BackTable / OBGYN / Podcast / Transcript #35

Podcast Transcript: The Natural Orifice Surgery: Vaginal Hysterectomy

with Dr. Amy Park

In this episode, hosts Dr. Mark Hoffman and Dr. Amy Park have an in-depth discussion on the topic of vaginal hysterectomy. Amy, who handles a substantial caseload of vaginal hysterectomies, takes the lead in this conversation as she walks through the procedure and its intricacies. In Mark's practice as a Minimally Invasive Gynecologic Surgery (MIGS) surgeon, he typically deals with cases involving candidates for laparoscopic hysterectomies, while many vaginal hysterectomy cases are referred to urogynecologists. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Vaginal vs Laparoscopic Hysterectomies

(2) Candidacy for the Total Vaginal Hysterectomy

(3) Gaining Surgical Competence

(4) Setting Up an OR for Vaginal Hysterectomy

(5) Procedure Considerations for Vaginal Hysterectomy

(6) Suturing & Tying Techniques

(7) Procedure Considerations for Vaginal Hysterectomy, Cont.

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The Natural Orifice Surgery: Vaginal Hysterectomy with Dr. Amy Park on the BackTable OBGYN Podcast)

Ep 35 The Natural Orifice Surgery: Vaginal Hysterectomy with Dr. Amy Park

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[Dr. Mark Hoffman]
Welcome back to another episode of BackTable OBGYN. This is Mark Hoffman, and I've got with me, Dr. Amy Park. Amy, how are you?

[Dr. Amy Park]
Good. How are you, Mark?

[Dr. Mark Hoffman]
I'm good. This is a special episode of BackTable OBGYN, where Amy and I are going to talk about some surgical techniques today. We'll talk about vaginal hysterectomy, and Amy's going to teach me all about how to do a [chuckles] vaginal hysterectomy because I don't think I've done one in a very long time, which is super depressing. I'm assuming you've done them recently?

(1) Vaginal vs Laparoscopic Hysterectomies

[Dr. Amy Park]
About two-thirds of our volume in the Cleveland Clinic is vaginal in terms of approach.

[Dr. Mark Hoffman]
For the whole clinic, or for your division?

[Dr. Amy Park]
For my division. I would say, my approach has evolved to prolapse where I used to do a lot of primary sacrocolpopexy for primary uterovaginal prolapse, and then now I'm just reserving sacrocolpopexy more for recurrences and plus hysterectomy prolapse.

[Dr. Mark Hoffman]
You do them primarily sacrospinous, what's your--

[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]
Have you done any vNOTES? We had Yan on from Belgium a few episodes ago and talked to us all through that. Have you seen one, have you done one, have you trained on one?

[Dr. Amy Park]
I did. I have done the vNOTES, and the hardest part about it is getting the Alexis retractor into the vagina-

[Dr. Mark Hoffman]
The rings, yes.

[Dr. Amy Park]
-the ring, yes. You have to get the double ring and get a tight seal. In order to get the seal, you have to get the peritoneum reaffixed to the vaginal cup, because otherwise, you get this huge, you know those skive that peritoneum are of?

[Dr. Mark Hoffman]
I remember them. I did the course, and I remember sewing the peritoneum to the vaginal cup, but now they have a new introducer. I don't know if you did it recently, but they have these new introducers where you shove the ring anteriorly and posteriorly, so it's much easier to get in apparently than it used to be. If you've not done one in a while, I don't know if you've seen that.

[Dr. Amy Park]
[chuckles] I haven't seen the new ones, but basically the thing about the vNOTES for me, is that when you use new technology, you should try and do it on easy patients. I booked vNOTES with these cases that were really hard of somebody who had a 14-week size uterus, not much dissensus. I booked another one that I didn't realize had endometriosis, so it was really hard to get in, and was completely fibrotic. Just word of advice, just do it on easy, so it's [crosstalk]--

[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.

Like you said, you nailed it on the head as always, it's patient selection. It's knowing what's the right procedure approach for that particular patient, and exam's a big part of it. How do you determine who gets the TVH?

(2) Candidacy for the Total Vaginal Hysterectomy

[Dr. Amy Park]
I do have a very specialized practice in prolapse and incontinence as a urogynecologist. I got a reputation for attempting to do some harder TVHs than other people who'd probably just do it laparoscopically. I do get some of those cases where a patient has atypical endometrial cells on PAP, or adenomyosis who want a vag HYST. Basically, like I said, if the patient has up to 14-week size uterus, and it's tall and mobile instead of the broad ones that are immobile, and there's some room inside the vagina, if their pubic arch is a tight steeple, those are really hard cases. The outlet hearkening back to our obstetric days when those are really tight, it's very difficult because you need access. Just like in principles of any surgery, you need exposure and access. As long as there's some dissensus,

I usually like to have a C-point, which is the cervix, or at least within like six centimeters of the opening or the hymenal remnant, so C at minus six. Do I have a hard cutoff on that? No, not really. If there's some mobility-- Honestly, I've had a bunch of cases lately who've had a history of endometriosis. I've been able to get in anteriorly and then make posterior colpotomy by putting my finger around, but those are hard cases. For me, C-section is not a contraindication. I love the patients. Sometimes they don't remember they had four C-sections. I was wondering why I couldn't get in anteriorly. [chuckles] My fellow rounded on it the next morning and she was like, "Oh, she had had four C-sections." I was like, "No wonder." I think it just depends on your skill set and your level. For me, I'll do those cases history of C-sections and endometriosis, but I think for some people that would be a contradiction, which is totally reasonable. I think it just depends on your comfort level.

