterosacral ligaments from the lateral wall of cervix.

Conventional technique using ligatures for hemostasis requires three steps (clamping, cutting and suture ligation), many instrument changes and a wide space for the movement of a curve needle on a holder where as the newer techniques of hemostasis using bipolar energy, Ultrasonic energy and electro thermal bipolar vessel sealer (EBVS), plasma kinetic energy require two steps (coagulation- and -cut) fewer instrument changes and less space for a thin forceps. The space required by a needle for its movement is eliminated.

Bipolar coagulation by ordinary bipolar forceps with fine tip can at least be used in place of the traditional ligature method. It is available in a standard operation theatre, cheap and safe in vaginal hysterectomy. Coagulation -and -cut manoeuvres will shave the uterus from its natural lateral attachments and adhesions precisely. Use of a right angle forceps as in Purohit technique radically solves the question of inaccessibility to vesicocervical- cardinal- uterosacral ligaments even in cases with very poor access. It acts as a helper, elevates the cervix from the posterior aspect by the tip and brings the ligaments to surgeon’s view. It creates a narrow working platform between its opened prongs sufficient for bipolar forceps and scissors and keeps the neighboring tissues away. Gentle lateral to medial push by index finger simultaneously with sequential stepwise detachment of Mackrnodt’s ligament by coagulation -and -cut manoeuvres will isolate the adhesion. It is then hooked by bend of right angle forceps and divided by scissor close to cervical wall. We believe that it is an easier and straightforward way to deal with these thick bands of adhesion than the conventional technique-requiring ligature for hemostasis. In a still very narrow space it is preferable to take the help of right angle forceps than index finger.

Opening of posterior Pouch

It is easier to access the posterior pouch than the anterior pouch by various techniques. Problem arises when pouch can not be opened due to dense adhesion, endometriosis or when it is highly placed due to posterior cervical myoma. There extraperitoneal dissection and uterine artery ligation, separation of adhesions close to uterine wall, debulking of large uterus or a myoma if obstructing will increase the descent of uterus. These manoeuvres help to approach the peritoneal cavity mostly from upper lateral side of uterus. The posterior leaf of broad ligament is then hooked by bend of right angle forceps and incised from above down wards and posterior pouch is opened. Adhesions in the pouch are easily hooked by the bend of right angle forceps as in Purohit technique and plucked one by one. It is easier than the inconvenience caused by the wide space requiring ligature method of hemostasis. Fiber optic rigid light source often increases visibility.

Detachment of adhesions.

Uterus can be detached from all the lateral adhesions and hysterectomy can be completed. It is easier and quicker by using the modern methods of hemostasis than by the ligature methods of hemostasis. A right angle forceps is of great help in ‘hooking’ adhesion. It works like a bend index finger during operation. It is almost not possible to detach vaginally the rarely found plastic adhesion of the uterine fundus to the anterior abdominal scar resulting from previous cesarean section. In a case of adhesion with bowel loop a slice of servos of the uterine wall is spared. We have an experience of failure to detach vaginally a thick wide adhesion of fundus of a normal size uterus to a suprapubic transverse anterior abdominal scar resulting from previous minilap tubal ligation operation. In another case of previous cesarean section whole of the anterior surface of uterus was adhered to the anterior abdominal wall scar. Both required laparoscopic assistance at the end. It is better not to attempt such vaginally (contraindication)

How to suspect fundal adhesion to anterior abdominal wall scar

Ordinarily cervix is visible on office speculum examination. In a case of previous cesarean section when cervix cannot be easily seen on speculum examination and it can only be seen with great difficulty with the help of an anterior wall retractor or when the cervix cannot be easily palpated on bimanual examination but with difficulty at a height behind the simphysis pubis.

When the traction of cervix by tenaculum causes a depression on the anterior abdominal wall scar over the site of adhesion. Backward and upwards movement of a sound or curette in uterine cavity under anaesthesia causes a depression of the anterior abdominal wall scar at the site of fundal adhesion.

