Table Of ContentThe Difficult Vaginal Hysterectomy
A Surgical Atlas
Mitehel S. Hoffman
William N. Spellaey
The Difficult Vaginal
Hysterectomy
A Surgie al Atlas
W'ith 121 Il/ustrations
Foreword by David H. Nichois
Springer Science+Business Media, LLC
Mitchel S. Hoffman William N. Spellacy
Associate Professor Professor and Chairman
Department of Obstetrics-Gynecology Department of Obstetrics-Gynecology
University of South Florida University of South Florida
College of Medicine College of Medicine
Suite 529 Harbour Side Medical Tower Suite 529 Harbour Side Medical Tower
Davis Islands Davis Islands
4 Columbia Drive 4 Columbia Drive
Tampa, FL 33606 Tampa, FL 33606
USA USA
Library of Congress Cataloging-in-Publication Data
Hoffman, Mitchel S.
The difficult vaginal hysterectomy : a surgical atlas / Mitchel S.
Hoffman, William N. Spellacy.
p. cm.
Includes bibliographical references and index.
1. Vaginal hysterectomy-Complications-Atlases. 1. Spellacy,
William N., 1934- II. Title.
[DNLM: 1. Hysterectomy, Vaginal-atlases. WP 17 H711s 1994]
RG391.H65 1994
618.1'453-dc20
DNLMjDLC
for Library of Congress 94-5703
CIP
Printed on aeid-free paper.
© 1995 by Springer Seienee+Business Media New York
Originally published by Springer-Verlag New York, Ine. in 1995.
Softeover reprint of the hardeover 1st edition 1995
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9 876 5 4 3 2 1
ISBN 978-1-4757-4325-8 ISBN 978-1-4757-4323-4 (eBook)
DOI 10.1007/978-1-4757-4323-4
This book is dedicated to the memory
of Dr. James M. Ingram) our beloved
friend, colleague) and extraordinary
vaginal surgeon.
Foreword
Knowledge of and experience with the basic technique of vaginal
hysterectomy is not univers al. Each surgeon must learn to identify
and appreciate the dimensions of individual variation in anatomic
findings and therefore surgical technical decisions and their execu
tion from one patient to another. Unexpected surgical difficulty can
be predicted, but ultimately it is dealt with retrospectively. Skilled
practitioners must study the particular patient and her problem
comprehensively and allow for such individual variations in find
ings and technical needs as are necessary to the surgical solution
for that patient's problem.
Recognizing these factors, Drs. Hoffman and Spellacy have orga
nized and prepared a comprehensive monograph concerning this
very real clinical entity. They have reviewed the experience of con
temporary surgeons and blended these recommendations with their
own experience in a useful compendium of surgical knowledge
about this important subject. Their monograph is recommended
not as a replacement for the many other fine surgical texts available
to the reader but as a supplement to the surgeon's library. It is for
those surgeons who, having mastered the basic techniques, are in
terested in extending the frontiers of personal knowledge of this
provocative subject and safely broadening the indications for effec
tive surgery and reconstruction.
David H. Nichols, M.D., F.A.C.S., F.A.C.O.G.
Harvard University School of Medicine
Massachusetts General Hospital
vii
Acknowledgments
The authors would like to thank Dr. Carol O'Kelly, the artist who
did aIl of the illustrations contained in this book. Her skill, hard
work, enthusiasm, and attention to detail are greatly appreciated.
They also wish to thank Lynn Larsen who provided the editorial
expertise to make the text finally become readable.
ix
Contents
Foreword vii
Acknowledgments IX
1 Vaginal Hysterectomy in Perspective 1
2 Standard Approach 5
3 Management of the Adnexa 23
4 Intraoperative Complications 39
5 Enlarged Uterus 53
6 Lack of Descensus 71
7 Markedly Prolapsed Uterus 81
8 Prior Pelvic Surgery 107
9 Miscellaneous Conditions 117
Index 129
xi
1
Vaginal Hysterectomy in
Perspective
The first successful vaginal hysterectomy is reported to have been
done by Langenbeck in 1813. During the nineteenth century re
ports of vaginal hysterectomies accumulated as the techniques be
came modified and the procedure safer. During the later part of
the century a few large series appeared that included enlarged uteri
requiring morcellation and patients with significant pelvic inflamma
tory disease.
At the turn of the century abdominal surgery became safer, and
by the early part of the twencieth century abdominal hysterectomy
came into widespread use and was championed over vaginal hyster
ectomy by several leading gynecologic surgeons, including Howard
Kelly at Johns Hopkins University. Few additional reports of vagi
nal hysterectomies appeared uncil the 1930s, however, when the
operation experienced a resurgence. At that time several gynecol
ogic surgeons, including N.S. Heaney, reported their results and
pointed to a lower morbidity with the vaginal approach. The opera
tion thus came into widespread use again, with its most common
indications being small leiomyomas, abnormal bleeding, and pro
lapse. The relative advantages and indications for these two ap
proaches became a subject of many papers over the ensuing years,
but no large prospective randomized study comparing the two
operations has yet been published.
Over cime, it was gradually accepted that the gynecologic surgeon
should be thoroughly familiar with both abdominal and vaginal ap-
1
2 1. Vaginal Hysterectomy in Perspective
proaches to hysterectomy so either could be optimaily applied on an
individual basis. Since the 1960s about one-third of hysterectomies
performed in the United States have been done vaginaily.
A review of the recent literature and gynecologic surgery texts
suggests that somewhat less emphasis has been placed on the
more difficult types of vaginal hysterectomy. It is likely that the ex
ceilent results obtained with abdominal hysterectomy have encour
aged its use for ail but those uteri that could be handled by a
straightforward vaginal approach. A few of the recent textbooks
have dealt with sorne of the technicaily difficult types of vaginal hys
terectomy, though not in great detail. A few notable recent studies
have shown that complicated vaginal hysterectomies, such as those
in patients with previous pelvic surgery or enlarged uteri, are safe
and may be advantageous for the patient. In 1986 Kovac reported
a series of 902 hysterectomies in which 80% were do ne vaginally.l
This remarkable figure was accomplished largely through the skillful
transvaginal removal of enlarged uteri. In this study, even the pa
tients who had undergone the complicated transvaginal removal of
enlarged uteri experienced less morbidity and a shorter hospital stay
than those who had undergone abdominal hysterectomy. The ad
vantages of pursuing a transvaginal approach are even more clear
in certain groups of patients, such as those who are obese or other
wise medicaily compromised, as shown in studies by Pratt3 and
Pitkin.2 There have even been a few reports of vaginal hysterectomy
being done on an outpatient basis in selected patients.
It is clear that vaginal and abdominal hysterectomies are not
opposing operations. The approach that best suits the individual
patient should be chosen. Abdominal hysterectomy is safe and is
clearly the proper approach for dealing with complicated pelvic or
intraabdominal pathology. The gynecologic surgeon will, therefore,
continue to ask why he or she should struggle to perform a difficult
vaginal hysterectomy. From a review of the literature as weil as our
own experience it is thought that, with ail other factors being equal,
the vaginal approach clearly results in less morbidity and is asso
ciated with a significantly quicker recovery. When the gynecologic
surgeon has the appropriate skill, the performance of the techni
caily difficult vaginal hysterectomy is a struggle do ne at the expense
of the uterus and the effort of the surgeon but to the advantage of
the patient. The purpose of this book is to serve as a guide to the
gynecologic surgeon in the approach to various types of technically
difficult vaginal hysterectomies.
References
1. Kovac SR. Intrarnyornetrial coring as an adjunct to vaginal hysterect
orny. Obstet GynecoI67:131-136, 1968
