I. History of transvaginal total hysterectomy The first transvaginal total hysterectomy in the world was performed by Langebeck in Gottingen, Germany, in 1813 and was not published until 1819 in a patient with cervical cancer combined with uterine prolapse. It was performed without anesthesia and without sterilization techniques, and the patient survived for 26 years after the operation, which was successful but not recognized at the time. It was not until an autopsy was performed after the patient’s death that it was confirmed that the patient had previously undergone a total transvaginal hysterectomy. Only after that was the procedure recognized.
In 1822, Souter performed a total transvaginal hysterectomy without anesthesia, using a high concentration of alum to stop the bleeding, with an intraoperative hemorrhage of 680 grams. The patient died of pneumonia 4 months later.
In 1850 Evo in the United States performed a total transvaginal hysterectomy in a patient with cauliflower-like cervical cancer combined with third-degree uterine prolapse by ligating the uterine artery with a biologically made ligature under trichloromethane anesthesia, who died three months later due to recurrence of cancer.
In 1890, Sohauta proposed that the first indication for total transvaginal hysterectomy should be cervical cancer, and 65 cases were reported at that time of which only 5 died, which was outstanding at that time when surgical techniques and related equipment and antimicrobial drugs were very backward, and 70% of total transabdominal hysterectomy deaths were due to infection, while the mortality rate of total transvaginal hysterectomy was 5% in many medical institutions. Around the 20th century, many treatises on transvaginal hysterectomy were published.
In 1910, Henrotin’s book Gynecolog and Abdomnal Surgery by Kelly documented four types of negative surgical methods. In 1911 Bandler completed his magnum opus “VAGINAI CELIOTOMY”. In 1934, Heaney reported 565 cases of total transvaginal hysterectomy. This was followed by a modification of the total transvaginal hysterectomy procedure and the invention of various surgical instruments, which established absolute authority in the United States.
In 1946 Camplell compared transvaginal and transabdominal total hysterectomy and noted that of the 7280 cases of total transvaginal hysterectomy, 24 died, with a mortality rate of 0.32%, while of the 41,485 cases of transabdominal hysterectomy, 1029 died, with a mortality rate of 2.4%, making the mortality rate of transabdominal surgery 7.5 times higher than that of transvaginal surgery. The reason for this is that transabdominal surgery operates in the abdominal cavity and is prone to peritonitis, intestinal obstruction and thrombosis.
Although the history of total transvaginal hysterectomy is long, due to recent developments in sterilization techniques, anesthesia, antimicrobial agents, and changes in surgical instruments, hysterectomy in most medical institutions is still predominantly transabdominal to date. Since the 1950s, a large number of papers have been published in Europe, the United States, and Japan on improved procedures. In Japan, Katsuhide Akashi’s faculty performed 10,000 transvaginal surgeries in 40 years, and now it has developed to extraperitoneal lymph node dissection + extensive transvaginal total hysterectomy, and transvaginal hysterectomy accounts for 50-80% of total hysterectomy cases at all levels of care in Japan.
In 1990, Xie Qinghuang and Liu Xiaochun of Foshan Maternal and Child Health Hospital researched and improved transvaginal hysterectomy and created the “new type of non-prolapsed hysterectomy via vagina”.
The indications and contraindications for choosing total transvaginal hysterectomy are based on three factors: First, the degree of training received by the surgeon. If both the surgeon and the assistant are formally trained and have rich experience, the indications can be relaxed, and if not, the indications should be controlled more strictly. The second is the size and mobility of the uterus, which is a relative indicator. The size of the uterus can be fragmented, such as by removal in pieces, halving, myoma removal, and debridement, to reduce the size of the uterus and then continue to remove the uterus.
Most of the previous reports and textbooks concluded that total transvaginal hysterectomy is not advisable for uterus larger than 12 weeks gestation. However, in recent years, with the accumulation of experience in surgical operation, the application of some special instruments and the improvement of surgical procedures, the size of the uterus is no longer a decisive factor in whether a total transvaginal hysterectomy can be performed as long as there are no adhesions around the uterus, the operator has more experience in vaginal surgery and the vagina is more relaxed. The volume and elasticity of the vagina can be fully adapted to the operation of transvaginal hysterectomy. In the past, most scholars listed the non-vaginal delivery as a contraindication to transvaginal surgery, but the authors’ experience is that if the size of the uterus does not exceed 12 weeks of gestation, total vaginal hysterectomy can be successfully completed even in those without a history of vaginal delivery. If the uterus is larger than 12 weeks’ gestation, a lateral perineal incision can be made to enlarge the vagina and facilitate the procedure, which is far less traumatic for the patient than open surgery.
