vaginal hysterectomy - description, indications, and questions

by: Custom Clinical Education

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okay so GYN procedure isn't vaginal hysterectomy so for our indications total vaginal hysterectomies that's TVH is a good operation it's not done all that commonly only sod a couple times on my rotation that's mainly because laparoscopic procedures have become a lot more common and when you do a tv8 you lose some of the standard benefits that come with doing things laparoscopically and the main ones are less time in the hospital after the operation and also less pain and but versus a total abdominal hysterectomy t v-- h total vaginal hysterectomy is recommended because t v-- h has been shown to have less infections and also less payment total abdominal hysterectomy some of the contraindications when you wouldn't want to do this or if cancer I mean because you can't explore the abdomen at all and see what's going on and then also size of the uterus so if you have a really big uterus you might have a problem delivering it through the vagina and you also might have problems because you're you're working sort of along the side of the uterus trying to access for example the uterine artery and the Cardinal ligament off to the side of the uterus now might be difficult just space wise if the uterus is really big and the indications these are the same as in general for hysterectomy so a lie on myoma what would be alternatives hysterectomy for that I think of two different ones so one of them to be my Mac to me and the other one would be uterine artery embolization so pelvic organ prolapse you could try pessary or pelvic for strengthening exercises for pain let's say you have pain caused by something specific like endometriosis what's medical therapy for that GnRH analogues you could use those and if you have abnormal bleeding you might want to try ablation of the endometrial lining before you perceive something like hysterectomy it's for the anatomy review we have the peritoneum coming down sort of draping over the uterus extending out towards us for performing the broad ligament to the lateral wall reflecting up anteriorly onto the bladder forming the vesikko uterine fold here this is anterior or cul-de-sac and then the posterior cul-de-sac back here and they get the bladder anteriorly rectum posterior Lee here's the vaginal opening coming to the cervix and then uterus so you might have to do a bimanual exam before the operation and if you do you're going to want to report something when you're done with this so you don't just you know stand there with nothing to say and we what you're going to want to say is the way you think diversion and the flexion is which are terms to describe the position of the uterus here in the in the pelvis in the pelvis so the version is the angle of the uterus with respect to the vaginal opening so the way I've drawn it drawn it here if you're pushing up on the cervix and you're feeling the abdomen with your other hand and you can feel the uterus pumping up against your hand and it's probably aunt diverted which is the way it's shown if you can't feel anything then it might be retro reverted like this and something you wouldn't be able to feel it when you're pushing so that's version the uterus with respect to the vaginal opening and you have flexion which is the uterus with respect to the cervix so let's say we're going up here like this like we're aunt inverted but then we branch off this way that would be aunt diverted and aunt flexed so continue along with the anatomy review we have the arterial supply so we have abdominal aorta dividing up into common iliacs then we have the common iliac spur they're dividing into the external and the internal and so the external what does that become after the inguinal ligament that becomes the femoral and the internal divides up into anterior and posterior divisions then I'll put the uterus and just to get oriented and the off of the anterior division of the internal iliac we have what matters to us which is the uterine artery there's also the vaginal artery the umbilical artery and some other important ones that come off of this division of the internal iliac so the ureter where does that go so that's coming down from the the kidney up here it crosses on top of the common iliac just before just before it bifurcates into the internal and external divisions and then comes down runs almost alongside the uterine artery then passes underneath the uterine arteries so that's where the water under the bridge comes from and just for general knowledge where does this division happen where does the the abdominal aorta divide up into the common into the common X that's at the navel so that's t10 at your belly but 10 and lymphatics in embryology so you have the uterus and part of the vagina where does that come from embryology wise those are the Larian structures and the lymphatics that serve them are the internal and external nodes and ultimately the common le ACK nodes up here and she have the distal vagina where does that come from embryology wise that's from the urogenital sinus and that goes over here to the inguinal nodes in the inguinal nodes are over by the femoral artery which is near the inguinal ligament the last layer of anatomy dad is the is the the ligaments that's the important thing I want to put in here so you have the blood supply to the ovary that's coming to right off the abdominal aorta and that travels in a ligament called the suspensory ligament of the ovary that's the way it was in years 1 & 2 of school but then I'm on the rotation that became the infundibulum pelvic ligament so if you hear people talking about the IP that's what they're talking about that's the