Vaginal Hysterectomy Shirish S Sheth
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The History of Vaginal HysterectomyCHAPTER 1

Christopher Sutton
 
INTRODUCTION
The operation of hysterectomy is one of the most common in surgical practice, but the removal of the uterus differs from the removal of other organs, in that it can be performed either by an open incision in the abdomen or by vias naturales, the access provided by the vaginal approach. Just as the surgical approach and technique is entirely different, so also is the history of the two types of approach to removal of the uterus.
 
THE EARLY HISTORY OF ABDOMINAL HYSTERECTOMY
We know that the first attempt at an abdominal hysterectomy was on 17 November 1843, when the Mancunian surgeon Charles Clay (Fig. 1) found that during his sixth attempt at ovariotomy (the removal of a huge ovarian tumor), the patient coughed and extruded a huge uterine fibroid through the massive incision that he had made from the xiphisternum to pubis. He, therefore, had no choice but to perform a subtotal hysterectomy, tying a ligature around the supravaginal cervix; unfortunately, the patient died of exsanguination a few hours later. Interestingly, another surgeon from Manchester, A.M. Health, had the same thing happen to one of his patients, a few days later, on 21 November 1843, and his patient also died from postoperative blood loss.1
The following year, Clay found himself in a similar situation and again proceeded to perform a subtotal hysterectomy, having placed a ligature of Indian hemp round the supravaginal cervix. On this occasion, the patient survived the operation but, sadly, died 15 days afterward, having fallen out of bed. This was unfortunate, not only for the patient, but also for Clay's claim to have performed the first successful hysterectomy, because she had in fact survived the critical immediate postoperative period and had not succumbed to sepsis, which was the usual mode of death; it was not for a further 20 years that Clay was able to claim the first successful hysterectomy in Europe.
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Fig. 1: Charles clay
2
Meanwhile, Ellis Burnham from Lowell, Massachusetts performed the first hysterectomy with the patient surviving2,3 but again the diagnosis was incorrect because Burnham also thought that he was operating on a massive ovarian cyst. In September of that year, Kimball, who also came from Massachusetts, carried out the first hysterectomy for a fibroid tumor with the patient surviving the operation.3,4 The patient made a full and complete recovery, but 8 months later the protruding ligatures were still causing inconvenience.
 
History of Vaginal Hysterectomy
With abdominal hysterectomy, the dates seem fairly certain, but the origins of vaginal hysterectomy are lost in the mists of time. The first was reputedly performed in AD 120 by Soranus, in the city of Ephesus, which was then situated in Greece but is now on the Turkish coast just north of Bodrum. There is an even more vague reference to the procedure having been performed 50 years before the birth of Christ by Themison of Athens.5 According to the medical historian Leonardo,6 the procedure performed by Soranus was the removal of an inverted uterus that had become gangrenous and had turned black in color. The ureters, and often the bladder, were invariably part of these early surgical excisions and the patients always died. Nevertheless, in the writings of the 11th century, Arabic physician, Alsaharavius, clearly states that if the uterus had prolapsed externally and could not be reinserted, then he advised his pupils that it should be surgically excised,3 and it is unlikely that he would have advocated this practice if death was the invariable result of such intervention.
In fact, there are several reports of patients surviving vaginal hysterectomy in the Middle Ages, and these are referred to in medical writings in the 16th and 17th centuries. The first authenticated case was reported by Berengarius da Carpi, who lived in Bologna in 1507 and was reputed to have performed a partial vaginal hysterectomy. Schenck of Grabenberg reported 26 cases during the early part of the 17th century, and the operation was also performed by Andreas da Crusce in 1560 and Valkaner of Nuremberg in 1675, when the patients appear to have survived.
Modern medical historians are somewhat sceptical about some of these early reports and, as usual, have largely ignored the contribution of the midwives of Europe who, from time to time, amputated prolapsed or inverted puerperal uteri. They have also overlooked an early example of self-help: the case of Faith Howard, a 46-year-old peasant woman who performed the operation on herself. This case was well documented and reported in 1670 by Percival Willoughby, an early male midwife and lifelong friend of William Harvey, who famously discovered the blood circulation. Apparently, while she was carrying a heavy load of coal one day, Faith's uterus prolapsed completely and, frustrated by this frequent occurrence, she grabbed the offending organ, pulled as hard as possible and cut the whole lot off with a short knife. In his report, Willoughby states that “there was a mighty bleeding which eventually stopped” and Faith lived on for many years after this with “water passing from her insensible day and night”, obviously from a vesicovaginal fistula.
 
