All patients who will be undergoing vaginal hysterectomy must have demonstrated mobility of the uterus upon pelvic examination. This is particularly important in the case of prior pelvic surgery. In this case, the gynecologist also should make every attempt to obtain her surgical records—especially those from her laparoscopic tubal ligation—to exclude major adhesive disease in the pelvis.
Laparoscopic adhesiolysis may facilitate vaginal hysterectomy
If there is any concern that the uterus is fixed to the abdominal wall, abdominal hysterectomy should be considered. Even more preferable is laparoscopic adhesiolysis, which can make it possible to proceed with vaginal hysterectomy. I have used this approach in women with as many as 5 previous cesarean deliveries and severe ventral fixation of the uterus.20 After adhesiolysis, the remainder of the hysterectomy can usually be performed solely through the vaginal route.
CASE 2 Medical records suggest the vaginal route is feasible
The gynecologist obtains C.S.’s previous medical records, which confirm that the cesarean delivery was uncomplicated. They also indicate that, at the time of the sterilization procedure, there was no evidence of ventral fixation of the uterus or other major adhesive disease.
The physician decides to proceed with vaginal hysterectomy, but remains very concerned about the possibility of bladder injury. How can she avoid inadvertent cystotomy?
Difficulty identifying and safely dissecting the bladder—because of distortion of the vesicouterine space from the previous cesarean delivery—is a legitimate concern. However, injury to a scarred and densely adherent bladder is a risk even with abdominal dissection.
The vaginal approach to the distal vesicouterine space has a clear advantage: The vesicouterine space closest to the initial vaginal dissection is unaffected by the previous operation on the lower uterine segment. In contrast, with the abdominal approach, dissection begins in the area of scar, and only after penetrating the scar does one find the unaffected space. With the vaginal approach, dissection begins in the correct surgical plane, which aids in identification of the location of the bladder and cesarean scar.
Sharp dissection is a must to protect the bladder
Once the correct surgical plane is encountered, sharp dissection is necessary to prevent tears of the adherent bladder, which can occur with blunt dissection.
Although sharp dissection is the key to success under these circumstances, other maneuvers may be helpful in some cases.
Nichols21 suggested performing dissection of the bladder after it has been filled with a dilute indigo carmine solution to stain the bladder tissues and help prevent bladder injury.
Hoffman and Jaeger22 describe the placement of a bent uterine sound in the posterior cul-de-sac. The sound is then brought around to the anterior cul-de-sac as an aid to dissection of the bladder and the vesicouterine peritoneal fold.
Sheth and Malpani23 describe developing a lateral “window” through the broad ligament to the bladder dissection when there are dense midline adhesions.
Although these are all valuable suggestions, I have found that they are rarely needed with careful sharp dissection. Remember, it is essential to avoid the temptation of blunt dissection when performing vaginal hysterectomy in women with a prior cesarean delivery.
CASE 2 Procedure is a success
The vaginal hysterectomy is carried out without incident, and cystoscopy following the hysterectomy is negative for any bladder injury; both ureteral orifices promptly efflux indigo carmine.
The surgeon encountered little difficulty during the bladder dissection, which was performed sharply. In fact, she was surprised at how well she could actually identify the hysterotomy scar and bladder. The patient goes home after 24 hours and is back at work in 2 weeks.
As noted in both cases presented here, the gynecologic surgeon must be certain that the urinary tract is intact and uninjured prior to leaving the operating room. This includes careful inspection of the bladder grossly for any sign of injury, as well as cystoscopy.
Most bladder injuries that occur with hysterectomy—either vaginal or abdominal—are usually well above the trigone and can be carefully repaired by the gynecologic surgeon. Complex injuries to the bladder involving the trigone or ureters usually require urologic intraoperative consultation.
The author reports no financial relationships relevant to this article.