suspensory ligament over and it's bringing the blood to the ovaries and you have the uterine artery what does that run in that runs in the Cardinal ligament coming in from the lateral wall to the uterus then you have the uterus sacral ligament and that sort of meets up with the Cardinal ligaments acryl Cardinal complex attaching here to the uterus the uterus sacral where does it where does it come from or where does it go depending on your looking at it and it goes posterior inferior to the ischial spine and the sacrum so that's sort of providing anterior posterior support reza cardinals providing more lateral support and you have the round ligament here what travels in the round ligament it's like a pimp question type of thing that's Samson's artery goes in there and so where's that headed to that's headed to the labia majora and then where does it travel an important place is the internal ring of the inguinal canal so the only other ligament to add is the is an easy one so the way it's named it's the utero ovarian ligament so that finishes off the Anatomy review now move on to the procedure so pre-op your standard sort of setup cephalosporins get a m-- and a half an hour before if somebody has a symptomatic bacterial vaginosis you have to treat it which means you have to test for it because you treat it even if it is asymptomatic can you use metro to treat it and along with that you get the disulfiram reaction headache metallic taste NG tube so that's important to keep air out of the intestines which helps prevent injury to the bowels Foley we didn't I didn't see those used I think it's plus or minus on those cancer screening you want to do this for everybody with hysterectomy see why to make sure they've had a pap smear recently in the last couple and a couple months leading up to the procedure and if it's age-appropriate greater than forty or forty five depending on the guidelines mammography endometrial cancer let's say you're worried about that there's some abnormal uterine bleeding or something you'd want to investigate that with the DNC and direct biopsy of the endometrial lining give UT prophylaxis so the standard set up the heparin and the PCB boots and then the patient's supine and stirrups and you're ready to get going with the procedure so the the general idea is for this because there's there's lots of different ways to do it everyone will do it differently but just it's important to know the general idea so you want to get inside of the peritoneum and you have to go do that by getting access anteriorly so that's between the vesikko uterine fold and then post you're getting into the posterior called the sac then you want to free up the uterus from its attachment from its attachments a pair to name like the broad ligament and also disconnected from its blood supply so maybe the uterine artery and then the buter ovarian or IP ligament depending on what you're doing with the upper vascular pedicles then you can keep a remove the ovaries and then you want to repair to neil eyes and create a vaginal cuff so now we'll go through step by step just to get a little bit more detail and sort of show an example so the first thing is positioning the patient so they're in dorsal lithotomy position so like this and so about with what goes along with that is um you're flexing the hip and so what damage could that could that cause or what what think what adverse event could that cause it compress the world nurse specifically the femoral cutaneous nerve l2 l3 which would cause anesthesia to the anterior part of the thigh after the procedure and then so at the knee what damage or patient positioning is you could calm put there there could be compression of the peroneal nerve there okay so that's that and then when you start out you might inject vasopressin into the cervix and that's to prevent bleeding so remember vasopressin that's ADH ADH the v2 receptor is helping put the aquaporins into the collecting tubules and then also at high concentrations is what you use here so that's why it's called vasopressin pressing those vessels to prevent bleeding all right so in terms of the actual procedure the first thing you might do is incise around the the cervix here at sort of the junction of the cervix and the vagina and then you want to gain anterior access so you have to dissect away between the bladder and the and the uterus until you get to the vesicle uterine fold and we'll go back up here to look at this picture too to get an idea about that so you're working here you're dissecting away here working your way up to the vesicle uterine fold you'll probably use a retractor like a right-angle retractor to pull up on the bladder to sort of get it out of the way then you when you find the vesicle uterine fold should be like a little white line you can pick it up with with pickups and then size it with Mayo scissors and then you've gained access to the to the anterior cul-de-sac so you've made a hole in the anterior peritoneum and then you can turn your attention to the posterior side and luckily the posterior peritoneum is actually really close you can see right here where you are sort of the junction of the cervix and the vagina the posterior pear theme is closed there so you just incise that and so now you've gained access anteriorly and posteriorly inside of the peritoneum so you've done that so you can now you can start to work on disconnecting the uterus from the ligaments in this blood supply so the first thing will be you want to take a bite of the uterus sacral ligament and so you can use heaney clamps to grab it and you want to grab you want to stay real close to the uterus so you grab your clothes cut take a bite and then you're moving up so what's the next thing you're going to run