Overview of Vaginal Hysterectomy
Surgeons have many options when it comes to performing a hysterectomy, which is the surgical procedure to remove the uterus. They can chose between vaginal, abdominal, laparoscopic, and robotic-assisted methods.
A vaginal hysterectomy is considered one of the least invasive types of this surgery. This method typically results in better outcomes and has fewer complications compared to other types. For these reasons, it is usually the preferred choice whenever it’s possible to use it.
Undergoing a vaginal hysterectomy tends to involve less pain and leads to a quicker recovery. Patients who have this type of procedure typically can go back to work faster than those who have other types. Plus, the procedure costs less and carries fewer health risks. It is most commonly used when the hysterectomy is being performed as a treatment for non-cancerous conditions.
Anatomy and Physiology of Vaginal Hysterectomy
A hysterectomy, which is a surgery to remove the uterus, can be done in several different ways. The common methods include through the vagina (vaginal hysterectomy), through the abdomen (abdominal hysterectomy), using a camera and small tools (laparoscopic hysterectomy), and with the help of a surgical robot (robotic-assisted hysterectomy).
Vaginal hysterectomy is considered one of the least invasive types of this surgery, meaning it’s less likely to cause complications or harm. It often has better results and fewer issues than the other methods. Whenever it’s possible to perform the surgery this way, it should be the first choice. Benefits of this kind of hysterectomy include less pain after surgery, quicker healing, being able to return to work sooner, reduced costs, and a lower risk of complications. This type is usually performed for non-cancerous (benign) conditions.
Why do People Need Vaginal Hysterectomy
Hysterectomy, or surgical removal of the uterus, is one of the most common procedures performed globally. There are various reasons why someone might need to have a hysterectomy. Here are some of them:
- Pelvic relaxation: This is a condition where the muscles and tissues supporting the pelvic organs become weak or loose.
- Fibroid uterus: Fibroids are noncancerous growths in the uterus which can sometimes cause problems such as heavy periods or pain.
- Abnormal uterine bleeding: This refers any vaginal bleeding that is different from normal menstrual periods. It includes excessively heavy, painful, or irregular periods, or bleeding between periods.
- Pelvic pain associated with endometriosis: Endometriosis is a condition where the tissue similar to the lining of the uterus starts to grow outside of the uterus, often causing severe pain.
- Pelvic organ prolapse: This occurs when the muscles and tissues supporting the pelvic organs weaken, causing one or more of the pelvic organs to fall downward or protrude into or out of the vagina.
- Benign ovarian mass: This refers to a noncancerous growth or tumor on the ovaries.
- Gynecological cancer: This is a term for cancers that start in a woman’s reproductive organs.
- Adenomyosis: This is a condition where the tissue that normally lines the uterus grows into the muscular wall of the uterus, causing heavy periods and pelvic pain.
Each of these issues can cause significant symptoms and may lead to a recommendation for a hysterectomy by your doctor.
When a Person Should Avoid Vaginal Hysterectomy
There aren’t any total reasons why a vaginal hysterectomy (a surgery to remove the uterus through the vagina) absolutely can’t be done. However, there are certain conditions that might make it more challenging, or more risky. These are known as relative contraindications, including:
– Having had pelvic radiation treatment, as it can cause changes and damage to organs in the pelvis.
– Having a larger than normal uterus as it may be too big to remove through the vagina.
– If you have had pelvic surgeries in the past, it may have caused scar tissue that could make this type of surgery more difficult.
– If you are suspected of having severe pelvic adhesions (scar tissue that causes organs to stick together) and anatomical distortion (changes in the normal structure) caused by pelvic inflammatory disease (an infection in a woman’s reproductive organs) or endometriosis (a condition where tissue similar to the uterus lining grows outside the uterus).
– If you are extremely overweight, also known as morbid obesity, as it could increase the risk of complications during surgery.
– If you have never given birth (a condition known as nulliparity), as the cervix and vagina may not be as flexible or stretchy.
– If your uterus is not dropped or descended into the vaginal canal. This is because in a vaginal hysterectomy, the surgeon removes the uterus through the vagina, which may be more difficult if the uterus is not descended.
Equipment used for Vaginal Hysterectomy
The following tools are needed for a surgery called a vaginal hysterectomy, which removes your uterus through the vagina:
Long, heavy Mayo scissors: These are used for cutting tissue. They are sturdier and longer than regular scissors.
