Vaginal Hysterectomy

Shirish S Sheth, John Studd

• Publisher: CRC Press
• Year: 2001
• ISBN:
  9781135312565
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

In recent years advances in laparoscopic technologies have led to renewed interest in the vaginal approach to hysterectomy, which has many proven benefits for patients. This volume, dedicated to explaining and promoting the vaginal route of hysterectomy, is written and edited by an international team of experts and provides a much-needed source of

1 The history of vaginal hysterectomy

C. Sutton

---

The operation of hysterectomy is one of the most common in surgical practice, but the removal of the uterus differs from the removal of other organs, in that it can be performed either by an open incision in the abdomen, or by vias naturales, the access provided by the vaginal approach. Just as the surgical approach and technique is entirely different, so also is the history of the two types of approach to removal of the uterus.

The early history of abdominal hysterectomy

We know that the first attempt at an abdominal hysterectomy was on 17 November 1843, when the Mancunian surgeon Charles Clay (Fig. 1.1) found that, during his sixth attempt at ovariotomy (the removal of a huge ovarian tumour), the patient coughed and extruded a huge uterine fibroid through the massive incision that he had made from the xiphisternum to pubis. He therefore had no choice but to perform a subtotal hysterectomy, tying a ligature around the supravaginal cervix; unfortunately, the patient died of exsanguination a few hours later. Interestingly, another surgeon from Manchester, A.M. Heath, had the same thing happen to one of his patients a few days later, on 21 November 1843, and his patient also died from postoperative blood loss [1].

Figure 1.1. Charles Clay.

The following year, Clay found himself in a similar situation and again proceeded to perform a subtotal hysterectomy, having placed a ligature of Indian hemp round the supravaginal cervix. On this occasion, the patient survived the operation but, sadly, died 15 days afterwards, having fallen out of bed.This was unfortunate, not only for the patient, but also for Clay’s claim to have performed the first successful hysterectomy, because she had in fact survived the critical immediate postoperative period and had not succumbed to sepsis, which was the usual mode of death; it was not for a further 20 years that Clay was able to claim the first successful hysterectomy in Europe.

Meanwhile, Ellis Burnham from Lowell, Massachusetts performed the first hysterectomy with the patient surviving [2, 3], but again the diagnosis was incorrect because Burnham also thought that he was operating on a massive ovarian cyst. In September of that year, Kimball, who also came from Massachusetts, carried out the first hysterectomy for a fibroid tumour with the patient surviving the operation [3, 4].The patient made a full and complete recovery, but 8 months later the protruding ligatures were still causing inconvenience.

History of vaginal hysterectomy

With abdominal hysterectomy, the dates seem fairly certain, but the origins of vaginal hysterectomy are lost in the mists of time.The first was reputedly performed in AD 120 by Soranus, in the city of Ephesus, which was then situated in Greece but is now on the Turkish coast just north of Bodrum. There is an even more vague reference to the procedure having been performed 50 years before the birth of Christ by Themison of Athens [5]. According to the medical historian Leonardo [6], the procedure performed by Soranus was the removal of an inverted uterus that had become gangrenous and had turned black in colour. The ureters, and often the bladder, were invariably part of these early surgical excisions and the patients always died. Nevertheless, in the writings of the eleventh-century Arabic physician, Alsaharavius, he clearly states that, if the uterus had prolapsed externally and could not be reinserted, then he advised his pupils that it should be surgically excised [3], and it is unlikely that he would have advocated this practice if death was the invariable result of such intervention.

In fact there are several reports of patients surviving vaginal hysterectomy in the Middle Ages, and these are referred to in medical writings in the sixteenth and seventeenth centuries. The first authenticated case was reported by Berengarius da Carpi, who lived in Bologna in 1507 and was reputed to have performed a partial vaginal hysterectomy. Schenck of Grabenberg reported 26 cases during the early part of the seventeenth century and the operation was also performed by Andreas da Crusce in 1560 and Valkaner of Nuremberg in 1675, when the patients appear to have survived.

