Difficult vaginal hysterectomy

Abstract

Vaginal hysterectomy is a safe and cost-effective approach for benign indications for uterine removal. This is well supported by the literature and advocated by the American College of Obstetricians and Gynecologists as the preferred surgical approach. Unfortunately, the relative proportion of vaginal hysterectomy remains low, while laparoscopic and robotic hysterectomies have steadily increased in proportion. This is due in combination to the introduction of new technologies and decreased comfort with the vaginal approach. Additionally, trainees in obstetric/gynecology residency programs are graduating with less experience in vaginal hysterectomy. These factors result in surgeons choosing abdominal, laparoscopic and robotic as their preferred approach, especially in the setting of relative contraindications such as nulliparity, previous cesarean delivery, uterine myomas or decreased mobility. However, these challenging situations can be overcome with adequate exposure, making the posterior colpotomy first, and most importantly obtaining adequate training.