Short and long weighted vaginal speculums with an extra-long blade: Vaginal speculums are devices that allow your doctor to see inside your vagina and cervix by spreading the walls of the vagina.
Heaney right-angle retractors: These tools help move and hold tissue aside so the doctor can see and work on the surgical area better.
Jorgenson scissors: These are a specific type of surgical scissors used in the surgery.
Long Allis clamps: These are used to hold or secure tissue during surgery.
Deaver retractors: These are used to move organs aside and make space for the doctor to work in the surgical area.
A long needle holder: This is used to hold the needle while stitching tissue.
Heany clamps: These are used to secure and manipulate tissue.
Single tooth tenaculum: This is a surgical instrument used to hold tissue in place.
Bovie extender: This is a tool used to stop bleeding by using heat.
Suction apparatus: This is used to remove blood or other fluids during surgery to keep the surgical area clear.
A neurosurgery headlight: This provides lighting for the doctor to see the surgical area better.
Who is needed to perform Vaginal Hysterectomy?
A Gynecologist or a Urogynecologist is a type of doctor who specializes in women’s health issues, particularly those dealing with the female reproductive system and urinary tract problems. These doctors are similar, but a Urogynecologist has extra training to help women with problems related to their bladder and pelvis. These two doctors can perform surgeries and provide various treatments to help women overcome these problems.
An anesthesiologist is a specialized doctor who gives you medication to help you sleep or numb certain areas before a surgery, so you don’t feel any pain during the procedure. Anesthetic technologists work with the anesthesiologist to make sure this goes smoothly.
Nurses and surgical assistants also play a significant role in your healthcare journey. They work alongside the doctors to carry out the procedures safely. The nurses work to monitor your condition before, during, and after the procedure, while surgical assistants help the doctors during the procedure.
Preparing for Vaginal Hysterectomy
When a patient is prepared for a vaginal hysterectomy (a surgical procedure to remove the uterus through the vagina), there are several steps involved:
First, the patient is positioned correctly, usually lying on their back with their legs in special supports called stirrups. This provides the surgeon the best accessibility when conducting the surgery.
Next, systems are put in place or medications given to help prevent blood clots (venous thromboembolism). This may include squeeze machines (sequential compression devices) on the patient’s legs or blood-thinning drugs (anticoagulants).
Before the surgery starts, the patient is given a dose of antibiotics, typically cefazolin given via an IV, to help prevent infections. This is usually done within 60 minutes of making the first cut into the patient’s skin to assure maximum effectiveness.
A process known as a ‘time out’ or pre-procedure verification checklist is performed. This is a final review of all important details, such as confirming the patient’s identity, the specific surgery to be performed, the equipment needed, and who the surgeon is. This is done following hospital protocol and ensures patient safety.
Once the patient is under anesthesia, they’re examined to check things like the size, shape, and mobility of the uterus, as well as the health of other structures in the pelvic area. The surgeon will also check the degree of drop of the uterus, the size of the vaginal wall, and any bulging of the bladder (cystocele) or rectum (rectocele) into the vagina are present.
Next, the vagina is cleaned with an antiseptic (usually Betadine) to further reduce the risk of infections. Finally, a sterile surgical drape is placed over the patient to keep the surgical area clean throughout the procedure.
How is Vaginal Hysterectomy performed
Urinary bladder and ureteral injuries are complications that can happen during a hysterectomy, a surgery that removes the uterus. These injuries, however, can be prevented. Here’s a simplified version of the steps followed in a hysterectomy procedure:
1. Emptying the bladder: A tube known as a Foley catheter is used to drain urine from your bladder.
2. Using clotting agents: A medical solution made of vasopressin (a hormone that controls smooth muscle contraction) and normal saline (a mixture of salt and water) is injected around the area where your cervix and vagina meet to help stop bleeding and to separate the tissues.
3. Making a cut around the cervix: A special cutting tool (either a scalpel or diathermy, a heat-based device) is used to make a full circle cut around your cervix at the point where it meets your vagina.
After the cut around the cervix is made, the surgeon uses a combination of precise and gentle separation techniques to detach your vaginal lining from the underlying tissue. The peritoneum (the lining of your abdominal cavity) is identified, and the surgeon carefully enters the peritoneal cavity. A surgical tool either a right angle or Deaver retractor is then placed into the cavity to protect the bladder.