How to achieve effective hemostasis

At vesicocervical- cardinal- uterosacral ligaments:

Traditionally ligaments are clamped, detached and replaced with transfixation suture when space is wide. The ends are held long for fixation to the vault at the end of operation. Clamp less technique is practiced when the space is inadequate. Use of a thick clamp, insertion of a curve needle lateral to the upper end of clamp and needle retrieval from posteriolateral aspect of the thick clamp requires a wide space. It is troublesome when space is still inadequate. Simultaneously a chance of ligature slippage causes apprehension of bleeding.

In Purohit technique ligaments are shaved from the cervix after bipolar coagulation (coagulation -and -cut manoeuvres) close to cervix. Chances of hemorrhage are not there in case the operation takes longer time. Ligaments are approached extraperitoneally. Tip of a right angle forceps is used to elevate the cervix from the posterior aspect to bring the target tissue to the operator’s view before their coagulation and division. This technique is helpful in all cases with poor access. In our experience lower ligaments of all cases with benign disease of uterus can be detached by Purohit technique.

Traction by the assistant is not so much required in our technique because tip of right angle forceps is used by left hand to elevate the ligaments from the posterior aspect for easy application of bipolar forceps by right hand. That reduces the tiredness of the assistant and postoperative pain of patient. The released Mackenrodts ligament does not retract back or missed in any case in this extraperitoneal technique. We found that the difficulty of application of thick clamp and needle holder with needle in such cases of poor access in conventional method could be solved by our technique. Therefore cases with poor access were not a contraindication in our technique.

Use of modern techniques of hemostasis like bipolar coagulation, harmonic scalpel etc requires passage of a thin instrument to the target organ and thus requires less space than the ligature technique of hemostasis. In Purohit technique use of a right angle forceps that delineates the anatomy and creates a space between its prongs for bipolar forceps and scissors further facilitates dissection and increases safety of the neighboring structures.

To achieve hemostasis of uterine arteries

Correctly applied ligature is a time tested reliable method of hemostasis if the space is wide for ligature application.

Clamp less technique used when the space is inadequate. When the space is still narrow then the modern hemostatic techniques like bipolar energy, ultrasonic energy, electrosurgical bipolar vessel sealer (EBVS) are used. When the distance between the ureter and cervix is <0.5 cm then the chance of ureteral injury relatively increases during hysterectomy. Isolation of uterine artery rather than bundle inclusion is a vital step to avoid coagulation injury to the neighboring structure. Purohit technique is different specially in showing advantages of use of a right angle forceps in dissecting the tissue planes, isolating the artery, creating space for bipolar forceps and scissors between its opened prongs, helps to protect the neighboring structures. It is more an anatomical approach. In this extraperitoneal technique a bleeding uterine artery protrudes itself towards the surgeon’s view rather than it retracts in contrast to the conventional intraperitoneal technique. A bleeding artery can be easily grasped by artery forceps and cauterized by this extraperitoneal technique. This technique enjoys the advantages of extraperitoneal approach like-blood does not enter peritoneal cavity, bowels do not protrude, extraperitoneal structures are dissected and exposed clearly. In intraperitoneal technique in contrast blood enters the peritoneal cavity; bowels come on the way of operation field, the lower ligament stumps and uterine artery stumps recoil back to the lateral pelvic wall and away from visibility immediately after separation from cervix and uterus. It is some time difficult to trace a bleeding uterine vessel in the intraperitoneal approach to uterine artery.

In our experience uterine arteries can be secured bilaterally in all cases of benign disease of uterus up to 16 weeks size easily by Purohit technique. We have not encountered postoperative hemorrhage from uterine artery. We believe bipolar method of hemostasis is reliable, safe, effective, and cheap in vaginal hysterectomy. Achievement of complete physical compression of the lumen (coaptation) of artery by prongs of bipolar forceps is a prerequisite before activating bipolar current. Bipolar needs 2-3 applications along the length of uterine vessel for complete hemostasis.