When you're first in attending, you got to put yourself out there and it's uncomfortable. You're going to take longer and there's a learning curve to being in attending and that's why you can't be a program director until five years out. You have to have been around the block, and you have to put yourself back on the saddle even when you have complications.

(3) Gaining Surgical Competence

[Dr. Mark Hoffman]
Those are feelings I just will never forget, especially being the first mixed person in a place or just being new anywhere, though. You're in these cases like, "What am I doing?" this is just not easy. The pressure on outside of just the clinical work itself being a surgeon stop being a doctor's hard, doing these really ridiculously hard cases and you on your own. I'll never forget that feeling.

I think it's also putting yourself out there but trying to find a safe way to do that, and I think that can be challenging in certain settings. If I'm going to do a TVH now, I'm going to have one of my partners who's a gynacholigst to be there with me to, at least the first few times to help getting in. To me, that's one of the biggest I guess cruxes of a case for TVH. Would you agree, or it just gets all easy to you?

[Dr. Amy Park]
Yes, we did a survey actually, one of my first fellows, we surveyed residents. We had them rate the steps of the case like posterior colpotomy, anterior colpotomy, security of the uterines, uterovarians, et cetera. Definitely, anterior colpotomy was rated the hardest and that's definitely the most challenging, I think. I think for any surgeon, it's just pattern recognition of being in the right plane, and that just takes a lot of cases. You alluded to the minimum number of cases before. That's an arbitrary number and that is a result of a lot of negotiation.

There was a paper published out of the Cleveland Clinic when I was a fellow, looking at the minimum number of hysterectomies to achieve competence based on the VSSI, which is the Vaginal Surgical Skills Index, and OSATs, which is the Objective Structured Assessment of, I can't remember what the T is, but technical skills, I think, it's between 20 and 30 cases, 22 to 25 cases, essentially, or is it maybe 22 to 27? Anyway, you get the drift. It's in the 20s, and we basically adjusted that bar lower because people weren't hitting it.

[Dr. Mark Hoffman]
It's based on a percentile. It's based on, this is the bottom, whatever, percentile of cases, and that's the number. It's not the number you actually need to become competent, it's just this puts you in that bottom whatever percentile, and we're going to say everything above that gets a pass. Otherwise, they would be penalizing too many programs. Instead of raising the bar, or insisting that every program raises their own bar, they're just lowering it for everyone. Is that what happened?

[Dr. Amy Park]
I don't know exactly the deliberations, because I wasn't sitting at the table. What you're describing is essentially grading on a curve. I think it's just too bad because it's just not enough for most people to feel comfortable with. If you're really good, you're really good. This is another thing I say all the time about surgical skills set and training is, either you're born with a beat, you got to cultivate the beat, or you have no beat. Most of us have to cultivate the beat. Just like athletics, maybe you can get out there and swing the chess racket and just be awesome from the get-go, but most of us have to practice and really iterate, and practice, and pattern recognition, and go through a bunch of complications so you can avoid them in the future. It's just not enough repetition to have those kind of experiences. It's also really hard to get exposure unless you're using that degradable bulk alter or you have another, it's hard to do a vaginal hysterectomy with just one assistant, I think. It's better to have two assistants and if you're in private practice, hopefully you can have two assistants. You have to have a really skilled assistant. It's harder to assist on vaginal surgery than it is to be the surgeon in the middle.

[Dr. Mark Hoffman]
No, good because you can't see. To your music analogy, I actually had band practice last night. I've been playing drums for 35 years and I still play with a lot of the same guys I grew up with. We talk about it, there are guys we know who've played music a long time and still just can't [chuckle] find the beat. Technically, they may have skills or they may have been playing for a long time, but sometimes they can't fit and slide into the pocket, they can't really get in the groove. and some people are just super easy. For both groups you have to do the work, you have to-

[Dr. Amy Park]
Practice.

[Dr. Mark Hoffman]
-keep with it, you have to practice, you have to practice, you have to practice. How long have you been out from fellowship?

[Dr. Amy Park]
I have been out almost 15 years. I came out of fellowship in 2009.

[Dr. Mark Hoffman]
How long before you felt comfortable in the OR?

