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Vaginal Hysterectomy

Setelah pasien diposisikan, speculum diletakkan pada vagina posterior dan right-angle retractor
diletakkan pada anterior dari serviks sementara bibir anterior dan posterior serviks dijepit dengan
tenakulum. Beberapa dokter menginjeksikan vasopressin (10-20 U dalam 50 mL salin) atau
lidokain 0.5% ke jaringan servikal, paracervikal, dan submukosal untuk membantu
mengidentifikasi bidang jaringan dan mengurangi perdarahan.
Vaginal incision and opening of posterior peritoneum
The initial vaginal incision is made circumferentially, beginning at the level of the vaginal rugae
through the full thickness of the vagina, just below the bladder reflectionnot on the cervix (see
the image below). If an incidental cystotomy occurs, the vaginal hysterectomy should be
completed before the bladder is repaired. The vaginal epithelium is dissected bluntly or sharply
to the underlying tissue with an open sponge over the index finger and Mayo scissors.

Initial vaginal incision.

The posterior peritoneum is then identified where rugae are not present and where the uterosacral
ligaments join the cervix. The peritoneum is grasped with tissue forceps and incised with Mayo
scissors in a generous bite (see the image below), and a Steiner-Anvard weighted speculum is
inserted into the posterior cul-de-sac.

Peritoneum is incised with Mayo scissors.

Division and ligation of uterosacral ligaments


The uterosacral ligaments are identified and clamped, with the tip of the clamp incorporating the
lower portion of the cardinal ligaments. The clamp is placed perpendicular to the uterine axis,
and the pedicle is cut so that approximately 0.5 cm of tissue is distal to the clamp. A transfixion
suture is placed at the tip of the clamp and tied. This suture may be held with a hemostat to
facilitate location of any bleeding at the completion of the procedure and to aid in vaginal
closure.
Opening of anterior peritoneum
Attention is then directed to opening the anterior peritoneum. The anterior peritoneal fold
appears as a crescent-shaped line. The peritoneal reflection is grasped with tissue forceps, tented,
and opened with scissors that have their tips pointed toward the uterus (see the image below). A
Heaney or Deaver retractor is placed into this space to protect the bladder and to facilitate
visualization of the abdominal contents.

Peritoneal reflection is grasped with


tissue forceps, tented, and opened.

If the peritoneal reflection is not readily identified, one can wait to make the entry, as long as the
bladder has been safely advanced cranially. A Deaver or Heaney retractor is placed in the midline
to keep the bladder out of the operative field. Blunt or sharp advancement of the bladder should
continue before each clamp placement until the vesicovaginal space is entered. Once this space is
entered, the Heaney or Deaver retractor is placed into the peritoneal cavity.
Division and ligation of cardinal ligaments
Next, the cardinal ligaments are identified, clamped, cut, and suture-ligated in a manner similar
to that previously described for the uterosacral ligaments. Alternatively, newer
electrocauterization devices (eg, LigaSure; Covidien, Boulder, CO) can be used in vessels up to 7
mm in diameter to accomplish the same task.
The uterine vessels are then clamped in such a way as to incorporate the anterior and posterior
leaves of the visceral peritoneum (an important step). A single-clamp technique reduces the risk
of ureteral injury (see the image below).

Uterine vessels are clamped


with single clamp so as to incorporate anterior and posterior leaves of visceral
peritoneum.

Delivery of surgical specimen


The uterine fundus is delivered posteriorly by placing a tenaculum or towel clip on the uterine
fundus in successive bites. The utero-ovarian ligament is identified with the surgeon's finger,
then clamped and cut. The pedicles are double-ligated, first with a suture tie and then with a
suture ligature medial to the first tie. A hemostat is placed on the second suture to assist in the
identification of any bleeding.
If the adnexa are to be removed,[10] traction is placed on the ovary by grasping it with a Babcock
clamp. A Heaney clamp is placed across the infundibulopelvic ligament, and the ovary and tube
are excised. Both a suture tie and a transfixion suture ligature are placed on this pedicle (see the
image below).

To remove adnexa, traction is


placed on ovary by grasping it with Babcock clamp. Heaney clamp is placed across
infundibulopelvic ligament, and ovary and tube are excised. Both suture tie and
transfixion suture ligature are placed on this pedicle.

Management of enlarged uterus


For enlarged uteri, the following techniques may be employed to facilitate removal of the uterus:
morcellation, intramyometrial coring, uterine bisection, and wedge debulking.
Morcellation can be used in cases involving uterine enlargement, uterine fixation, or limited
vaginal exposure. It should not be performed if the uterine arteries cannot be secured or if
malignancy is suspected.
Intramyometrial coring (see the image below) is accomplished by circumferentially incising the
outer myometrium beneath the uterine serosa with a scalpel while placing the cervix on traction.
The incision should be kept as close to the uterine serosa as possible. The enlarged uterus is
delivered as an elongated mass inverting the uterine fundus.

Intramyometrial coring
technique.

Uterine bisection is performed by cutting the cervix and the uterine fundus in the sagittal plane.
This technique is often combined with myomectomy or wedge morcellation to reduce the bulk of
the uterine halves so that the tubo-ovarian vessels can be ligated.[11]
Completion and closure
A sponge-stick or laparotomy pad is placed into the peritoneal cavity to allow the surgeon to
visualize each of the pedicles and confirm that hemostasis is adequate. If any bleeding points are
identified, a suture is used to ligate the bleeding vessel under direct vision. The pelvic
peritoneum is left open.
Finally, the vaginal epithelium is reapproximated either vertically or horizontally with either a
continuous suture or a series of interrupted sutures. These sutures are placed through the full
thickness of the vaginal epithelium, with care taken to ensure that the bladder is not entered.
Culdoplasty for prevention of enterocele
A culdoplasty is generally recommended to reduce the risk of subsequent enterocele formation
and potential vaginal vault prolapse. The 2 methods commonly described are the Moschcowitz
repair (ie, closing the cul-de-sac and bringing the uterosacral-cardinal complex together in the
midline) and the McCall culdoplasty (ie, obliterating the cul-de-sac, plicating the uterosacralcardinal complex, and elevating any redundant posterior vaginal apex). There is some evidence
to suggest that the McCall procedure is superior in preventing enterocele.[12]
In this procedure, an absorbable suture is placed through the full thickness of the posterior
vaginal wall at the apex of what will be the vaginal vault. This suture is passed through the left
uterosacral ligament pedicle, the posterior peritoneum, and the right uterosacral ligament and
completed by being passed from the inside to the outside at the same point where it was begun.
The suture is then tied, thus approximating the uterosacral ligaments and the posterior
peritoneum. It is not necessary to use a vaginal pack or leave a bladder catheter in place.

Complications of Procedure
The primary intraoperative complications are visceral injury and hemorrhage. Reported rates of
hemorrhage range from 1.4% to 2.6%, whereas reported rates of ureteral and bladder injury are
0.88% and 1.76%, respectively.[11]
The most common postoperative complication is pelvic infection. Febrile morbidity occurs in
approximately 15% of women who undergo vaginal hysterectomy and can be reduced by means
of prophylactic antibiotics. Infections after vaginal hysterectomy include vaginal cuff cellulitis,
pelvic cellulitis, and pelvic abscess. These infections occur in approximately 4% of women.[13]
Diagnosis banding