into the next thing will be the Cardinal ligaments so you can bite those clamp them cut them make vascular pedicles out of those keep working your way up the broad ligament and now you've sort of loosened up the uterus from a lot of its attachments and you can walk its way out a little bit and you have to and then once so once you've done that I'll just put put on what we've done to summarize so uterus sacral we dealt with that Cardinals we made that vascular pedal we've worked pedicle we've worked our way up here along the broad and so now depending on what's going on with the ovaries we can decide what to do next and so I'll put in the utero of aerion here so let's say we're going to take the ovaries keep the ovaries inside so then we could cut the round and utero ovarian and then we could remove we could remove remove the uterus so we're grabbing the uterus here we're pulling it out of the hole we've created by slicing around the cervix and let's say that we're gonna take the ovaries with us instead what we do there well we could start by doing the same thing we could cut the round utero variant we could tag the utero of aerion with them some suture so we remove the cervix to get it out of the way and then we grab the tag that we put in here in this ligament pull on it to put some tension on and help us identify infundibular pelvic remember the infundibulum pelvic is suspensory ligament of the ovary bringing the blood to the ovaries we want to find that and then we want to cut that and then we can remove the ovary so now what's left is repaired needle ization than making the vaginal cuff so repaired immunization that's putting putting the peritoneum back together so we we cut the peritoneum anterior at the vesicle uterine fold posterior lis and then also as we worked our way up we took different bites out for example this might be the uterus sacral ligament part of the broad ligament maybe this is tube ovarian so when you're repaired to kneel eyes you take a needle and suture and you sew these back together to bring them bring them back together with each other and so that's shown over here now they're close together you do that to recreate the the structure and support to the peritoneum provides in the pelvis and so once you do that then you want to make the vaginal cuff and again you have suture and your string you're closing off the vaginal cuff and you can get little bites of for example let's say this is uterus a curling we can get bites of that as you as you're working and that will help provide some structure and support to prevent complications for example things like in Tara seals so that's why you want to that's why they take the time to do all this suturing all right so complications so we have the the standard complications that come along with doing hysterectomy fever hemorrhaged injury to the bladder ureter although we noted that this is at least a study showed this to be less common doing it vaginally than laproscopically bowel injury cuff davison so that's the cuff that we just talked about sewing closed if that doesn't so close all the way or if it comes open and some some ballo it goes through it and his blood supply gets cut off and gets strangulated that's vaginal constant to cuff distance with potentially evisceration which would be sort of a serious rare but unique complication of this type of operation and the cuff can also get infected so then you have the general surgical complications and my stroke renal failure and then common-sense things like you want to avoid magical inter intercourse for some time after this procedure so the post-op you have this the standard set up donate a antibiotics after day one keep you can put you put a Foley in sort of after you do this procedure if you didn't have one in during it I get some fluids DVT prophylaxis till the person's walking around you can air ambulate them day one post-op get people walking around and you advance the diet from water to clear liquids to regular depending on flatus appetite bowel sounds and so questions things that I got asked during this procedure so what space are we entering so that's in the beginning of the procedure so if you're below the cervix you're probably entering the posterior called a sac if you're above the cervix and you can say I think we're entering the anterior called the sacrum or through the vesicle uterine fold so why do you have to clamp and cut the ligaments and vessels right next to the uterus you do that because you want to avoid injury injury to the ureter so I'm like doing this laparoscopically or abdominal II you can't really see what's going on as well so you can't identify the ER door watch your peristalsis and then and then cut so you just want to avoid injury by keeping a close eye on where you're working and then questions that you could ask you could ask if they notice the difference in complication so they think that for example there's less injury to be ordered by doing this and also you could say what makes you select vaginal versus laparoscopic white why are we doing this vaginally things that could favor vaginal approach would be someone who's has had multiple children someone who has a uterus that's small those are things that might favour of vaginal approach then laparoscopic assisted vaginal hysterectomy I didn't see those you could ask them if they do those frequently and what sort of indications would would make them want to do that and you could bring up things like if you you're having trouble with getting the ovary outer or accessing then fadila pelvic ligament will you would you want to do but you want to add laparoscopic assistance the procedure to help make that happen okay so that's our



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