[Dr. Amy Park]
I think it's bad luck to answer this question. I'm not a very superstitious person, but--

[Dr. Mark Hoffman]
I don't mean confident and cocky. I'm not saying, "Oh, I don't have complications." I'm saying, you wake up in the morning and you're not like, "Oh man, what is this case?" You’ve seen a lot of things and whatever it is, for the most part, have at least an answer for it. There's no such thing as perfection, and we're not talking about being amazing, but I want to speak for you. When I was starting out, I stood and worried about things. Now it's not I don't think about it, but pretty much whenever I walk into an OR, either I can handle it or I know who to call to come in and take a look at something. I'm not losing sleep about what's coming up.

[Dr. Mark Hoffman]
I think it's probably in the range of three to five years, but I will say the caveat. Just when I feel good about myself, that's when I'm smite with the three to five complications that come in a row because they always come in at least threes. I hesitate to talk about my confidence in this [chuckles] because whenever you feel good about yourself, that's when someone or something happens to smite you down and because that's the thing about being a surgeon, those things always keep you humble.

I've seen this graphic about grief, and I don't know if you've seen it, but it's like if you talk about grief as a circle and then your being as this other circle around it, they say about the grief stays the same size, but then you're able to grow around it. That's how I feel about complications too. The hole a complication creates in terms of ruining your life and all that, that does get better with time because you can contextualize it and you've seen it before. Yes, I still lose sleep over those things and I still worry a lot about all of that stuff. It's just, I've grown around that. [chuckles]

[Dr. Mark Hoffman]
I love that analogy. I heard that grief description relatively recently and I absolutely love it. Grief never gets smaller, you just put more love around it and try to find more ways to make the whole pie bigger. I had a new partner who joined me last year and I've got that N of hundreds and hundreds of cases over the last 10 years. I've been out now, this is my 11th year out. Yes, I think, no, this is year 12. Complications that happen frequently when you're first starting out, it's a bad place to be, because if you have two complications out of your first three cases, versus two complications out of your first 100, it looks different. I think we're going to do an episode coming up on complications. I don't want to spend too much time on that, so we'll talk about that more in-depth.

I think I'm talking less about confidence in that, oh, nothing can go wrong. I am always aware [chuckles] that every case you do, you can be surprised, you can be reminded exactly how difficult this job is. I guess what I'm trying to get to is that point in which you're doing this job and go, "I feel like whatever comes today, at least I know how I would approach it, and I have a level of confidence from less anxious or panic about it." I would say, yes, it took probably about three to five years where you go, I might be okay at this job and just give yourself a little bit of a break because you've got that N of cases behind you where you go, oh, okay, objectively, whatever I think of myself, the numbers say I'm okay at this.

That's part of it. It's like introducing a new thing now for me to start doing TVH, or if I'm going to do vNOTES entry is one of the biggest things for me. I get it, just the process of how you get there. Before we get into the actual OR, we talked about how you pick patients to go to the OR and it's going to be different, like you said, for your patient population, your practice, your experience, let's talk about your OR setup. How do your patients come to the OR, talk about how you set the room up getting ready for a TVH.

(4) Setting Up an OR for Vaginal Hysterectomy

[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.

[Dr. Mark Hoffman]
Let's talk about that. We're doing an SSI deal at our institution, and that was one of the things we decided on, was changing from Betadine to a chlorhexidine or Hibiclens prep, because it does seem the SSI rates are lower compared to Betadine, right?

[Dr. Amy Park]
Yes. There was one study that came out that showed that chlorhexidine was not superior and Betadine was, but then, all the other ones showed that chlorhexidine is superior. I also give Ancef and Flagyl, or cefazolin and metronidazole. I think I'm probably one of the few urogyns who does that. I know MIGS, you guys have really taken that up from the-

[Dr. Mark Hoffman]
That was the Michigan study, right?

[Dr. Amy Park]
-yes, the Michigan study. I just figured metronidazole has such a low adverse reaction rate. It's very, very, very low. I like the coverage that it provides for anaerobes and potential BV.

[Dr. Mark Hoffman]
Are you doing it routinely?

[Dr. Amy Park]
For hysterectomy, yes, not for routine vaginal cases, I just give cefazolin alone. Then I set up the field using a LAVH drape and I put the abdominal aperture on the vagina.

[Dr. Mark Hoffman]
I need to think about this for a second.

[Dr. Amy Park]
Do you know the big part?

[Dr. Mark Hoffman]
You just bring it down.

[Dr. Amy Park]
I just bring it down because that's the field, I need the space. Oftentimes-

[Dr. Mark Hoffman]
It gives you a lot more room.

[Dr. Amy Park]
-it gives me more room than this little triangle slit. Oftentimes, I'm doing a sling so I just need the room superiorly to the mons as well. The other thing that I do that I love, these two things, I'm always preaching to the trainees about it, is cutting the bags so that it's attached to suction.

[Dr. Mark Hoffman]
The plastic bag that's catching all the-

[Dr. Amy Park]
Yes.

[Dr. Mark Hoffman]
-stuff? Oh, just so it doesn't weigh it down?

[Dr. Amy Park]
Yes.

[Dr. Mark Hoffman]
Oh.