Purohit approach to uterine artery is an easier and quicker approach to access, identify, dissect and skeletonise the uterine artery even in cases of rotated and distorted uterus due to myoma. Its desiccation under direct vision between the prongs of right angle forceps further increases confidence and reduces intraoperative hemorrhage and chances of injury to ureter. Intraoperative security of the uterine artery is promising in this technique with out the use of suture. Also there was no postoperative hemorrhage from the uterine artery in our study. It was found that the bulge of the artery was the elbow portion of the uterine artery before becoming ascending branch and was hooked by the bend of the right angle forceps. The divided lower end of the ascending branch on the side wall of uterus must be identified to confirm the division of the uterine artery. Intact uterine artery is suspected in cases where the oozing continues and the soft tissue of broad ligament does not move up freely along the side of uterus when pushed by index finger.

To achieve hemostasis of upper pedicles

It is easier to deal with upper pedicles for these are longer than lower ones. We feel bipolar method is also reliable one and requires less space although it requires multiple strokes of application to achieve complete hemostasis. It is preferable in cases of narrow lateral space resulting from moderately expanded uterine fundus.

To check effective intraoperative hemostasis

In our technique posterior leaf of broad ligaments is routinely climbed up bilaterally by the technique described above to trace bleeding if any from the lateral wall up to infundibulopelvic ligaments to prevent postoperative vault hematoma.Intraoperatively bleeding occurs from 3 places:(1) from the veins and arteriole of Mackrnodt’s ligament (2) from the ovarian pedicles and occasionally from a tiny vessel below round ligament. (3) From uterine artery.To deal with the bleeding from upper pedicles trace the pedicles by the technique described above, pull them down and coagulate properly. Use pelvic illuminator if needed. To deal with the uterine artery bleeding- trace it by the tracing technique described above, Use pelvic illuminator if needed and then hold by an artery forceps and then cauterize proximal to the forceps. For bleeding from Mackrnodt’s ligament hold the lateral vaginal wall by Allis forceps, pull it laterally to expose the ligaments, see any bleeder and cauterize it. Otherwise fix the ligament to the vault as described above. It will stop the venous bleeding that can not otherwise be cauterized, no time is wasted in catching the venous bleeding from in side the ligament tear.

Primary postoperative bleeding if any from the lateral wall can also be traced and secured by this technique safely after opening vaginal vault with out affecting security of other stumps.

Salpingo oophorectomy at vaginal hysterectomy

Separation of round ligament from the ovarian ligament and tube as in abdominal hysterectomy is a prerequisite to reach the infundibulopelvic ligament in vaginal salpingo oophorectomy. It is anatomical than bunch inclusion of all pedicles. Transfixation by suture, stapling and Roeder’s loop has been the methods of hemostasis to occlude the ovarian vessels. Because of the inadequate space and chances of ligature slippage suture ligation is often difficult. Taking the advantages of the use of a right angle forceps as in Purohit technique salpingo oophorectomy can be done in almost all indicated cases. It elevates the infundibulopelvic ligament from posterior aspect and brings it to surgeon’s view and creates a working space between its prongs for bipolar forceps and scissors. It retracts and protects the neighboring structures. A standby operative laparoscopy facility increases the confidence of the surgeon. Adhesions are dissected by right angle forceps. All benign movable ovarian cysts, tubo-ovarian mass, chocolate cyst with minimal adhesions can be removed (indications) by this technique. Larger cysts are aspirated by suction aspiration using a long Verses needle to increase working space. Dense benign adhesion and endometriotic adhesion of ovary to the anterior abdominal wall, dome of bladder, sigmoid colon, broad ligament cyst in our experience should not be attempted vaginally(contraindications). It needs laparoscopic assistance or minilaparotomy after vaginal extraction of uterus. Use rigid fiber optic light cable during minilaparotomy. Laparoscopic salpingo oophorectomy at this stage is easier and takes less time. Vaginal vault is clamped by three Allis forceps horizontally to reduce gas leak. The excised tube and ovary are removed vaginally.