The First Elective Vaginal Hysterectomies
Baudelocque from France introduced the technique of artificially prolapsing and then, in favorable cases, cutting away the uterus and appendages. He performed 23 such procedures during the 16 years following 1800, but gave Lauvariol the credit for having performed the first operation in France. This was well before the time of the first abdominal hysterectomy carried out by Charles Clay in 1843.
Most of these procedures were performed on puerperal uteri and were undertaken on an emergency basis, but the first planned procedure was by Osiander of Göttingen in 1801. Wisely, he did not report the case until he had operated on his ninth patient. In 1810, Wrisberg, in a prize essay read before the Vienna Royal Academy of Medicine, advocated vaginal hysterectomy for cancer and, 2 years later, Paletta performed the operation. He was not entirely certain, however, that he had extirpated the entire uterus.
 
Conrad Langenbeck, Surgeon-General to the Hanoverian Army
Conrad Langenbeck (Fig. 2), who came from Göttingen, was a surgeon of such supreme swiftness that he once amputated a shoulder while a colleague, who had come to observe the procedure, turned his back for a moment to take a pinch of snuff. Langenbeck was Surgeon-General to the Hanoverian Army and also a Professor of anatomy and surgery, and was certainly the most distinguished surgeon of his day. He had read Wrisberg's paper and also the report of Paletta, and this encouraged him to perform the first deliberately planned vaginal hysterectomy for carcinoma in 1813.7 He did not, however, report the operation until 1817 and, because of the abuse that he was subjected to, he probably regretted ever doing so.3
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Fig. 2: Conrad Langenbeck, Surgeon-General to the Hanoverian Army: who performed the first vaginal hysterectomy for endometrial cancer in 1813
He had little precedent to follow, so he had to devise his own plan for the removal of the entire uterus. He performed a retroperitoneal dissection, taking great care not to enter the peritoneal cavity. Unfortunately, toward the end of the operation he encountered very heavy bleeding and called upon his assistant to help him. His assistant, a Surgeon Commander debilitated by gout, was unable to rise from his chair when called upon to render assistance. Langenbeck had no option but to grasp the bleeding artery with his left hand and with his right hand he passed a needle carrying a ligature through the tissues beyond the bleeding point. With no one to assist him, he had to tie the ligature by grasping one end between his teeth and secured the pedicle with a one-handed slip knot using his right hand. After the procedure he could detect no opening into the peritoneal cavity and the patient made a surprising and uneventful recovery. Sadly, after such a display of surgical virtuosity, none of his colleagues would believe the report of his operation when it was published 4 years later. The specimen had somehow been lost and never reached the pathology department and the assistant with gout died some two weeks later, so there was no one to testify that the procedure had in fact taken place. The patient herself was demented and thus an unreliable witness and died of senility some 26 years later; only then could Langenbeck prove, by postmortem examination, that he had performed the operation. During those 26 years, he was ridiculed and subjected to the jibes of his colleagues, and no one gave him credit at the time for this spectacular achievement.
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Fig. 3: Péan
 