For those with a history of previous surgery, the possibility of performing a total transvaginal hysterectomy cannot be generalized, but should be based on the current situation of the pelvic cavity. The problem is how to accurately determine whether there are adhesions in the pelvic cavity and the degree of adhesions before surgery, which is sometimes difficult to determine by general gynecological examination alone. If the conditions allow, including the degree of microscopic operation and complete laparoscopic surgical instruments, laparoscopic hysterectomy can also be chosen.
In summary, the indications for total transvaginal hysterectomy are summarized as follows: 1, functional uterine bleeding, drug treatment is ineffective, no fertility requirements, 2, uterine fibroids, adenomyosis, uterine size less than or equal to 16 weeks of gestation, with surgical removal of the pointer, if the size of the uterus is greater than 16 weeks of gestation, combined laparoscopic and transvaginal surgery can be selected. 3, cervical lesions: chronic cervicitis with poor results of physical therapy, recurrent episodes, or cervical episiotomy. recurrent episodes, or cervical intraepithelial neoplasia grade II-III. 4, cervical carcinoma in situ, stage Ia. 5, endometrial adenoma-like hyperplasia, endometrial carcinoma stage Ia.
Contraindications: 1.Severe endometriosis, or chronic inflammation to extensive pelvic adhesions with poor uterine mobility. 2.Inflammatory diseases of the vagina and reproductive system that have not been cured. 3.Combined systemic bleeding disorders. 4.Important organ (heart, lung, liver, kidney) diseases that make it difficult to tolerate anesthesia and surgery. 5.Advanced malignant lesions of the reproductive system that require extensive excision and exploration.
III. Pre-operative preparation
1, preoperative examination of the leucorrhoea, to exclude infectious diseases, such as the presence of infectious diseases, should be cured before considering surgery, and those who have the conditions try to do mycoplasma chlamydia culture, such as culture positive should also be regular treatment before surgery.
2. Routinely perform vaginal cervical exfoliation cytology examination or selective cervical biopsy segmental scraping and hysteroscopy before surgery to exclude malignant and precancerous lesions of the cervix and uterine body and to prevent the presence of malignant or precancerous lesions that are not detected before surgery but only found in the pathology report after surgery.
3. Three days before surgery, vaginal scrubbing with diluted mucosal disinfectant solution (0.5% iodine volt solution for the author) should be done routinely, and special attention should be paid to cleaning the deep vagina and the secretions in the anterior and posterior domes.
4. Make a clean enema in the evening before and in the morning of the operation day, and shave the pubic hair.
5.Use a metal catheter for urinary catheterization and empty the bladder before the start of the operation.
6.Before sterilization of the surgical field, a vaginal examination is performed after the anesthesia takes effect to get a full understanding of the size, position, mobility and bladder condition of the uterus so that the operator can have a good idea.
7. The perineum and vagina are strictly disinfected with mucosal disinfectant (the author uses undiluted iodophor stock solution) and the surrounding skin is disinfected with iodine alcohol. The disinfection range is from the abdomen to the level of the umbilicus and from the second leg to the upper third of the thigh. The use of adhesive plastic film can isolate the skin and the anus from the vaginal surgical field and play a role in enhancing the disinfection effect.
IV. Surgical steps
1.Take the bladder amputation position (LithotomyPositon) head low hip high tilt 15 degrees. Special attention is paid to make the buttocks exceed the edge of the operating table by about 10 cm or more, so that the posterior vaginal wall hook can be placed easily. The labia minora on both sides are sutured to the lateral skin so that they can be exposed. And cover the anus with gauze or surgical towel to reduce the chance of contaminating the surgery.