[Dr. Amy Park]
I'll cut the little nipple and I attach another suction to it. Then the vaginal part, I take off the little sticky things and I stick them to the - There's a sterile under-buttock thing that I use, then I just stick it to that so that the water from the cysto and the blood will just go right into the bag. The piece to resistance is putting an Allis clamp to cover Mr. R, which is the rectum, and the rectum is definitely a mister. You got to cover that guy with an Allis clamp because that Mr. R, bacteria is going to get all over your field with the sutures and everything else. I just want to cover that guy up on the perineum.

[Dr. Mark Hoffman]
One of my favorite drape maneuvers on TVH was to take the drape-- When you put the drape, you use a weighted?

[Dr. Amy Park]
Yes, and then you put the--

[Dr. Mark Hoffman]
Put the drape around the weighted and use an Allis to snap it and that keeps the weighted from slipping out.

[Dr. Amy Park]
Yes. That's only a problem when they have a soft tissue dystocia problem, or they're not far enough down on the bed.

[Dr. Mark Hoffman]
Maybe I wouldn't have to do that.

[Dr. Amy Park]
Yes.

[Dr. Mark Hoffman]
I love all the little drape tricks that we have because we get one-size-fits-all drapes and they don't exactly have what we think. Remind me, next time we'll talk about all my draping tricks for TLH because they're similarly--

[Dr. Amy Park]
There's a lot.

[Dr. Mark Hoffman]
Oh, man.

[Dr. Amy Park]
It's very particular. The thing is, once I tell the fellows, the fellows are like, "You're the only one who does this," and like, "Okay," I can't speak for anybody else, but this is very important because in sacrocolpopexy, especially, you're having someone put a manipulator into the vagina, and sometimes it ends up in the wrong place. You cannot blame people because it's really dark, it's a very enclosed space and sometimes you can't see. If you cover the rectum up, I'm not saying it couldn't happen, but your probability goes down. Do you know what I mean?

[Dr. Mark Hoffman]
I'm trying to remember who it was, but they used to put the drape. They put Mastisol and then stick glue the drape to the perineum.

[Dr. Amy Park]
Yes, but the Allis is fine, and then you stick the vaginal part onto the under buttock and then the fluid all goes there. Otherwise, you can get a hot mess underneath the bed, from the cysto and the blood, from the vaginal hysterectomy.

[Dr. Mark Hoffman]
I never thought about putting suction on the bag, but as always it does, it just pulls down. When you get anything in there at all, it just pulls the whole drape down. By putting it on suction, you decrease the weight of the bag with all the fluid in it.

(5) Procedure Considerations for Vaginal Hysterectomy

[Dr. Amy Park]
Yes. Some of my fellows like to dump the urine in the bag and it just measures it, so you can just measure it that way. I usually just drain it into a bucket. Anyway, I disconnect the Foley from the bag and I do intermittent clamping. We do timeout. I'll put the Foley in, short deep weighted, get two Jacobs tenacula. I usually just use a curved Jacobs on the anterior lip, and then a straight one on the posterior lip, because then I can always be oriented. Sometimes it's really hard to tell. It can get pretty twisted around as you're going up. I just inject circumferentially with some lidocaine with epinephrine, either half or 1%, and then just make an incision with a 10-blade. I don't make the teardrop in the posterior fornix because then you get this little divot, and sometimes patients have pain there at the cup.

[Dr. Mark Hoffman]
If you go too far back?

[Dr. Amy Park]
No, if you make a teardrop, a V, in the posterior fornix.

[Dr. Mark Hoffman]
Posterior, you make the V or if you go too far back with the V as opposed to just making it.

[Dr. Amy Park]
Even if it is not too far, it just shortens it and they can feel it sometimes at the cup, so I just do a circle.

[Dr. Mark Hoffman]
What do you inject around the cervix?

[Dr. Amy Park]
Lidocaine with epinephrine.

[Dr. Mark Hoffman]
1%?

[Dr. Amy Park]
1% or 0.5%.

[Dr. Mark Hoffman]
You're doing that to develop the plane, or just for bleeding or both?

[Dr. Amy Park]
Both.

[Dr. Mark Hoffman]
How much are you putting in there?

[Dr. Amy Park]
Just whatever it takes.

[Dr. Mark Hoffman]
Like a 10 cc?

[Dr. Amy Park]
Yes, 10 cc syringe and then I get a control syringe, put it all around.

[Dr. Mark Hoffman]
Knife all around, and then what?

[Dr. Amy Park]
I use rations and I pretty much almost always try and get to the right plane with a knife or either with the knife or the curved Mayo scissors. Once you get into the right plane, and this just takes experience, you could peel back the vaginal epithelium, cephalad, until you get to the peritoneal folds. I can tell, especially in elongated cervix, you have to really go far. It can be like 4 or 5 centimeters back. If you think about the cervix, that peritoneal fold posteriorly, it can just be really far up. I'll bluntly push back the vaginal epithelium circumferentially until I can see the vesicouterine folds.

