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Vaginal Hysterectomy: Patient Candidacy & Anatomical Considerations

Author Taylor Spurgeon-Hess covers Vaginal Hysterectomy: Patient Candidacy & Anatomical Considerations on BackTable OBGYN

Taylor Spurgeon-Hess • Jan 15, 2024 • 56 hits

Vaginal hysterectomy, a longstanding method in gynecological surgery, faces new challenges and considerations in the modern clinical landscape. Anatomical factors such as uterine size, mobility, and patient-specific conditions like adenomyosis or fibroids are crucial in determining candidacy for this procedure. The shift towards laparoscopic techniques has impacted the proficiency in vaginal methods, underscoring the need for a nuanced approach in both training and practice. Gynecologists Drs. Amy Park and Mark Hoffman discuss the intricacies of patient positioning, intraoperative decision-making, and the evolving dynamics between traditional and minimally invasive surgical techniques.

This article features excerpts from the BackTable OBGYN Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.

The BackTable OBGYN Brief

• Vaginal surgery is historically recognized as the original minimally invasive method. Many modern clinicians have shifted their preference towards minimally invasive gynecological surgery (MIGS).

• Training in vaginal hysterectomies requires active participation and practice by faculty to provide learning opportunities for residents.

• Suitability for vaginal hysterectomy is influenced by uterus size (ideally up to 14-week size) and mobility.

• Adequate access within the vagina and the nature of the pubic arch are crucial considerations. A restrictive outlet can complicate the procedure.

• History of C-sections or endometriosis are considerations but not absolute contraindications.

Vaginal Hysterectomy: Patient Candidacy & Anatomical Considerations

Table of Contents

(1) Vaginal vs. Laparoscopic Hysterectomy: A Shift in Practice Trends

(2) Determining Candidacy for Vaginal Hysterectomy

(3) Patient Positioning Considerations for Vaginal Hysterectomy

Vaginal vs. Laparoscopic Hysterectomy: A Shift in Practice Trends

The evolving landscape of gynecological surgeries has seen a marked shift in the approach to hysterectomy. While vaginal surgery is essentially the "original" minimally invasive method, many modern clinicians have veered towards laparoscopic procedures, leading to a decline in clinicians’ vaginal hysterectomy skillsets. When breaking down surgical decision-making for hysterectomies, the majority of it revolves around pre-operative selection, while the remainder is about technical skills and intraoperative judgment. Therefore, when opting for a vaginal hysterectomy, there is an increased emphasis on choosing the right candidate; patient selection can make a profound difference in surgical outcomes.

[Dr. Amy Park]
My vag plate special is the vaginal hysterectomy, bilateral salpingectomy, vaginal uterosacral, so intraperitoneal vagal colpopexy, interior, posterior repair cystoscopy, plus or minus the sling. I do between 250 and 300 cases a year, and I would say probably the majority of it is vaginal.

[Dr. Mark Hoffman]
Wow. I remember I was a member of AAGL's, fMIGS Fellowship Board for a couple of years, and I was the fellow representative. It was me and a bunch of guys who were pretty senior to me. I was just starting my practice and feeling very self-conscious about everything, a lot of imposter syndrome going on, and I was asking the person next to me, and I won't name names, but I was like, "When's the last time you did a vaginal hysterectomy?" He looked up, he goes, "1991." Everybody around the whole table, nobody had done a vag HYST at the table in years. None of these senior laparoscopic surgeons.

[Dr. Amy Park]
Why? MIGS is minimally invasive. Vaginal surgery is the OG minimally invasive method.

[Dr. Mark Hoffman]
I know. That's why we're doing this because we've gotten so comfortable doing what we do. Yes, it's minimally invasive, it's not deletion-invasive. This is where you're going to teach me how to, obviously, not be in the OR with me, but we're going to go over your process for vaginal hysterectomy, because it is something that, where I trained, if it was a good vag HYST scan, you just kick him across the whole urogyn, and if they had a patient they felt was a good TLH candidate, urogyn would just kick it back to us.

We divided and conquered that way, but the result was that we got very comfortable with a laparoscopic or robotic approach, but really just did very little, if any, true vaginal surgery in that way. I think it's pretty common in a lot of MIGS fellowships.

[Dr. Amy Park]
Yes. I think it's too bad. I know at the clinic, Rose and Coe used to do a lot of vaginal hysterectomy in males. Scott still does a lot of vaginal hysterectomy using the [unintelligible 00:03:59]. We do a mix of approaches, but I think the interesting thing is the vag HYST that you would do as a generalist, are the ones for bleeding, and those are the most difficult ones. I do those because I get those referrals, not a lot of dissensus, and they have adenomyosis or fibroids, and I'll usually do it up to 14-week size as long as it's mobile. Those are tough cases, you have to have pretty good skills in order to do the vag HYST.