Debulking of large uterus

Normal size uterus generally does not obstruct to the accessibility to lateral pedicles. An enlarge uterus fills the pelvic cavity centrally and compresses drastically the lateral working space. It obstructs to the visibility and accessibility to the lateral pedicles to be secured. Uterus is separated from body after coagulation and division of all lateral attachments of uterus. Therefore removal of the bulk is essential to increase the lateral space.

Feasibility of debulking

Uterus larger than 12-14 weeks sizes invariably requires debulking. But only 10-15 % of uteri removed are above 12 weeks size or 280grams.Logically the rest 85-90% cases should not require morcellation. Uterus up to 14-16weeks sizes can be removed vaginally easily. Uterus size above the level of true pelvis can be attempted by experienced surgeons but a standby facility for conversion to LAVH or laparotomy is needed to deal with failure cases(therefore be careful). It is not wise to attempt vaginal hysterectomy on a uterus of above 20 weeks size. (contraindication)

It was observed that majority of uteri weighing less than 280 grams did not require volume reduction manoeuvres thus only13.55% women required bisection and morcellation by our technique. It was mainly the advantage of the use of right angle forceps along with use of thin instruments like bipolar forceps, telescope with light source as thin torch for illumination, Purohit approach to uterine artery along with conventional volume reduction manoeuvres for large uterus in our technique made the vaginal hysterectomy so much easier to achieve such a high feasibility rate in our study.

Techniques of volume reduction manoeuvres.

Bisection of cervix, myomectomy of visible myoma and wedge morcellation by knife and scissors of the directly visible bulk of the uterus are commonly practiced methods and enough to minimize or remove the centrally occupying obstruction to the lateral pedicles. In our experience generally uteri weighing up to 300 grams do not require debulking. A soft uterus of 450 grams can be removed intact by Purohit technique (www.purohittechnique.com) for a right angle forceps can ‘hook’ a lateral pedicle from a tight working space and brings it to the mouth of bipolar forceps and scissors. When no further lateral pedicle is ‘hooked’ on sweeping the tip of forceps around the expanded lateral wall of uterus debulking is initiated.

Only13.55% cases required volume reduction manoeuvres when Purohit technique was used in contrast to more than 30% cases by conventional techniques

Lash procedure of intramyometrial coring is available for moderate size uterus and in a case with suspected endometrial carcinoma where uterine cavity is kept intact. With the development of Purohit technique a moderate size uterus can be removed intact thus coring was not needed.

To deal with expanded lower segment

Volume reduction manoeuvres are normally carried out after bilateral ligation of uterine arteries. Hemorrhage is expected in conducting debulking before ligation of uterine arteries in cases of large cervical polyp, big central cervical fibroid and requires blood transfusion. Smaller ones do not cause problems thus can be attempted. Intracapsular morcellation of myoma removes the fear of injury to the neighboring tissues.

To deal with expanded uterine fundus

Success of the debulking procedure depends on the successive descent of the uterus to the surgeon’s view in response to the removal of wedges and traction. Solid big firm myoma occupying above the level of true pelvis and sitting above the brim does not descend adequately following morcellation and consumes lots of time, energy and patience. Soft cystic degenerated myoma following debulking responses well to the traction and descend faster towards the surgeon. A funnel type below upwards expansion of uterus is better for debulking than umbrella type expansion of fundus with a long stalk below. A big pedunculated fundal fibroid with a long stalk some time does not come out with uterus and often needs traction and debulking.