Further Developments in Technique at the End of the 19th Century
In 1829, Recamier pointed out the necessity of isolating and controlling the uterine vessels, which was a great step forward in standardizing the procedure.8
Surgeons from France were successful in designing clamp methods for securing the ligaments and vascular pedicles, and they also devised remarkable morcellation and hemisection techniques and even proposed the vaginal approach for pelvic inflammatory disease.9 The great French surgeon Péan (Fig. 3) reported 60 cases of vaginal hysterectomy in 1886, all of whom survived the operation.10 By contrast, in a study that he published in 1881 on 51 women with fibroids treated by abdominal hysterectomy, 18 died with a mortality rate of 35%. Although this compared favorably with a similar study produced by Lawson Tait (Fig. 4) in 1882, which had a 33% mortality rate among 30 cases, it was clearly much safer for the procedure to be carried out vaginally, if the size of the fibroids allowed it.14
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Fig. 4: Lawson Tait
Probably the worst figures produced in those days were by Spencer Wells who spent much of his time lecturing and demonstrating his surgical prowess, but in reality of the 40 cases that he published 29 had died, giving a shockingly high mortality rate of 73%.
Lawson Tait and he were great enemies, and the former, who came from Birmingham, delighted in castigating and chiding the fashionable London surgeons and drawing attention so their appalling results. Some cynics attributed the great French results to their postoperative regimen: 4 hours after surgery the patient was given iced champagne in teaspoonful doses!
The German school developed methodical suture techniques; in 1880, Schroeder presented his technique of opening the cul-de-sac and pulling the fundus through posteriorly and then cutting the bladder flap. The broad ligaments were ligated with a single ligature or in separate portions from above downward. The peritoneum was closed and the stumps of the ligaments sutured into the vagina, everting them around a T-shaped drainage tube that was inserted between the stumps.11
Doderlein described a similar technique using an anterior colpotomy, inverting the fundus through that incision and then taking the uterine arteries and cardinal ligaments under direct vision. An adaptation of that procedure has been proposed by Garry to remove the uterus after laparoscopic division of the upper pedicles.12,13
In 1894, Richelot14 reported on an operative manual of vaginal hysterectomy techniques in which he described vertical and oblique morcellation of the wall of the uterus, and this was further refined by Doyen, who described hemisection and other techniques of reducing uterine size.15 In Richelot's monograph, he describes operating techniques for three different types of cases: mobile uterus, adherent uterus, and fibromatous uterus. It is clear that the French vaginal hysterectomists at the end of the 19th century were very skilful, and, in those days, their patient survival numbers, before antibiotics and blood transfusion, were indeed remarkable.
The last years of the 19th century witnessed further development, and the technique for abdominal hysterectomy was refined and standardized by Freund. Czerny, following Langenbeck's original description, did the same for vaginal hysterectomy.16
The first planned hysterectomy performed on a gravid uterus took place in 1876 by Porro from Milan.17
Radical hysterectomy for cervical cancer by the vaginal route was introduced by the German surgeon Schuchardt and was later refined and popularized by Ernst Wertheim, the famous Austrian surgeon from Vienna, after whom the operation is now somewhat unfairly named. In 1909, Schauta described his radical vaginal hysterectomy, although clearly he was unable to remove the lymph nodes; nowadays, this can be done laparoscopically. In the early days, however, the Schauta procedure was combined with extraperitoneal lymphadenectomies on both sides.18,19 The end of the 19th century and the early years of the 20th century witnessed the introduction of specially modified instrumentation, anesthesia, and antisepsis, and the mortality rate for vaginal hysterectomy dropped precipitously: by 1886 it was approximately 15%; by 1890 it had reached 10%; and by 1910 it was as low as 2.5%. Abdominal hysterectomy lagged far behind and, at one time, it was formally condemned by the Academy of Medicine of Paris, when they met in 1872. Even 8 years after that, TG Thomas6 reported on 365 collected cases, which revealed a staggering mortality rate of 70%. It is extraordinary that, given this high mortality, women allowed themselves to be subjected to this procedure, and there was a time when it was advocated for hysteria and menstrual melancholia, the modern equivalent of which is the premenstrual syndrome.5
Increased surgical skill and prowess from an apprenticeship type of training has ensured that the operation is now extremely safe, with an incidence of ureteric injury of 0.2%–0.5% and a mortality rate of 0.12%.20,21
The advent of prophylactic anticoagulants and antibiotics has further increased the safety of this procedure. The oft-quoted figures of Dicker et al.22 showing the superiority of vaginal hysterectomy with a morbidity rate of 24.5% compared with one of 42.8% for abdominal hysterectomy, are an eloquent testimony to the efficacy of prophylactic antibiotics, because those who had a vaginal hysterectomy had the benefit of these drugs, whereas those having an abdominal hysterectomy did not. Almost inevitably, the increased safety of the operation led to an explosive increase in the number of hysterectomies performed, so that it is now the second most common operation undertaken in the USA, with over 650,000 being performed annually at a cost of approximately US$3 billion. With the increasing safety, the indications for the procedure have become more lax, to the extent that at the end of the 1980s a Californian woman only had a 50% chance of going to her grave still in possession of her uterus.
 
