Hysterectomy is one of the most common procedures performed in gynaecology. It can be performed abdominal, laparoscopically or vaginally. There are no specific contraindications for the vaginal hysterectomy, and whenever possible, the patients should be offered minimal invasive surgery. The benefits of the vaginal procedure are clearly demonstrated in multiple studies, including the shorter hospitalization and recover time and fewer complications and bleeding loss. As minimally invasive technology continues to be developed and refined, surgeons must be discerning in choosing the safest, cost-effective surgical approach associated with the best outcomes for each patient.
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Hysterectomy is one of the most common procedures performed in gynaecology. It can be performed abdominally, laparoscopically or vaginally, the last ones being considered “minimally invasive”. The indications are wide and include a large spectrum of diseases, both benign or malign.
Choosing the route of hysterectomy depends on the diagnosis, uterine size, surgeon experience, available technology, whether the surgery is emergent or scheduled and patient choice. Different studies analysed the occurrence of the procedures and despite the clear benefits of the minimally invasive surgery (vaginally of laparoscopically), the abdominal hysterectomy is the preferred method among surgeons (1, 2).
According to the last guidelines, minimally invasive surgery should be performed whenever possible. The doctor should discuss with the patient and should explain the advantages and disadvantages of one procedure over another with the benefits and the complications.
Indications for vaginal hysterectomy
Vaginal hysterectomy is associated with better outcomes and fewer complications.
Multiple studies compared the days of hospitalization, the recovery time and the rate of complications in vaginal hysterectomy versus laparoscopically or abdominally procedure (3, 4).
The results demonstrate that vaginal route was superior to both laparoscopically and abdominally procedure and it was associated with a shorter hospitalization period and a recovery time. The blood loss and the operating time is usually lower in the vaginal approach.
The route of hysterectomy generally depends on a various of the facts. The surgical indication for hysterectomy and the extent of gynaecologic pathology is the first questions to bear in mind when choosing the surgical route. Taking into considerations the pathology, what is the best access for the management of concomitant pathology? Is there a need for additional techniques? The patient must be informed about all the possible procedures, about the complications with each technique and his preference should be taken into consideration.
The surgeon’s competence, the availability and facility of the method are other reasons that should be taken care of when selecting a method.
The common indications for vaginal procedure are an uterine volume less than 12 weeks gestations or less than 180g, normal adnexa, no history of pelvic surgery, wide maternal pelvis, previous vaginal deliveries and no other surgical contraindications (4, 5). Also, women with chronic pelvic pain who are candidates for hysterectomy (6) should be offered the choice of vaginal hysterectomy. ACOG committee sustains that “vaginal hysterectomy is the approach of choice whenever feasible, based on its well-documented advantages and lower complication rates” (1). There are several conditions that support a non vaginal hysterectomy but in reality there are no absolute contraindication to the method (7). Nulliparity, extremely large uterine size with lack of uterine descent, previous pelvic surgery or caesarean delivery with significant adhesions, increased body mass index, of history of pelvic radiation can make a vaginal approach more difficult and challenging compared to abdominal hysterectomy (5, 8).
A bulky uterus, large fibroids, a narrow pelvis that limit or block the access to uterine vessels can lead to abdominal conversion (8). When there is a large uterine volume, the approach can be accomplished safety by using different techniques of uterine size reduction such as wedge morcellation, uterine bisection and intra-myometrial coring (1, 9, 10).
Transvaginal morcellations was first proposed to remove a large uterus since 1800 in safe conditions and without the need for abdominal hysterectomy (11). The method is also used for reducing the large hysterectomy specimens through small incisions in laparoscopic procedures. Multiple studies demonstrated that transvaginal morcellation is safe and feasible in cases of vaginal hysterectomy (11-13). Thus, it was demonstrated that a large uterus alone is not a contraindication to vaginal removal through morcellation. But, despite the benefits, the suspicion or known of malignant disease is a contraindication for the technique. To minimize the risk of occult malignancy, an endometrial biopsy prior to surgery is recommended (14, 15).
Adhesions, concomitant adnexal pathology, severe endometriosis with severe adhesions can influence the technique and the vaginal approach can be impossible to make. In these cases, a previous inspection of the abdominal cavity via laparoscopy before deciding on the route of hysterectomy, should be taken into consideration (1).
Evidence suggests that in general, vaginal hysterectomy is associated with a good prognosis and a better outcome compared to abdominal or laparoscopic hysterectomy. Multiple studies proved the advantages of vaginal hysterectomy over other procedures, with fewer complications rate (1, 3).
The frequent intraoperative complications are haemorrhage, bladder injury and bowel injury. Haemorrhage appear because of losing a vascular pedicle or from visceral injury. The greatest risk comes from the risk of retracting the loosen suture into the abdominal cavity with intraabdominal or retroperitoneal bleeding. In these case, the conversion to laparotomy should be taken into consideration (16).
Bladder injury typically appears during entry into the anterior cul-de-sac. Besides the bladder, the ureter can be injured during vaginal hysterectomy (16, 17). The degree of lesion can vary from transection, crush or anatomic distortion from an adjacent suture. The concomitant pelvic floor repair does not increase the risk of urinary tract injury during operative session (18).
The bowel can be injured during vaginal surgery and the help from a general surgeon always be safest choice (16).
One of the intraoperative complications that can appear is the conversion to laparotomy. The haemorrhage from a loosen pedicle, significant pelvic adhesions or unusual anatomy can lead to difficulties in dissection and the need for laparotomy should be taken into consideration. The gynecologist should understand when it is the time to stop the vaginal approach and to convert to laparotomy, as prolonging intraoperative time has no benefits on the patient.
There is a wide spectrum of postoperative complications. Urinary retention or incontinence, fever, bleeding, sexual disfunction, vesicovaginal or rectovaginal fistula or pelvic organ prolapse are some of the complications that can develop after vaginal surgery.
Different treatment techniques should help in dealing with the complications (19).
Vaginal hysterectomy is a feasible method with multiple benefits and should be the first choice in cases of hysterectomy. If more women could undergo vaginal hysterectomy rather than abdominal hysterectomy, the reduction in morbidity and in length of stay in hospital would result in considerable savings in medical costs.
TOADER Oana  
VINTEA Alexandra  
VOICHITOIU Andrei  
BODOG Alin  
SUCIU Nicolae  
 “Carol Davila” University of Medicine and Pharmacy, Bucharest (ROMANIA).
 “Alessandrescu-Rusescu” National Institute for Mother and Child Health, Polizu Department, Bucharest (ROMANIA).
 University of Medicine and Pharmacy Oradea (ROMANIA).
 Pelican Hospital, Oradea (ROMANIA).
Contributo selezionato da Filodiritto tra quelli pubblicati nei Proceedings “4th Congress of the Romanian Society for Minimal Invasive Surgery in Ginecology – Annual Days of the National Institute for Mother and Child Health Alessandrescu-Rusescu - 2018”
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Contribution selected by Filodiritto among those published in the Proceedings “4th Congress of the Romanian Society for Minimal Invasive Surgery in Ginecology – Annual Days of the National Institute for Mother and Child Health Alessandrescu-Rusescu - 2018”
To buy the Proceedings click here.