The Difficult Vaginal Hysterectomy: A Surgical Atlas PDF
Preview The Difficult Vaginal Hysterectomy: A Surgical Atlas
The 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 Ali rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher Springer Seienee+Business Media, LLC except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use of general descriptive names, trade names, trademarks, etc., in this publication, even if the former are not espeeially iden tified, is not to be taken as a sign that such names, as understood by the Trade Marks and Merchandise Marks Act, may accordingly be used freely by anyone. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Production managed by Jim Harbison; manufacruring supervised by Vincent Scelta. Typeset by Asco Trade Typesetting Ltd., Hong Kong. 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
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