THE INCIDENCE OF DIFFERENT TYPES OF HYSTERECTOMY
From the above study by Dicker et al.,22 it would appear that vaginal hysterectomy is associated with the least number of complications and is therefore the safest, certainly the cheapest and can be performed comfortably while sitting down. Although the incidence of vaginal hysterectomy varies considerably in different countries and in different centers and, to a large extent is dictated by the preference of an individual surgeon, nevertheless the popularity of this approach seems to have waned in recent years. The results of the VALUE (Vaginal, Abdominal, and Laparoscopic Uterine Extirpation) study published in 1998,23 which included all hysterectomies performed in the United Kingdom in 1995, showed that 74% of the 15,379 hysterectomies performed in the absence of structural disease for dysfunctional uterine bleeding were by the abdominal route. This was in the early days of advanced laparoscopic surgery so only 7.6% were performed laparoscopically, and vaginal hysterectomy accounted for a modest 18.4%. I have found it difficult to explain why a procedure that is so clearly advantageous is not performed more often. There is little doubt that vaginal hysterectomy is a more difficult technique to teach because of the difficulty of supervising a trainee surgeon who is essentially operating down a blind hole, which can be difficult for the trainer to visualize and also requires an uncomfortable posture, slightly bent, and twisted sideways, often for a considerable length of time before surgical competence of the trainee is gained. Indeed, this time restraint imposed by unreasonable operating department managers may itself be a reason that training is curtailed. Even laparoscopic hysterectomy, which is technically more difficult, is easier to teach because the trainer is standing upright and is afforded excellent visualization by modern laparoscopes and high definition and, recently, 3-D television monitors.
To a large extent, the preferred method of removing the uterus is determined by the preference of the individual surgeon and his or her training and experience in a particular technique. Querleu,24 the renowned French oncological surgeon, reported on a series of 149 patients who required hysterectomy, and he was able to do this by the vaginal route in 77% of cases. Similarly Kovac25 showed that 548 of 617 (89%) of patients needing hysterectomy could be successfully treated by vaginal hysterectomy, and the masterly vaginal hysterectomist, Shirish Sheth, from India reported a huge personal series of 5985 hysterectomies (excluding those indicated for uterine prolapse), in which he managed to remove 80% by the vaginal route.26 He also described the usage of the uterocervical broad ligament space, which was named “Sheth's space” by John Monaghan, the brilliant oncological surgeon from Gateshead in the North East of England. To open up this nonadherent space, under the lateral one-fifth of the bladder, is of immense help to allow access to the vesicouterine peritoneum to separate adherent bladder after cesarean sections, which hitherto had been regarded as a contraindication to vaginal hysterectomy.27,28 This is an important technical advance to prevent tearing of the bladder particularly in patients who have had several cesarean sections, which is not unusual nowadays with the incidence of this mode of delivery rising throughout the world.29,30
 
