Vaginal Hysterectomy: Patient Candidacy & Anatomical Considerations

[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.

[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.