[Dr. Mark Hoffman]
It's so funny, it's just so backwards for me because everything gets pushed up and when you push it up, up, up, it becomes very thin from the inside. I'm not searching for anything, it's all right there, you're pushing it away almost.

[Dr. Amy Park]
Yes, I'm pushing it away until I can see the peritoneal fold, and then posteriorly you can just see that there's just very thin tissue. Sometimes you can get it right away if there's not too much of an elongated cervix posteriorly. Sometimes with an elongated cervix, it can be quite far, and someone who has Stage IV prolapse, it can take a while, just because this tissue is so stretched out.

[Dr. Mark Hoffman]
Then you're just taking your fingers and widening it or do you do it sharply?

[Dr. Amy Park]
No, I just do it with the ration, I pull it back. Once you get into the right plane, the tissue will go back.

[Dr. Mark Hoffman]
Now once you've made your colpotomy posteriorly to widen it, do you put your long weighted?

[Dr. Amy Park]
Once I make posterior colpotomy sharply with a curved Mayos, I'll affix the posterior peritoneum to the posterior vaginal epithelium with a figure-of-8 suture. I'll put the long deep weighted into the posterior cul-de-sac. I usually try and get it anteriorly either after I take the uterosacrals or beforehand. You want to make sure the bladders off because if it's a big cervix it doesn't matter, but sometimes you can be close in these smaller services. I'll take the uterosacrals tag those and hold them, and then get in anteriorly.

[Dr. Mark Hoffman]
Are you tagging them because you're going to use them for support later?

[Dr. Amy Park]
The uterosacral ligament, yes. Just so I can tell. The middle one I usually tag with a straight hemostat and then the uterosacrals I tag with either curved hemostats or Kelly clamps. It just depends on which hospital I'm at because the sets are slightly different. I usually get in sharply anteriorly when I see the fold, but if I don't see the fold and I think it's difficult, like say it's a prior C-section situation or what have you if it's a small uterus, I'll just put my finger around the posterior fundus and then put my finger anteriorly and then just Bovie on top of it.

The other thing that you can do to help with delineate the anterior dissection is just push up on the posterior aspect of the uterus and the cervix and just use a ray-tech and see if you can find the right plane or sharply. I tend to use the finger around the fundus as soon as I can if I'm having difficulty getting in. If you put your finger around and your Bovie on top of the finger, you know you're safe.

[Dr. Mark Hoffman]
Yes. I'm always going to compare this at least for now the way my brain has been wired the last decade of it being a laparoscopic approach. The way I get my uterines, the way I deal with any anterior adhesive disease, any C-section scar or whatever, is going lateral to medial because it's always safe. It sounds like you don't really have that choice vaginally or is it not? Normally, I'd go find the uterines and go just anterior to that and find my plane, and then work lateral to medial to dissect the bladder off. At this point, you're going right at it midline, correct?

[Dr. Amy Park]
Yes, but then you have to remember the C-section scarring all happens cephalad or superior to where I'm dissecting. There's not much scar tissue lower, it's usually higher.

[Dr. Mark Hoffman]
Where you'll getting uterines, the C-sections is going to be above that, right?

[Dr. Amy Park]
Yes. If there's adhesions going from below, there's less adhesions than from above.

[Dr. Mark Hoffman]
I've heard a lot of urogyns say C-sections are way easier from below than they are from above.

[Dr. Amy Park]
Yes, it is a lot easier. Then if there's adhesions on the top, as long as you can get your finger into the plane where the vesicouterine fold is, it's fine. The thing to know is just making the anterior colpotomy large enough to get the-- I use a Heaney right angle retractor and you don't want to have a little hole. There's a rookie mood to do as a hole once you make anterior colpotomy. Slide the Heaney retractor underneath the finger, and then you want to make sure that all that lateral tissue is pushed back because that's also a mistake. If you don't take the tissue off laterally a little bit, the ureter could be hanging out in that area.

[Dr. Mark Hoffman]
What lateral tissue? Where are you saying, within the broad ligament?

[Dr. Amy Park]
No, the vaginal epithelium in the first clamp. When you get the uterine secure, the uterine getting the anterior and posterior peritoneum at a right angle to the uterus, sometimes that tissue is still hanging around. You have to make sure that the vaginal epithelium and the bladder are well off the sides.

[Dr. Mark Hoffman]
Those are things again you just have to do so many of those to know where that is. Again, laparoscopically I see the uterines, I dissect them completely skeletonize them before we do anything, before we ever deal with bladder stuff. You've gotten your uterine you're all done with all that stuff before you ever deal with adhesive disease anteriorly. Thinking about how to do that from below, it's just a different order sometimes.

[Dr. Amy Park]
Yes. I use the curved Heaney clamps for all of this. The other thing I will say is that I am a two-handed knot tie OG-method person.

[Dr. Mark Hoffman]
We're not using fancy energy devices here at all in Amy's OR?

