CASE 1 Problems entering the cul-de-sac
M.K. is a 43-year-old gravida 2 para 2 who is undergoing a vaginal hysterectomy for menorrhagia. A preoperative pelvic exam and ultrasound suggested a 12-week-size uterus with several small leiomyomata. Her gynecologist estimates the uterine weight at 240 g and notes that the uterus is mobile. M.K. asks that her ovaries be removed at the time of hysterectomy because of a family history of ovarian cancer.
During the initial dissection, the surgeon is unable to enter the anterior cul-de-sac due to distortion created by an anterior fibroid. The surgeon has entered the posterior cul-de-sac, but the uterus is too large to manipulate a finger around anteriorly to identify the peritoneal fold. Although he feels confident that the bladder has been adequately mobilized from the cervix, the surgeon is strongly considering abandoning the vaginal approach and completing the hysterectomy abdominally.
How should he proceed?
Entry into the peritoneal cavity through the anterior or posterior cul-de-sac can sometimes be challenging, as this case illustrates. However, there is no need for the surgeon to abandon the vaginal approach just yet. In my experience, the anterior peritoneal fold can be high or distorted by fibroids in some women. The key to successful surgery is a pause in activity to consider the case at hand and determine whether additional progress can be made safely without changing the approach.
Avoid blind entry at all costs
No less an authority than Heaney1 advised against blind attempts to enter the anterior cul-de-sac. Such attempts are often frustrating, can involve bleeding, and raise the risk of injury to the bladder. However, once the surgeon is confident that the bladder is free and retracted out of the way, he or she can proceed without intraperitoneal entry. This is especially true if the posterior cul-de-sac has been entered safely.
The “climb up” technique
In some cases, the surgeon may safely proceed extraperitoneally even if neither cul-de-sac has been opened. Krige2 coined the term “climb up” to describe the extraperitoneal approach to the inaccessible posterior cul-de-sac. He performed extensive extraperitoneal dissection that, if necessary, included both uterosacral and cardinal ligaments as well as uterine vessels. A surgeon may carry a total extraperitoneal dissection completely to the uterine fundus as long as the bladder and rectum are free.3
In M.K.’s case, the surgeon should proceed to take the uterosacral and cardinal ligaments posteriorly without swinging the clamps around to the anterior aspect of the cervix, if possible. Once these ligaments are taken, the uterus often descends enough that the anterior peritoneal fold becomes accessible. Once it is identified, the anterior cul-de-sac can be entered safely.
If safe entry still is not possible, the surgeon can take the uterine vessels if he or she is confident that the bladder is out of harm’s way. If the fold still cannot be identified after this bite, proceed with broad-ligament clamps, which usually lead to eventual opening of the peritoneal fold.
CASE 1 Some progress, then surgery stalls
The surgeon proceeds to operate extraperitoneally, as described above, and successfully enters the anterior cul-de-sac after the uterine vessels are ligated. However, after several additional bites of broad ligament on each side, progress stalls because of uterine size. The surgeon seems to be stuck and is growing increasingly frustrated.
What is the best way around this impasse?
Morcellation can involve a range of techniques
Whenever a large uterus prevents further progress, and the uterine vessels have been ligated, uterine morcellation can be performed. Morcellation techniques originated when vaginal hysterectomy was the archetypal gynecologic operation,4-7 and include uterine bisection,8-11 Lash intramyometrial coring,6,8,9 myomectomy,10,11 and wedge debulking.9 Although every surgeon has a favorite, some or all of these procedures may be necessary in the same patient.12-15 In all cases it is mandatory that the uterine vessels be ligated before any morcellation procedure is initiated.
In my experience, a uterus in the range of 240 g usually lends itself very nicely to Lash intramyometrial coring. This technique is a nearly bloodless procedure that does not violate the endometrial cavity when it is performed properly. In addition, any intramyometrial fibroids can be easily removed.
If coring does not decompress the uterus enough for safe delivery, the core can be cut off and the remaining uterus can be further morcellated by removing wedges of myometrium or by bivalving the uterus. Since there is usually more room in the posterior vagina than in the anterior vagina, as much of the wedge morcellation as possible should be done posteriorly.