Otherwise, with the prolapse, you really should be doing a prolapse repair with it. I can understand how it's gotten so subspecialized. I think with the advent of vNOTES that's enabling technology, essentially, I remember talking to other people and they're like, "Is this making a vaginal hysterectomy like a laparoscopic one through the vagina?" [laughs]



[Dr. Mark Hoffman]
That's my fear for all vaginal surgery. Again, case selection, the vast majority of the patients that I'm getting referred are big giant uteruses, 20-plus week uteruses, stage 3, 4 endo, a bunch of previous surgery. None of those patients are what we would consider or what maybe the average person would consider good TVH cases, or according to the folks at good vNOTES candidates if you've had prior pelvic surgery if you have concern for hyssop disease and stuff. Is that similar? I've also heard stories of Rosanne Kho doing 40-week uteruses, stage 4 endo, all had knowing that's just her approach.

[Dr. Amy Park]
Yes. First of all, choosing the right candidate for surgery is like pre-operative selection for any surgery is 80% of the decision-making. The rest of it is, yes, technical skills and interoperative judgment. I always say it's like that Kenny Rogers song, it's like, "You need to know when to hold them, know when to fold them, know when to walk away, know when to run." That's a lot of it.

Getting back to your point about MIGS doing TLHs, urogyn doing the vag HYST, we've gotten into this space where laparoscopic HYSTs have taken-- you see the volume going up, but it's eaten away at the vaginal hysterectomy volume first, and then the abdominal hysterectomy volume stayed the same for a long, long, long time. Then, I think finally after 20 years, it's gotten better, but you see this data in California state data. I remember seeing this in the 2000s, and you just see this trend that's been continuing, and then the skill set for vaginal hysterectomy has just continued to go down.

[Dr. Mark Hoffman]
I agree. I've seen the data and the numbers, it's hard to find the most up-to-date things. End of the 2018s data, it was still 45% abdominal HYST rates nationally, which seems awful high. The vag HYST numbers went down way more than the abdominal HYST numbers with the rise in laparoscopic. In robotic surgery, part of what we've talked about before on the show is training. You have to do 15 of each approach for a total of 85 MIS hysterectomies or something like that for training, which is, there's a lot of approaches. If we, the faculty, aren't doing tons of TVHs, it's going to be tough for residents to have that one perfect case.

Listen to the Full Podcast

The Natural Orifice Surgery: Vaginal Hysterectomy with Dr. Amy Park on the BackTable OBGYN Podcast)
Ep 35 The Natural Orifice Surgery: Vaginal Hysterectomy with Dr. Amy Park
00:00 / 01:04

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Determining Candidacy for Vaginal Hysterectomy

Determining the right candidates for vaginal hysterectomy requires a nuanced understanding of several anatomical and clinical factors. The size and mobility of the uterus play critical roles; an ideal candidate's uterus should be tall and mobile. Additionally, the spatial considerations within the vagina, including the presence of adequate room and the nature of the pubic arch, are significant. A restricted outlet or a tight pubic arch can add complexity to the procedure. Fundamental surgical principles, such as ensuring adequate exposure and access, remain paramount.

The position of the cervix, or the "C-point," and its distance from the vaginal opening is another pivotal factor. While historical surgical interventions like C-sections or pre-existing conditions like endometriosis might be viewed as potential complications, they don't necessarily preclude a patient from being a viable candidate. The final call often depends on the surgeon's comfort and expertise. As surgeons navigate these complexities, recognizing and embracing the inevitable learning curve is essential.

[Dr. Amy Park]
I do have a very specialized practice in prolapse and incontinence as a urogynecologist. I got a reputation for attempting to do some harder TVHs than other people who'd probably just do it laparoscopically. I do get some of those cases where a patient has atypical endometrial cells on PAP, or adenomyosis who want a vag HYST. Basically, like I said, if the patient has up to 14-week size uterus, and it's tall and mobile instead of the broad ones that are immobile, and there's some room inside the vagina, if their pubic arch is a tight steeple, those are really hard cases. The outlet hearkening back to our obstetric days when those are really tight, it's very difficult because you need access. Just like in principles of any surgery, you need exposure and access. As long as there's some dissensus,

I usually like to have a C-point, which is the cervix, or at least within like six centimeters of the opening or the hymenal remnant, so C at minus six. Do I have a hard cutoff on that? No, not really. If there's some mobility-- Honestly, I've had a bunch of cases lately who've had a history of endometriosis. I've been able to get in anteriorly and then make posterior colpotomy by putting my finger around, but those are hard cases. For me, C-section is not a contraindication. I love the patients. Sometimes they don't remember they had four C-sections. I was wondering why I couldn't get in anteriorly. [chuckles] My fellow rounded on it the next morning and she was like, "Oh, she had had four C-sections." I was like, "No wonder." I think it just depends on your skill set and your level. For me, I'll do those cases history of C-sections and endometriosis, but I think for some people that would be a contradiction, which is totally reasonable. I think it just depends on your comfort level.