Next, the surgeon holds a part of the vagina with a surgical instrument and gently lifts it. Again, the peritoneum is identified and carefully opened with a type of surgical scissors. Once the peritoneal cavity is open, the vaginal lining is stretched or cut at the sides and a special speculum is reinserted into the peritoneal cavity.
Certain structures connected to the uterus, like uterosacral ligaments (tissues that support the uterus) and cardinal ligaments (those that support the cervix), are identified. They are clamped with a special instrument, cut, and then stitched. Special care is taken during this process as the tubes that carry urine (ureters) are very close to the uterosacral ligaments.
Next, the blood vessels connected to the uterus are identified. They are carefully clamped, cut, and then stitched. After that, the broad ligament (the wide fold of peritoneum that connects the sides of the uterus to the walls and floor of the pelvis) is clamped from the inside, cut, and stitched.
Finally, the round ligament (tissue that supports the uterus), the part of the Fallopian tube near the uterus (cornual end), and the ligament connecting the ovary to the uterus (utero-ovarian ligament) all are clamped and cut, either altogether or one at a time. After all ligaments and vessels are cut and secure, the uterus is carefully removed. The surgeon then checks all cuts (pedicles) for any bleeding.
The cut in the vagina (vaginal cuff) is stitched. In order to prevent the vagina from dropping (prolapse) in the future, the uterosacral ligaments are stitched into the angle of the vaginal cuff.
The surgeon usually does not pack the vagina, as it has not been proven to prevent bleeding or improve other outcomes.
A Foley catheter is left in, to drain urine, until the patient can move around. The patient can start eating and drinking as comfortably tolerated.
Possible Complications of Vaginal Hysterectomy
During a vaginal hysterectomy, which is a surgery to remove the uterus, there could be some issues that occur during the operation. Here are some of them:
1. Bleeding – This happens most often from parts in the uterus, from ligaments nearby, and from the area of the vagina where the uterus was removed.
2. Ureteral injury – The ureters are tubes that carry urine from the kidneys to the bladder, and they could be harmed during surgery. This happens in about 0.5% of cases.
3. Bladder injury – The bladder could also be harmed during this procedure, and it happens in up to 1.2% of cases. The risk is higher for someone who has had surgery in the pelvic area before or is having bladder surgery at the same time.
4. Bowel injury – The intestines could be accidentally harmed during the surgery, and this happens about 0.4% of the time.
5. Nerve injuries – Sometimes, the nerves in the leg can be affected by the tools used during surgery or from the position of the legs during the procedure.
In some cases, the surgeon might need to switch to an abdominal hysterectomy, which is where they make a cut in the belly to remove the uterus. This might happen if there are unexpected large growths in the pelvic area, if there is difficult-to-control bleeding, or with negative reactions to the anesthesia used.
After the surgery, there are also some complications that could occur:
1. Ileus and bowel obstruction – Both of these involve issues with the movement of the intestines.
2. Vaginal cuff dehiscence – This is a fancy way of saying that the stitches at the top of the vagina, where the uterus was removed, could come apart.
3. Infections – They could occur at the vaginal cuff, or deeper in the pelvic area.
4. Fistulas – These are abnormal connections that could form between the vagina and other parts like the bladder, ureter, or rectum.
5. Prolapse of the pelvic structures – Parts like the fallopian tube could fall out of place.
Injuries to the ureters are most likely to happen at certain times during the surgery, such as when separating the uterus from ligaments nearby, and during the closure of the top of the vagina. It’s important to note that this summary doesn’t include how these complications would be managed, which would depend on the specific situation.
What Else Should I Know About Vaginal Hysterectomy?
A vaginal hysterectomy is a less invasive way of removing the womb compared to other forms of the procedure. This type of hysterectomy has many benefits, such as causing less pain, allowing for a faster recovery, enabling patients to return to work sooner, and costing less. It also has a smaller risk of complications, making it the recommended option whenever feasible. Often, this kind of hysterectomy is carried out when the patient is suffering from non-cancerous conditions.
Having a hysterectomy can seriously influence a person’s life in the long run. It can have effects on their physical health, along with their psychological and mental wellbeing. Thus, it is extremely important for healthcare providers to explain every point about the procedure thoroughly to their patients. This will provide patients with all the necessary information they need to make a well-informed decision about their treatment options.
