Subtotal vaginal hysterectomy

A new technique for supracervical hysterectomy: Anterograde vaginal subtotal hysterectomy

To review the results of a novel method of subtotal hysterectomy, called anterograde vaginal subtotal hysterectomy (AVSH), and to compare them with those of laparoscopic subtotal hysterectomy (LSH).We recruited 100 women with non-prolapsed uteruses and benign lesions of the uterus who required surgery. Of these, 60 underwent AVSH and 40 underwent LSH. Clinical data included average operation time, average volume of bleeding, postoperative anal exsufflation time, operative complications, average length of hospital stay and average hospital maintenance fee.There were no significant differences in terms of average operation time, average length of hospital stay, or operative complications between the AVSH and LSH groups. The AVSH group showed early postoperative anal exsufflation (P = .000), and had a low average hospital maintenance fee (P = .000). The AVSH group showed a higher perioperative bleeding volume than the LSH group (P = .001), which may be a result of the relatively amateur AVSH technique.AVSH is a minimally invasive, safe and feasible surgical procedure, with favorable early postoperative anal exsufflation and a low average hospital maintenance fee.

Subtotal hysterectomy and myomectomy - vaginally

Vaginal subtotal (or supracervical) hysterectomy and vaginal myomectomy are elegant procedures rarely carried out by the average gynaecologist. Both techniques, however, are easily learned, and in view of the proven advantages of vaginal surgery over abdominal or laparoscopic approaches, they are worthy of a wider application. Subtotal hysterectomy may be preferred to excision of the entire uterus in certain circumstances, and may be carried out vaginally. Vaginal myomectomy allows for a more thorough myomectomy and stronger uterine repair than a laparoscopic procedure, as well as avoiding abdominal wounds. It may represent the optimal approach where fibroids are favourably sited. We first set out the case for subtotal hysterectomy and then describe the development of vaginal subtotal hysterectomy and vaginal myomectomy. We discuss the evidence supporting their use and indications, and then describe techniques for both vaginal procedures.

Hysterectomy: evolution and trends

Hysterectomy was mentioned in Greek manuscripts 2000 years ago, but there is no proof that it was performed. Early--usually fatal--attempts at vaginal hysterectomy are recorded from the 16th century. The origins of vaginal and abdominal hysterectomy are traced from the 19th century after the pioneering work of Langenbeck and Clay. Advances in anaesthesia, blood transfusion, antibiotics and surgical technique led to hysterectomy becoming the second most common operation in women. In the first part of the 20th century subtotal abdominal hysterectomy was standard, but by the 1950s this was replaced by total abdominal hysterectomy. There has been a recent, albeit minor, resurgence of interest in subtotal hysterectomy. The development of laparoscopic assisted hysterectomy in the 1990s has, ironically, led to the re-emergence of standard vaginal hysterectomy as the method of choice for most cases of benign gynaecological disease requiring hysterectomy. At the start of the 21st century there are signs that alternatives to hysterectomy-such as hysteroscopic surgery, uterine fibroid embolization, and the levonorgestrel intrauterine device-are leading to a reduction in hysterectomy rates.

A prospective study to evaluate oophorectomy at the time of vaginal hysterectomy

OBJECTIVE

To assess the feasibility and safety of vaginal removal of ovaries at the time of vaginal hysterectomy.

DESIGN

Prospective study.

SETTING

London teaching hospital.

POPULATION

Between March 1993 and March 1995, 40 women were admitted under the care of one consultant for vaginal hysterectomy and bilateral oophorectomy.

METHODS

The success rate of removing the ovaries vaginally was calculated and the operative time, blood loss, intra- and post-operative complications and patient recovery were analysed and compared with 48 patients who had a vaginal hysterectomy but retained their ovaries during the same time period.

RESULTS

Thirty-nine (97.5%) of the 40 women due to undergo removal of the ovaries were managed successfully via the vaginal route; one woman required laparoscopic removal of one of her ovaries containing an ovarian cyst which was not diagnosed pre-operatively. A variety of techniques were used for vaginal oophorectomy which included salpingo-oophorectomy, oophorectomy without salpingectomy, and transvaginal endoscopic oophorectomy utilising endoloop sutures or bipolar electrosurgery. Oophorectomy added a mean of 23.4 min (88.3 vs 64.9 min, 95% CI 10.2-36.7, P < 0.001) to the total operating time compared with vaginal hysterectomy alone. No laparotomies were required, and both the complication rate and post-operative inpatient stay were similar for the two groups.

CONCLUSIONS

The need to perform oophorectomy should not be considered a contraindication to vaginal hysterectomy.