When you're first in attending, you got to put yourself out there and it's uncomfortable. You're going to take longer and there's a learning curve to being in attending and that's why you can't be a program director until five years out. You have to have been around the block, and you have to put yourself back on the saddle even when you have complications.

Patient Positioning Considerations for Vaginal Hysterectomy

Patient positioning is a cornerstone of a successful vaginal hysterectomy. The patient should be placed in the high dorsal lithotomy position with their bottom flush to the bed's end. The patient’s knees should be oriented to face the contralateral shoulder, and care should be taken to avoid excessive peroneal nerve pressure. Leg angle monitoring can help prevent potential femoral neuropathy. Dr. Park highlights the importance of the patient's buttocks placement. Specifically, positioning the perineum right at the edge of the bed can circumvent challenges tied to "shelf" formation, ensuring seamless surgical access.

[Dr. Amy Park]
We use the SCDs, the prophylaxis, put patient in high dorsal lithotomy position. I trained with [unintelligible 00:20:15], but I prefer yellowfins, I just think it's easier. It's very important with the positioning, bring their bottom so that it is like flush with the end of the bed, and to make sure that the knees are facing the contralateral shoulder and there's no pressure on the peroneal nerve. I often will pad them laterally with a piece of foam just to make sure, because during the case, sometimes you have them up in low dorsal lithotomy position for three hours and they can move a little bit, or their knee can move a little bit, or what have you. Only if you need it.

[Dr. Mark Hoffman]
Where are you placing the pads?

[Dr. Amy Park]
Laterally, just in case. Sometimes the knees are big. They can just have some compression. I just try and make sure that there's no compression on the peritoneal nerve area. You have to also be careful of femoral neuropathy at the inguinal ligament. Even though it's high dorsal lithotomy position, you don't want to have too much hip flexion because that can cause some compression.

[Dr. Mark Hoffman]
Hips flexed 90 degrees, or less, or more? I'm trying to think.

[Dr. Amy Park]
I don't know about the exact angles. Just taking a look after you put them down at the end of the table and make sure that their legs are not overly flexed or extended in the dorsal lithotomy position. I noticed for MIGS, you guys flex the knees a little bit more than I do. I usually leave them a little bit more extended just because otherwise, it's very difficult for three surgeons to get there into the field. Otherwise, these legs are right over your shoulders. We extend them.

[Dr. Mark Hoffman]
Arms are out to the side?

[Dr. Amy Park]
Yes, arms are out to the side. Just a word on positioning. When it's time to cysto, I just put the legs down to give them a break.

[Dr. Mark Hoffman]
Interesting.

[Dr. Amy Park]
Changing position just is good, and just a little reassessment.

[Dr. Mark Hoffman]
I think the positioning of the butt is one of the most underappreciated steps of any MI hysterectomy. I think we call it the butt shell if the sacrum has to be supported. It's supported at the edge of the mat., everything distal to that, butt cheeks can hang off because if the butt cheeks are on the mattress, it creates a shelf. You can't put a speculum in there. It makes the job of a uterine manipulator for doing a TLH way harder. I'm sure it's the same thing for TVH, having the cheeks off the bed, having the sacrum supported is like that?

[Dr. Amy Park]
Yes, I don't necessarily put the cheeks off the bed, but I just like to have them so that essentially, the perineum is right there at the edge of the bed. I pretty much put them on a pink pad or some anti-slip mat, just like you guys do in laparoscopy because we do put them in a fair amount of T-burg and they can slip in the bed. I use Hibiclens or chlorhexidine prep. I know for some people, especially your guys, for some reason, are resistant and want to use the Betadine.

Podcast Contributors

Dr. Amy Park discusses The Natural Orifice Surgery: Vaginal Hysterectomy on the BackTable 35 Podcast

Dr. Amy Park

Dr. Amy Park is the Section Head of Female Pelvic Medicine & Reconstructive Surgery at the Cleveland Clinic, and a co-host of the BackTable OBGYN Podcast.

Dr. Mark Hoffman discusses The Natural Orifice Surgery: Vaginal Hysterectomy on the BackTable 35 Podcast

Dr. Mark Hoffman

Dr. Mark Hoffman is a minimally invasive gynecologic surgeon at the University of Kentucky.

Cite This Podcast

BackTable, LLC (Producer). (2023, September 28). Ep. 35 – The Natural Orifice Surgery: Vaginal Hysterectomy [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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