Modern medical historians are somewhat sceptical about some of these early reports and, as usual, have largely ignored the contribution of the midwives of Europe who, from time to time, amputated prolapsed or inverted puerperal uteri. They have also overlooked an early example of self-help: the case of Faith Howard, a 46year-old peasant woman who performed the operation on herself. This case was well documented and reported in 1670 by Percival Willoughby, an early male midwife and lifelong friend of William Harvey, who famously discovered the blood circulation. Apparently, while she was carrying a heavy load of coal one day, Faith’s uterus prolapsed completely and, frustrated by this frequent occurrence, she grabbed the offending organ, pulled as hard as possible and cut the whole lot off with a short knife. In his report, Willoughby states that ‘there was a mighty bleeding which eventually stopped’ and Faith lived on for many years after this with ‘water passing from her insensible day and night’, obviously from a vesicovaginal fistula.

The first elective vaginal hysterectomies

Baudelocque from France introduced the technique of artificially prolapsing and then, in favourable cases, cutting away the uterus and appendages. He performed 23 such procedures during the 16 years following 1800, but gave Lauvariol the credit for having performed the first operation in France. This was well before the time of the first abdominal hysterectomy carried out by Charles Clay in 1843.

Most of these procedures were performed on puerperal uteri and were undertaken on an emergency basis, but the first planned procedure was by Osiander of Göttingen in 1801. Wisely, he did not report the case until he had operated on his ninth patient. In 1810, Wrisberg, in a prize essay read before the Vienna Royal Academy of Medicine, advocated vaginal hysterectomy for cancer and, 2 years later, Paletta performed the operation. He was not entirely certain, however, that he had extirpated the entire uterus.

Conrad Langenbeck, Surgeon-General to the Hanoverian Army

Conrad Langenbeck (Fig. 1.2), who came from Göttingen, was a surgeon of such supreme swiftness that he once amputated a shoulder while a colleague, who had come to observe the procedure, turned his back for a moment to take a pinch of snuff. Langenbeck was Surgeon-General to the Hanoverian Army and also a Professor of Anatomy and Surgery, and was certainly the most distinguished surgeon of his day. He had read Wrisberg’s paper and also the report of Paletta and this encouraged him to perform the first deliberately planned vaginal hysterectomy for carcinoma in 1813 [7]. He did not, however, report the operation until 1817 and, because of the abuse that he was subjected to, he probably regretted ever doing it.

Figure 1.2. Conrad Langenbeck, Surgeon-General to the Hanoverian Army, who performed the first vaginal hysterectomy for endometrial cancer in 1813.

He had little precedent to follow, so he had to devise his own plan for the removal of the entire uterus.He performed a retroperitoneal dissection, taking great care not to enter the peritoneal cavity. Unfortunately, towards the end of the operation he encountered very heavy bleeding and called upon his assistant to help him. His assistant, a Surgeon Commander debilitated by gout, was unable to rise from his chair when called upon to render assistance. Langenbeck had no option but to grasp the bleeding artery with his left hand and with his right hand he passed a needle carrying a ligature through the tissues beyond the bleeding point.With no one to assist him, he had to tie the ligature by grasping one end between his teeth and secured the pedicle with a one-handed slip knot using his right hand. After the procedure he could detect no opening into the peritoneal cavity and the patient made a surprising and uneventful recovery. Sadly, after such a display of surgical virtuosity, none of his colleagues would believe the report of his operation when it was published 4 years later.The specimen had somehow been lost and never reached the pathology department and the assistant with gout died some 2 weeks later, so there was no one to testify that the procedure had in fact taken place. The patient herself was demented and thus an unreliable witness and died of senility some 26 years later; only then could Langenbeck prove, by postmortem examination, that he had performed the operation. During those 26 years, he was ridiculed and subjected to the jibes of his colleagues and no one gave him credit at the time for this spectacular achievement.