(6) Suturing & Tying Techniques

[Dr. Amy Park]
No, we're using curved Heaney clamps, curved Mayos, straight Mayos and you got to learn how to drive the needle driver. Use a Heaney needle driver, Heaney stitch everything, two-handed knot ties, surgeons knots, heel, and then make sure to angle the heel of the clamp to the last pedicle because otherwise, you get dead space in between. This is just like surgical principles, this is on an abdominal hysterectomy too.

[Dr. Mark Hoffman]
Always important to remind though, it's always good to talk about it.

[Dr. Amy Park]
The other thing is, I just don't think you can get a secure knot with a one-headed knot vaginally. I think you just have too many axes that are creating tension. I always caution the trainees, I'm like, "This is not practice. [chuckle] Typically, you have to come into the OR knowing how to tie two-handed knots."

[Dr. Mark Hoffman]
No, we could have an entire podcast on that. Do your homework please before you come to the OR.

[Dr. Amy Park]
Yes.

[Dr. Mark Hoffman]
Can we ask just to generally talk about why we don't, because Barb Levy, and I have talked about this in the past, because she does uses a lot of energy as a vaginal surgeon. Why is it that laparoscopic surgeons have adopted tons and tons of technology whereas it seems like it's a little bit slower to adopt for vaginal surgeons? We've got ligature impact or these other brands of handheld devices that can seal and cut. Why don't you use those devices?

[Dr. Amy Park]
For me, I remember checking it out in fellowship and we had a case where the patient got a steam burn on the vulva.

[Dr. Mark Hoffman]
Oh.

[Dr. Amy Park]
You guys are close to the ureters and the uterine, but when I first came out I remember seeing a couple of patients who'd had a vesicovaginal fistula from not dissecting the bladder off. I know a lot of people who use energy, I don't think it's a big deal. I personally, I'm more comfortable using sutures. As you know we're very close to the ureters with the uterine at all times, and I think that's just my comfort level. I don't think it's wrong or right, it just is.

[Dr. Mark Hoffman]
Is everybody in your practice using the same techniques? Are you saying people outside of the clinic are using energy, or is it vary among you and your partners?

[Dr. Amy Park]
I think all of us use sutures. I'm the one who's the most insistent on two-handed knot tie techniques. I basically don't allow one-handed for anything on the vaginal hysterectomy, only for closing the cuff.

[Dr. Mark Hoffman]
Why is that, because are the knots not the same?

[Dr. Amy Park]
I think you pull up too much and then you're not having the right amount of tension. I like to have the lateral hand throw the knot, and then tie the medial hand posteriorly because that's where you have more room inside the vagina.

[Dr. Mark Hoffman]
Can I just take a moment to just reflect on how neurotic we all are in this business in a good way? I say that as a compliment to us. The way I set my or again we'll talk about laparoscopic just in another episode. The way we're able to get down into the minutia with the drapes and the tape and every little thing that we want done a certain way, part of it is like, "Oh, we're all just nuts," but part of it is, no, I need to control the things I can control because there are so many variables in this operating room that I need to not think about all the other stuff. I need to make sure that all the knots are the same. I need to make sure all the clamps are the same. I need to make sure all the steps are the same because there's going to be variability within that." That's how I think about it anyway. I need the setup to be a way that I can make sure that stuff doesn't fall off a table and that things aren't tangly. I can just focus on the one thing that is totally unique and that's the patient.

[Dr. Amy Park]
I think it's surgery and also just generally medicine is like that. I've seen this expression, I'm not super religious but it's like God is in the details. It's all these little things that will get this patient out of the hospital. It's like glycemic control, I remember this guy in the SICU. He was so sick and then we got his sugars under better control and he was extubated. He'd been intubated for months and months and months. It's just all these little things you have to control. One of the most revolutionary things that has happened over the course of my career is enhanced recovery after surgery. That is just a bundle of a lot of little things. Normothermia, IV fluid restriction, normal glycemia, lots of things like--

[Dr. Mark Hoffman]
All the pain stuff, like get the pain control.

[Dr. Amy Park]
Multimodal pain regimen, early ambulation, DC drains early, including Foleys, early feeding. This is all stuff that's like it's not one thing it's like all the things. That's a thing about surgery, it's all the little things.

[Dr. Mark Hoffman]
It's a snowball. Any little thing if left alone can become a big thing. That's what I counsel my patients and their family is like, "Call me with the little stuff. That makes me feel smart when I can fix the little thing because if we let that go that little tiny thing becomes a big thing after 2, 3, 4, 5 days. If you're not sure whether to call or not, just call.

(7) Procedure Considerations for Vaginal Hysterectomy, Cont.

[Dr. Amy Park]
Just going back to the steps of the hysterectomy. I just sequentially go up with the clamps up the utero-ovarian, again making sure that the heel of the clamp is at the last protocol, Heaney suturing 200-knot tie, till I get to utero-ovarian. I think the thing about the utero-ovarian is you don't want too much to tissue, you don't want too little, you want just right. If you put too much tissue in the clamp it's really hard to cinch down that pedicle and some of the vessels can just retract laterally. Conversely, if it's too small you can shear it when you're manipulating the uterus, if it's just the little piece of the round left. I also double-tie that.

