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Frick, A. C.; Diwadkar, G. B.; Walters, M. D.; Barber, M. D.
Cleveland Clinic, Cleveland, OH
DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Matthew Barber:TivaMed:honorarium:consultant
To demonstrate multiple techniques for overcoming the challenges of a difficult vaginal hysterectomy.
This video demonstrates techniques for approaching a vaginal hysterectomy with a difficult anterior peritoneal entry, difficult posterior entry, pelvic organ prolapse, cervical elongation, or an enlarged uterus. Difficult anterior and posterior peritoneal entry can be facilitated by traction-countertraction, sharp dissection, ligation of extraperitoneal pedicles until entry can be achieved, as well as identification of the peritoneal reflection digitally, with a uterine sound or bladder backfilling. Transcervical posterior entry is an alternative approach which minimizes risk of rectal injury. In pelvic organ prolapse, normal anatomic relationships can be distorted. Careful identification of the peritoneal reflections is key to safe cul-de-sac entry in these patients. Finally, uterine enlargement is not a contraindication to vaginal hysterectomy, as wedge resection, myometrial coring, uterine bivalving, and facilitating myomectomy are effective uterine debulking techniques.
Having a diverse armamentarium of approaches to a difficult vaginal hysterectomy will increase the liklihood of a safe, successful procedure.
vaginal hysterectomy; morcellation; vaginal prolapse surgery; peritoneal entry
© 2010 by Wolters Kluwer Health | Lippincott Williams & Wilkins
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