••• CHAPTER 32^ Hysterectomy^311
❍ Is the risk of ureteral injury greater with abdominal hysterectomy or vaginal hysterectomy?
Abdominal hysterectomy has a greater risk.
❍ Some surgeons inject a dilute solution of Pitressin into the vaginal mucosa just before beginning a vaginal
hysterectomy. In whom must this be avoided?
In hypertensives and patients with cardiac arrhythmias.
❍ What maneuvers during vaginal hysterectomy facilitate entry into the posterior cul-de-sac without injury to
the rectum?
Upward (anterior) and outward (caudad) traction applied to the cervix along with retraction of the posterior vagina
places the cul-de-sac peritoneum on tension, making entry into the correct space easier.
❍ What should be done if the rectum is inadvertently entered during attempted entry into the cul-de-sac?
The rectum should be repaired in layers at that time.
❍ What should be done if fluid is encountered when opening the posterior cul-de-sac?
Approximately 75 to 100 mL of peritoneal fluid is a normal finding. However, if a much larger collection of fluid
is encountered, the operator should carefully explore the exposed pelvis for findings that might necessitate an
abdominal approach.
❍ What maneuvers can be used to help identify the anterior cul-de-sac?
Moving the cervix up and down will help identify the point of attachment between the vagina and the cervix.
Strong downward traction on the cervix helps identify the relatively avascular plane between bladder and
cervix. A Foley bulb can help to identify the location of the bladder. Methylene blue can also be placed in the
bladder. Often, a finger can be passed over the uterus from the posterior cul-de-sac to help identify the proper
space. However, as long as the bladder is dissected off of the cervix, entry into the anterior cul-de-sac can be
delayed.
❍ What should be done if the bladder is inadvertently entered while trying to enter the anterior cul-de-sac?
The bladder should be closed at that point.
❍ How can ureteral injuries best be avoided while performing vaginal hysterectomy?
By maintaining downward (outward) traction on the cervix, by carefully dissecting the bladder off the cervix, and
by placing clamps as close to the cervix and uterus as possible.
❍ What maneuvers can be used vaginally to facilitate removal of a large uterine fundus?
The size of the uterus can be reduced by coring, wedging, morcellating, or bisecting the fundus after the uterine
arteries have been ligated. Care must be taken to avoid injury to a loop of bowel that may be adherent to the
uterus.
❍ What is the most common reason for inadequate vaginal vault support after vaginal hysterectomy?
Failure to recognize and repair an enterocele. An enterocele should always be checked for by placing a finger into
the posterior cul-de-sac.