I used to put the free tie on first and then do a transfixion suture, but now I do the transfixion suture first and then I hold that with either a Kelly or a Coker, depending on what my uterus sickles are tagged with on the set. Then I pull the utero-ovarian tag. I look for the tube and the ovary. I look for the fimbria, then I take the tube. One thing I've been doing a lot of lately that I've been liking is using an endo loop for the tube or the ovary if I have to take them out. You don't even need a clamp, you just lasso it, push it down it's so easy, it's awesome.

[Dr. Mark Hoffman]
You do it around the whole tube. If you're just doing the tube, you'll do an endo looper on the entire mesosalpinx and just cinch it up.

[Dr. Amy Park]
Yes, then just cut it. Usually, I only do that if it's high up or if it looks like it's hard, but I usually clamp it with either a Zeppelin clamp or a Heaney, and then I use a transfixion suture of two, Vicryl and SH. All the other ones I use zero Vicryl on a CT-1 pop-off.

[Dr. Mark Hoffman]
You can get the mesosalpinx probably in two clamps?

[Dr. Amy Park]
No, just one.

[Dr. Mark Hoffman]
Just one of all of the clamps? Okay.

[Dr. Amy Park]
Just one, yes. If it looks like really flimsy, the endo loop is really nice because with sucks is losing the pedicle. You are like, "Oops, it's just came right off." I take the utero-ovarian and the uterosacral because I've tagged those guys and I look for any dead space bleeding. I'll put an Allis and any areas that look like they're bleeding and I'll just put a little figure-of-8 suture to close off any dead space. I'll cut the utero-ovarian long just in case I need to grab it in the future, and that's it. Then I do Cysto.

[Dr. Mark Hoffman]
Cysto then close, or close in cysto?

[Dr. Amy Park]
Actually, to be honest, I do the uterosacral first, and then I do the anterior repair, I do the sling, and then I cysto. I have partners who will cysto after every single step. I usually cysto after vag HYST if I am worried, I put a bunch of stitches--

[Dr. Mark Hoffman]
You won't cysto after the cup closure if you've already cysto after the uterosacral. Is that what you said, cysto or after?

[Dr. Amy Park]
I usually cysto after the sling. I do the uterosacral stitches, anchor them, tie the cup or no-- Sorry. If I do anterior repair, I'll put in the uterosacral stitches, hold them, do the anterior repair, close the anterior repair, anchor the stitches, tie down the cup, put in the sling, then I'll do the cysto. The reason why I do that is that statistically, the uterosacrals have about a 4% entrapment rate. Vag-s it's about 2%, lower your urinary tract and injury rate, and then anterior repair is like 0.4 to 0.5%.

[Dr. Mark Hoffman]
The uterosacral is the big step where you worry the most about ureteral injury.

[Dr. Amy Park]
Yes. 96% of the time it's not. Do you practice for the 94% or do you practice for the 96%?

[Dr. Mark Hoffman]
I practice for the less than 1% because when I do a TLH hysterectomy every time, luckily you've seen jets but just--

[Dr. Amy Park]
I'm just saying, if you add up all that time, that you cysto after each step-

[Dr. Mark Hoffman]
It's a lot.

[Dr. Amy Park]
-it's a lot of steps. Like I said, I do 250 to 300 cases a year. If I did that added up all those minutes that I'm--

[Dr. Mark Hoffman]
You're cystoing for days.

[Dr. Amy Park]
During the cysto for 4% of the time is the highest percentage. If you added that up it's what, 6% or something or 7%. It's still like 93% of the--

[Dr. Mark Hoffman]
Of the time you're not seeing anything.

[Dr. Amy Park]
Yes, anyway that's my rationale. It is a pain when you don't see jets and you have to take it down, but then I take down the uterosacral distal stitch first, and then if I don't see it I still, then I take down the other two stitches and that resolves it most of the time. Have I had an anterior repair ureteral kinking stitches, yes, but it's so rare.

[Dr. Mark Hoffman]
How do you close?

[Dr. Amy Park]
Because I put the uterus sacral stitches, the anterior and posterior cuff when I tie down the uterus sacral stitches, it closes the cuff. It just pull it up.

[Dr. Mark Hoffman]
You're not running the cuff in any way.

[Dr. Amy Park]
No. Sometimes I have to do a figure-of-8 in the middle but most of the time we don't.

[Dr. Mark Hoffman]
I just have to see it. That was where I think John Delancey or the Michigan guys used to have a laparoscope that would film some of their cases. I know Rose & Co does a version of that too. Sometimes being able to get in there to see things in vaginal surgery is tough. These people who've been innovative and how they record their vaginal cases is pretty incredible to see how they do that. That was a masterclass. I feel like I'll have to listen to this a couple of times, because to you it's just so routine, like you do these in your sleep honestly, just the steps.

