Curvature to the Aperture: Step by Step through Minimally Invasive Vaginal Hysterectomy

by Yiu Luke, Medical Communications, Digital Surgery

Touch Surgery™ is proud to present Minimally Invasive Vaginal Hysterectomy, available for free on our app. This virtual simulation takes you through the key steps of a vaginal hysterectomy surgery, with four educational modules covering preparation, entry, removal and closure. It is intended for professional reference and training in the field of gynecology.

Touch Surgery™ thanks Henri Clavé, M.D., of Clinique Saint-George, Nice, France, for his authorship of this simulation.

What are the benefits of the vaginal approach to hysterectomy?

In a vaginal hysterectomy, the surgeon removes the uterus through the vagina.1 The use of the vagina as a natural access point minimizes surgical trauma, making vaginal hysterectomy a less clinically tolling approach than open or laparoscopic surgery. The vaginal approach offers the benefits of faster postoperative recovery, less pain, and enhanced safety.2,3 The American College of Obstetricians and Gynecologists (ACOG) recommends the vaginal approach as the first option to consider when planning a hysterectomy.4

What are the drawbacks of the vaginal approach to hysterectomy?

Vaginal hysterectomy is not always the most suitable approach, depending on the circumstances of each case. Some uteri may be impossible to remove through the vagina due to their size or shape. These cases would need a more invasive surgical approach.4Another drawback of the vaginal approach is the historical difficulty of performing hemostasis at the fundus.5 However, advances in electrosurgical vessel sealing, such as Medtronic’s LigaSure™ device, have significantly reduced the bleeding risk.6

What is the LigaSure™ device?

Medtronic’s LigaSure™ devices offer bipolar electrosurgical sealing and cutting functions.7 This type of instrument is featured in our Minimally Invasive Vaginal Hysterectomy simulation as the device of choice for hemostasis and division of anatomical structures. For more information, please see Medtronic’s LigaSure™ product presentation.

Why perform a vaginal hysterectomy?

Hysterectomies, in general, are performed to treat a range of gynecological conditions, from abnormal uterine bleeding (AUB) to cancer.8 Vaginal hysterectomy, in particular, has tended to be the preferred approach for benign conditions, such as fibroids, endometriosis, prolapse and chronic pelvic pain.1,8

What about the other approaches to hysterectomy?

Please browse Touch Surgery’s™ library to view our other hysterectomy simulations, including Total Laparoscopic Hysterectomy.

What are the key stages of a vaginal hysterectomy?

Vaginal hysterectomies typically go through the following summarized sequence:

1. Patient positioning and preparation

Dorsal lithotomy is the preferred patient position for vaginal hysterectomy. At this stage, the surgical team should also disinfect and drape the patient, prepare the instruments, and apply anesthesia. In our simulation, we demonstrate a multimodal anesthesia method, combining low-dose general anesthesia with local anesthesia injections.

2. Posterior and anterior entry

The surgeon makes a pericervical incision to enter the vesicovaginal plane. Curved scissors are used to dissect this plane up to and including the supravaginal septum. The next step is to open the peritoneum of the rectouterine pouch using sharp incision. In this simulation, we demonstrate the amputation of the cervix to improve mobility and visibility when accessing the uterus.

3. Removal of the uterus and salpingectomy

After placing a retractor to protect the bladder, the hysterectomy can be performed. First, the surgeon divides and seals the uterine pedicles. Our simulation demonstrates how to use the LigaSure™ device to complete this step safely, minimizing the risk of accidental cuts or thermal injuries. Having achieved hemostasis, the surgeon can divide the adnexae and remove the uterus, bisecting or morcellating the specimen if needed.

4. Vaginal cuff closure

To complete the procedure, the surgeon sutures the posterior and anterior walls of the vagina, incorporating the posterior and anterior peritoneum. Lastly, the vagina can be closed with an absorbable monofilament running suture. A running suture results in a supple, linear scar after healing.

Ready to delve into the details of how to perform a minimally invasive vaginal hysterectomy? Access the full simulation now in the Touch Surgery™ app.

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How to cite this simulation: Clavé H. Minimally Invasive Vaginal Hysterectomy (MIVH). Touch Surgery Simulations. https://doi.org/10.18556/touchsurgery/2021.s0179. Published Mar. 15, 2021.

References

1. Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. 2015;8:CD003677. doi: 10.1002/14651858.CD003677.pub5

2. Nelson G, Altman AD, Nick A, et al. Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations–Part I. Gynecol Oncol. 2016;140(2):313-322. doi:10.1016/j.ygyno.2015.11.015

3. Nelson G, Altman AD, Nick A, et al. Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations–Part II. Gynecol Oncol. 2016;140(2):323-332.

4. American College of Obstetricians and Gynecologists (ACOG). Choosing the route of hysterectomy for benign disease. Committee opinion no. 701. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2017;129:e155-159.

5. Panza J, Heft J, Zimmerman C. The Loss of Vaginal Hysterectomy. Curr Obstet Gynecol Rep. 2018;7:51-57. doi: 10.1007/s13669-018-0235-5.

6. Elhao M, Abdallah K, Serag I, El-Laithy M, Agur W. Efficacy of using electrosurgical bipolar vessel sealing during vaginal hysterectomy in patients with different degrees of operative difficulty: a randomised controlled trial. Eur J Obstet Gynecol Reprod Biol. 2009 Nov;147(1):86-90. doi: 10.1016/j.ejogrb.2009.07.011.Epub

7. Gizzo S, Burul G, Di Gangi S, et al. LigaSure vessel sealing system in vaginal hysterectomy: safety, efficacy and limitations. Arch Gynecol Obstet. 2013;288(5):1067-1074.

8. Dorsey JH, Steinberg EP. Clinical indications for hysterectomy route: Patient characteristics or physician reference. Am J Obstet Gynecol.