There was a patient who was undergoing an abdominal hysterectomy for menorrhagia and uterine leiomyomas. They called me half way through the surgery for an opinion.
"Sir, the rectum is adherent to the back of the supravaginal cervix. Shall we perform a subtotal hysterectomy and leave the rectum attached to the cervix undisturbed?"
I could understand the thought behind this suggestion. There was risk of rectal injury if one tried to separate it. Removal of the uterus above that level would get rid of the leiomyoma and the patient's problems."
I looked at the operative field. It looked like this (Sorry, there was no time to take a snapshot). I have drawn the structures as they would have been prior to any operative steps for better understanding of the readers.
The rectum was drawn up and stuck just above the anterior ends of both the uterosacral ligaments.
"Wait. Let me wash up and have a feel of it" I said.
I scrubbed and joined them. The rectum would indeed be injured if the uterosacral ligaments were clamped without separating it, and it could be injured during an attempt to separate it.
"I think I can get around this problem" I said.
Then I cut the posterior uterine wall transversely to a depth of 2-3 mm, just above the level of the uterine pedicles. I held the edges with Allis' forceps and cut sharply under the surface downward in the direction of the vagina. Once I reached the vagina, the posterior flap with the rectum attached to it could be pulled away from the uterus and uterosacral ligaments. I cut the ligaments within this cuff and ligated them. Then I cut the vagina all around and removed the uterus.
"This was somewhat like an intrafascial hysterectomy" I said. "The difference was that I kept a cuff of cervical fibrous tissue along with the fascial cuff to give additional protection to the rectum on the outside. After all, the serosa and fascia are thin and can get torn during dissection. Cervical fibrous tissue strengthened the cuff. Now will you close the vagina within this cuff? It won't injure the rectum, which is well away."
"Yes, Sir" they said happily.
I went away happy for having removed the patient's cervix successfully and also for having taught our doctors something new."
"Sir, the rectum is adherent to the back of the supravaginal cervix. Shall we perform a subtotal hysterectomy and leave the rectum attached to the cervix undisturbed?"
I could understand the thought behind this suggestion. There was risk of rectal injury if one tried to separate it. Removal of the uterus above that level would get rid of the leiomyoma and the patient's problems."
I looked at the operative field. It looked like this (Sorry, there was no time to take a snapshot). I have drawn the structures as they would have been prior to any operative steps for better understanding of the readers.
"Wait. Let me wash up and have a feel of it" I said.
I scrubbed and joined them. The rectum would indeed be injured if the uterosacral ligaments were clamped without separating it, and it could be injured during an attempt to separate it.
"I think I can get around this problem" I said.
Then I cut the posterior uterine wall transversely to a depth of 2-3 mm, just above the level of the uterine pedicles. I held the edges with Allis' forceps and cut sharply under the surface downward in the direction of the vagina. Once I reached the vagina, the posterior flap with the rectum attached to it could be pulled away from the uterus and uterosacral ligaments. I cut the ligaments within this cuff and ligated them. Then I cut the vagina all around and removed the uterus.
"This was somewhat like an intrafascial hysterectomy" I said. "The difference was that I kept a cuff of cervical fibrous tissue along with the fascial cuff to give additional protection to the rectum on the outside. After all, the serosa and fascia are thin and can get torn during dissection. Cervical fibrous tissue strengthened the cuff. Now will you close the vagina within this cuff? It won't injure the rectum, which is well away."
"Yes, Sir" they said happily.
I went away happy for having removed the patient's cervix successfully and also for having taught our doctors something new."
