Difficult Vaginal Hysterectomy: New Technique

Difficulty may be encountered in vaginal hysterectomy due to conditions like absence of uterine descent, large size of the uterus, pelvic adhesions, and uterine distortion. It is our policy not to perform vaginal hysterectomy for uteri larger than 12 weeks of gestation. We prefer abdominal hysterectomy in such cases. But sometimes the patient has risk factors that make abdominal hysterectomy less desirable than vaginal hysterectomy. Extreme obesity is one such condition. The degree of access is limited, the duration of suergery is longer, and the risk of wound sepsis and breakdown is increased manyfold. In such cases we try and achieve removal of the uterus vaginally, with full understanding that we may have to abandon the approach and complete the surgery abdominally. We usually adopt methods like uterine bisection, myomectomy, uterine morcellation, and Lash procedure to facilitate vaginal removal of the uterus. These methods reduce the bulk of the uterus and make removal of the large uterus easier. However the bisection by itself does not reduce the bulk much. It has to be combined with myomectomy (if there are uterine leiomyomas) or uterine morcellation (if there is adenomyosis). If the uterus is enlarged in a craniocaudal as well as transverse direction by adenomyosis, even morcellation may not be adequate. The top of the uterus lies at a level much higher than the level of attachment of the cornual structures. In such situations we modify the conventional method. After ligation and division of the uterine blood vessels we displace the uterine mass to one side. With the uterine corpus still inside the pelvis, we clamp, cut and ligate the cornual structures on one side, made accessible by uterine displacement to the opposite side. It may not be possible to clamp the structures together. In that case they are clamped, cut and ligated step by step. The location of this clamping is often very lateral in the operative field owing to the large size of the uterus. Once the uterus is freed from the adnexa on one side, its separated lateral surface is held with instruments like Allis' long forceps, tenaculum, vulsellum, bulldog vulsellum, Jacob's clamp etc. and the corpus is swung downwards around an anteroposterior axis, delivering the part of the corpus on that side first, then the fundus, and finally the part of the corpus on the opposite side. Then the round ligament, fallopian tube and uteroovarial ligament on the opposite side can be clamped, cut and ligated and the uterus can be removed. It is our observation that the smooth surface of the uterus (owing to its serosal covering) glides quite easily, so that the specimen can be delivered even without reducing the size of the corpus.