Surgical principles of vaginal hysterectomy with cervical elongation

Abstract

A review of strategies and key surgical principles for approaching the difficult anterior and posterior peritoneal entry encountered during vaginal hysterectomy with cervical elongation. Cervical elongation is a known entity among pelvic surgeons, however it lacks a universal quantitative definition. In the literature, it has been variably defined by pathologic measurements, POP-Q exam, or surgeon’s perception. One study found that cervical elongation was present in 16-40% of patients undergoing vaginal hysterectomy for pelvic organ prolapse and was associated with increased operative time. Unfortunately, cervical elongation is often discovered for the first time intraoperatively, at which time it can make anterior and posterior entry difficult due to altered anatomy.1–6 When cervical elongation is discovered, patience is key. This video highlights four surgical principles we have adopted from the laparoscopic approach to assist in safe completion of the procedure. First, continue to completely excise the vaginal attachments to the cervix. This will allow the uterus to begin to descend into the operative field and improve exposure/visualization. Two, as the cardinal ligament is reached, separate the leaves of the broad ligament to visualize the uterine vessels. Isolate the descending uterine branches at the 3 and 9 o’clock position. Three, continue to secure the uterine vessels laterally until the lower uterine segment is reached. Four, once the ascending branches of the uterine artery are isolated, the vesicouterine peritoneal fold can be approached from lateral to medial and anterior entry accomplished. Cervical elongation is difficult to predict. When encountered, we've found it helpful to adopt strategies from laparoscopy. These techniques may be applied in other scenarios where anterior or posterior entry is difficult.