Further developments in technique at the end of the nineteenth century

In 1829, Recamier pointed out the necessity of isolating and controlling the uterine vessels, which was a great step forward in standardizing the procedure [8].

Surgeons from France were successful in designing clamp methods for securing the ligaments and vascular pedicles, and they also devised remarkable morcellation and hemisection techniques and even proposed the vaginal approach for pelvic inflammatory disease [9]. The great French surgeon Péan (Fig. 1.3) reported 60 cases of vaginal hysterectomy in 1886, all of whom survived the operation [10]. By contrast, in a study that he published in 1881 on 51 women with fibroids treated by abdominal hysterectomy, 18 died with a mortality rate of 35%. Although this compared favourably with a similar study produced by Lawson Tait (Fig. 1.4) in 1882, which had a 33% mortality rate among 30 cases, it was clearly much safer for the procedure to be carried out vaginally, if the size of the fibroids allowed it [1]. Probably the worst figures produced in those days were by Spencer Wells who spent much of his time lecturing and demonstrating his surgical prowess, but in reality of the 40 cases that he published 29 had died, giving a shockingly high mortality rate of 73%. Lawson Tait and he were great enemies and the former, who came from Birmingham, delighted in castigating and chiding the fashionable London surgeons and drawing attention to their appalling results. Some cynics attributed the great French results to their postoperative regimen: 4 hours after surgery the patient was given iced champagne in teaspoonful doses!

The German school developed methodical suture techniques; in 1880, Schroeder presented his technique of opening the cul-de-sac and pulling the fundus through posteriorly and then cutting the bladder flap. The broad ligaments were ligated with a single ligature or in separate portions from above downward. The peritoneum was closed and the stumps of the ligaments sutured into the vagina, everting them around a T-shaped drainage tube which was inserted between the stumps [11].

Doderlein described a similar technique using an anterior colpotomy, inverting the fundus through that incision and then taking the uterine arteries and cardinal ligaments under direct vision; an adaptation of that procedure has been proposed by Garry to remove ...

Table of contents

• Cover page
• Title page
• Copyright page
• List of contributors
• Introduction
• 1: The history of vaginal hysterectomy
• 2: Indications and contraindications
• 3: Preoperative assessment
• 4: Access to vesicouterine and rectouterine pouches
• 5: Vaginal hysterectomy for genital prolapse
• 6: Simplified technique of vaginal hysterectomy
• 7: The nulliparous patient
• 8: Uterine fibroids
• 9: Uterine debulking at vaginal hysterectomy
• 10: Use of gonadotrophin-releasing hormone agonist before hysterectomy
• 11: Hysterectomy after previous abdominopelvic surgery
• 12: Contraindicated abdominal route
• 13: The place of prophylactic oophorectomy at hysterectomy
• 14: Oophorectomy
• 15: Adnexal pathology
• 16: Subtotal vaginal hysterectomy
• 17: The difficult vaginal hysterectomy
• 18: Hysterectomy on high-risk women
• 19: Malignancy related to vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy
• 20: Technical minutiae of vaginal hysterectomy
• 21: Newer perspectives
• 22: Associated urethral sphincter incompetence
• 23: Associated non-gynaecological surgery
• 24: Opportunity to initiate prophylaxis
• 25: Place of sacrospinous colpopexy at vaginal hysterectomy
• 26: Hysterectomy and hormone replacement therapy
• 27: Psychological outcome of hysterectomy
• 28: Hysterectomy and sexuality
• 29: Vaginal or abdominal hysterectomy?
• 30: Vaginal hysterectomy versus laparoscopically assisted vaginal hysterectomy
• 31: Vaginal hysterectomy versus transcervical resection of the endometrium
• 32: Complications, morbidity, and mortality of vaginal hysterectomy
• 33: Decision-making for vaginal and abdominal hysterectomy