Thus Purohit technique of vaginal hysterectomy is a feasible, safe, effective technique in conducting vaginal hysterectomy and salpingo oophorectomy for almost all cases of benign disease of uterus up to 20 weeks gestation size irrespective of preexisting conditions listed as the relative contraindications to vaginal route excluding endometriosis. This technique promises advantages of a high success rate, reduces need of laparoscopic assistance with low requirement of volume reduction manoeuvres, less intraoperative and postoperative bleeding, mild postoperative pain, early discharge from hospital thus reduces cost and complications

Vaginal hysterectomy can be made easier by adopting newer techniques using modern methods of hemostasis.

Presently, if the ligature technique of hemostasis can be replaced at least with the bipolar coagulation and further if a right angle forceps is used as a helper or anatomy delineator as in Purohit technique then the feasibility vaginal hysterectomy would be widely expanded. It will drastically reduce the number of abdominal and laparoscopic hysterectomies.

INTRAOPERATIVE COMPLICATIONS:

Hemorrhage and blood transfusion: if the size of the uterus is more than 18 weeks or if the size of cervical fibroid is more than 7-8cm then be prepared for the need of blood transfusion for it requires exhaustive morcellation and sometime before ligation of atleast one uterine artery.

Bladder injury-

In our extraperitoneal technique of bladder separation from the cervix and anterior wall of uterus, cystostomy is suspected if finger enters to a smooth empty space of bladder lumen and plenty of fluid floods the field on removal of finger. Hold the incised margins and repair in layers.

Rectal injury, bowel injury or ureter injury: we have not faced such injuries till today

POSTOPERATIVE COMPLICATIONS:

Vault hematoma

We have seen in few cases during the early part of our study. But after adopting the technique of routine tracing of the incised edge of posterior leaf of broad ligament up to upper pedicles to check proper hemostasis and after routine use of our technique of vault closer no case of vault hematoma was seen in the last 330 cases. However the vault hematoma is drained under transabdominal sonographic guidance after filling bladder with about 300 ml normal saline.

Small burn injury to vulval skin and labia minora-Inner side of the vaginal skin and labia minora are occasionally trapped between the prongs of the activated bipolar forceps which have broken insulation and are cauterized without the intention of surgeon. Thus do not use bipolar forceps with broken insulation beyond its active tip or be careful.

The patient with a small burn ulcer complain of burning during micturation.It is treated with adequate antibiotic ointment. Ask her to apply ointment before she intends to pass urine. It heals in few days.

Bleeding from vaginal vault-

We have not seen postoperative bleeding from uterine artery in consecutive 680 cases. Occasionally a phone call is received at the end of one month after operation saying few drops of blood came out of vagina.

It usually comes from suture points of vault mucosa. It usually stops on its own. No treatment other than haemostatic drug is required. In one case out of 680 we had to cauterize a tiny arteriole at the suture line of vault.

Vaginal discharge: It remains till suture materials are there at vaginal vault. It stops on its own. No special treatment is required.

Post operative pyrexia occurs mostly due to cystitis in few cases. No infection is seen at the operation site.

Vault granulation –very rare and are cauterized if needed

Vault prolapse: We have seen 4 cases of cystocele out of 680 cases in the last 8 years. In all cases cystocele occurred within one year of vaginal hysterectomy. In the last 330 cases and in the last 2 years after we adopted our technique of applying vault plication suture as described above we have not seen a case complaining of some thing coming out of vagina.

POSTOPERATIVE MANAGEMENT:

Routine prophylactic antibiotic, anti emetic (Ondansetron), ranitidine

IV fluid 12 hours,

Oral fluid after 3 hours

Catheter removal after 12 hours

Vaginal pack and drain removal after 12 hours

Solid diet after 12 hours

Analgesic for minimum 12 hours then if needed

Patient can go home after 24-36 hours of operation if feels comfortable with oral antibiotics, analgesic, antacid, laxative, multivitamins.She is told to have mild vaginal discharge for few days, mild lower abdominal discomfort for few days. Advised to telephone if any problem occurred.

Can join work once she gains confidence. Postoperative check up after one month

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Anaesthesia during operation - we prefer spinal anaesthesia

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Last updated on 3rd May, 2008

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