2.Use a single-page anterior and posterior vaginal wall hook to hold open the anterior and posterior vaginal walls and use a double grasping forceps to clamp the cervix, if the cervix is small, a double grasping forceps can be used to clamp the anterior and posterior lips of the cervix at the same time, if the cervix is fat, use a double jaw grasping forceps to clamp the anterior lips and another ordinary cervical forceps to clamp the posterior lips, use a vaginal pressure plate to hold open the lateral wall of the vagina to fully expose the cervix.
3.Inject a saline solution containing 1:200,000 epinephrine under the vaginal mucosa at the level of the bladder sulcus at the junction of the cervix and vagina, commonly known as the “water pad”.
4.Circumferential dissection of the cervical and vaginal junction mucosa.
5.Separate the bladder-cervical space and rectal-cervical space.
6.Cut the ligated sacral and primary ligaments and the cervical ligaments of the bladder.
7.Open the anterior and posterior reflexed peritoneum.
8.Treat the uterine arteries and veins.
9.Treat the intrinsic ovarian ligaments, fallopian tubes and round ligaments.
10.Comminution of the uterus: There are various methods of dissecting the uterus, such as halving, myoma picking and enucleation, etc. The method used by the authors is to first transect the cervix.
11.Exploration of the adnexa and examination of the stumps for bleeding.
12.Suture the pelvic floor peritoneum and vaginal wall mucosa.
V. In order to do a good yin-type total hysterectomy, we have the following experience.
1. Correctly grasp the indications for surgery. First, it is necessary to find out whether there are adhesions in the pelvis. The size of the uterus, is not the main indicator.
2, The surgeon must have a solid theoretical foundation and skilled basic surgical skills, including separation, suturing and knotting.
3. The vaginal mucosa must be incised in its entirety and the level of separation of the bladder-cervical space and the cervico-rectal space must be accurate.
4. Generally, there is more bleeding after the posterior vaginal wall is incised. At this time, electrocoagulation with electric knife can be used to stop bleeding. If the result is not good, several stitches of continuous locking edge suture with No. 4 silk thread can be used to temporarily stop bleeding.
5. Appropriate position and tacit cooperation of the surgical team.
Positioning requirements: head low and hip high (about 15°), bladder truncated position; buttocks protruding from the bed edge.
Surgical team requirements: 4 doctors participated, the main surgeon and assistant sat in front, the main surgeon leaned on the right side of the recipient, the first assistant was on the left side, and one assistant stood on each side of both thighs. The division of labor is clear and tacit cooperation is necessary to ensure the smooth operation.
VI. Common methods of hysterectomy are
l abdominal hysterectomy, l negative hysterectomy, l laparoscopic hysterectomy, laparoscopic assisted negative hysterectomy.
Each procedure has its advantages and disadvantages and is suitable for different patients.
VII. Advantages and disadvantages of the negative hysterectomy I. Advantages 1. Transvaginal hysterectomy opens the peritoneum to the smallest extent, with minimal disturbance to the intestine, and the occurrence of postoperative intestinal obstruction is much less than that of transabdominal hysterectomy.
2, Transvaginal hysterectomy can avoid complications caused by abdominal incision such as wound infection and discomfort, and patients are satisfied with the absence of scars on the abdomen. Avoiding abdominal incision can also reduce the depth and length of anesthesia.
3. Because the surgery is less invasive, patients can get off the floor earlier and take better care of themselves after the surgery. There is also less need for nursing care, bowel function recovers faster, patients can eat earlier, and intravenous rehydration therapy is reduced. The postoperative infection rate is only half that of transabdominal total uterus, and the need for postoperative antibiotics is reduced, as is the application of postoperative pain medications, and the length of hospital stay for patients is shortened.
4. Elderly patients and patients with medical comorbidities tolerate transvaginal hysterectomy better.
5, Excessive obesity increases the technical difficulty of transvaginal or transabdominal hysterectomy, but it will be less difficult to do transvaginal hysterectomy.
6. Transvaginal hysterectomy can be performed simultaneously with repair of vaginal wall laxity and pelvic floor surgery.
Disadvantages
1.Small surgical field of view.
2.Requires more technical skills from the operator.
3.Requires the surgeon to be very clear about the anatomical relationship of the surgery.