There's no thinking involved, it's unconscious competence. You've just done it so many times. To get from conscious competence to just having it be routine takes years, takes cases and cases. I think it's so easy for you to come to a show like this unprepared and just this is what we do. I'm thinking, wait a second, let me get a pen, but amazing. I think our listeners are going to be pretty excited to hear about how Dr. Amy Park does TVH.

[Dr. Amy Park]
I don't know about that.

[Dr. Mark Hoffman]
I'm excited and I got to call my resident back here in a minute. Dr. Nun is a fan of the show and is going to be fired up to hear this.

[Dr. Amy Park]
The other thing that I will say that I think has changed over the years is that when I was training and probably when you were training too because we're similar vintage, THS were a second-year case. I'm taking these second years through their first HYST and they don't get abdominal hysterectomies until their fourth years. They're not easy cases, they're all the onc-cases.

[Dr. Mark Hoffman]
Right, they're all the toughest. They're all the ones that we don't do-- I've done five 600 cases of hysterectomies, thousands of cases, but less than 1% open in that time. Again, so they're just not seeing very much of it especially if they're operating with me. It's a tougher time I think to train. In residency, I saw almost no laparoscopic HYSTs. I saw it was all open and vaginal, almost no laparoscopy in my residency program, very little.

[Dr. Amy Park]
Yes, I think that the whole training experience is different in the operating room and so I think people have to--

[Dr. Mark Hoffman]
Be like Dr. Lerner and just sim it up, lots of sims.

[Dr. Amy Park]
Yes, I think that's the thing but a SimLab isn't going to help with throwing knots. You got to throw a loop over your scrub tie and just watch some TV and do some knots.

[Dr. Mark Hoffman]
Hundreds and hundreds before you ever go in the OR, 100%, seriously.

[Dr. Amy Park]
The sim lab will give you some of these steps with these technical skills you have to practice. I don't think I'm alone in that, I think everybody.

[Dr. Mark Hoffman]
[chuckles] If you come into my OR and you can't load a needle laparoscopically, I can already tell you've not done your work to get ready to close this cuff. I cannot watch you struggle to load the needle and expect you're going to be able to run a cuff back and forth. You've got to be able to do these steps in a lab. You've got to be able to practice doing this a bunch, a bunch, a bunch of times. When we're in the operating room, when that precious time in the OR can use it to learn how to operate not how to practice your technical skills. That's a big differentiator.

[Dr. Amy Park]
If you know how to do it, then you'll get to do more.

[Dr. Mark Hoffman]
Oh, 100% I know there were cases that I did as a resident that the attending was a little shaky but surgically I was still a resident obviously but technically laparoscopically I was really good with my instruments. I could grab what they wanted me to grab and hold tissue in certain ways and do things. I kept that case laparoscopic, and many times they would've just been like, we can't keep going because we can't keep moving. Having someone who knows the anatomy would have-- The better you are in the OR, the more practice you've done at the OR is going to make that time in the OR go a whole lot better for everyone, especially the learner. I agree.

All right, you're the best. That was awesome. I feel like I have so much to learn. Again, we talk about doing this for a long time a minute I feel good. Just put me in a bad chest and I'll be reminded very quickly how hard this job is. I think I need to get back on the horse, I got to do it again. What percentage of your cases is laparoscopic or do you do robotic?

[Dr. Amy Park]
No, I do conventional laparoscopy. I do probably like a quarter.

[Dr. Mark Hoffman]
Of your HYST or TLHS?

[Dr. Amy Park]
Actually just laparoscopic, sacrocolpopexy really.

[Dr. Mark Hoffman]
Not doing many TLHS.

[Dr. Amy Park]
No, because I do primarily-- I did earlier in my career and then I switched over--

[Dr. Mark Hoffman]
At least next time we do this pretend like I can tell you something about laparoscopic. I have to feel like I know how to do something.

[Dr. Amy Park]
[chuckles] No, you definitely do way more laparoscopic HYSTs than I do.

[Dr. Mark Hoffman]
We'll come back and we'll talk about TLH.

[Dr. Amy Park]
Perfect.

[Dr. Mark Hoffman]
You're the best. I know you're busy. Let's finish this up another day, we'll come back and talk about laparoscopic hysterectomy Dr. Amy Park. Masterclass on vaginal hysterectomy, that was awesome. Thank you and have a good rest of your week.

Thank you so much for listening. If you haven't already, make sure to follow the podcast, rate it five stars, and share with a friend. If you have any questions or comments, direct message us at _BackTableOBGYN on Instagram, Twitter, or LinkedIn.

Podcast Contributors

Dr. Amy Park

Dr. Amy Park is the Section Head of Female Pelvic Medicine & Reconstructive Surgery at the Cleveland Clinic, and a co-host of the BackTable OBGYN Podcast.

Dr. Mark Hoffman

Dr. Mark Hoffman is a minimally invasive gynecologic surgeon at the University of Kentucky.

Cite This Podcast

BackTable, LLC (Producer). (2023, September 28). Ep. 35 – The Natural Orifice Surgery: Vaginal Hysterectomy [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.