THE DEVELOPMENT OF GYNECOLOGICAL SURGERY IN THE 20TH CENTURY
During the middle part of the 20th century apart from a more conservative approach to the treatment of ovarian cysts and fibroids introduced by Bonney31 in the United Kingdom Howard Kelly and the Mayo brothers in the USA32,33 and the surgical refinements in instrumentation and technique introduced by tubal microsurgeons, 6gynecological surgery was in the doldrums and few technical advances were made. This changed radically with the introduction of laparoscopic surgery by pioneers such as Raoul Palmer in Paris and Hans Frangenheim in Konstanz in the 1940s, but such advances were hampered by the lack of communication during the Second World War,34 and it required the publication of the first text book on this new technique in the English language by Patrick Steptoe in 1967 to allow the widespread dissemination of this new technique to the English-speaking world.35
Initially, laparoscopy was used for diagnosis and relatively simple therapeutic procedures such as female sterilization and puncture or fenestration of benign ovarian cysts but gradually became more sophisticated owing much to the pioneering work of Professor Kurt Semm of Kiel University, Germany, and Professor Maurice Bruhat and Hubert Manhes and their gifted team from the University of Clermont Ferrand in the Auvergne, France.
By the 1980s, minimally invasive surgery had become a reality but for a long time gynecologists struggled with primitive equipment relying on advances in laser technology and electrosurgical devices to achieve cutting and coagulation. This was before the time of disposable instruments and self-sharpening scissors, and it was necessary to return laparoscopic scissors to the factory and wait several weeks while they were sharpened.
The advent of laparoscopic cholecystectomy and its rapid uptake by our general surgical colleagues enabled industry to see the full potential of this new type of surgery, and there were rapid developments in the quality of instrumentation and sophistication in optics with the introduction of the rod led system and external cold light source by Professor Harold Hopkins36 of Reading University in the UK and later with the development of silicone chip cameras and high-resolution television monitors to enable surgeons to operate comfortably and to usefully employ assistants to help with the operation.
In a remarkably short time, these techniques were adopted universally to the extent that at least 80% of gynecological operations are performed using endoscopic techniques with several small incisions for the access of surgical instruments resulting in less pain, shorter hospital stays, and rapid recovery compared with conventional laparotomy. Nevertheless, these techniques required special visual skills and hand-eye coordination, which are not achieved by all surgeons, and the universal uptake of minimal access surgery, which was so confidently predicted in the 1990s, has not become a reality, and conventional techniques are still employed by the majority of practicing gynecological surgeons.
 
Laparoscopic Hysterectomy
The first total laparoscopic hysterectomy was performed in the Autumn of 1988 at the William Nesbit Memorial Hospital in the small coal mining town of Kingston, Pennsylvania, by Harry Reich37 far away from the University Teaching Hospitals.
His original intention was to replace some of the abdominal hysterectomies rather than to encourage the laparoscopic approach in patients who were suitable for vaginal hysterectomy. Unfortunately, the best of intentions is not always realized, and many cases of laparoscopic hysterectomy are still performed when the uterus could much more easily have been removed by the vaginal route because this is still the safest and cheapest minimal access surgical approach.
 
Laparoscopic-assisted Vaginal Hysterectomy
The original total laparoscopic hysterectomy was too complicated and time consuming and required a very high level of laparoscopic skills so was soon replaced by many surgeons with the laparoscopic-assisted vaginal hysterectomy whereby the upper pedicles were ligated, electrocoagulated, or stapled while the remaining part of the operation was performed as a routine vaginal hysterectomy. It soon became evident that none of the laparoscopic part of the operation did anything to make the vaginal approach easier and because there is no descent until the uterosacral and cardinal ligaments are transected so most surgeons found that, with the limited access involved, the procedure became a very difficult vaginal hysterectomy. Cynics pointed out that this was, in fact, a complicated way of performing a vaginal hysterectomy, but it certainly had the advantage of honing vaginal surgical skills and allowed dissection of bowel adhesions laparoscopically, as well as the treatment of any existing endometriosis, particularly deep infiltrating endometriosis in the rectovaginal septum, and the easier removal of ovaries where this was indicated.
It also had the advantage that the internal incision could be inspected at the completion of the procedure, and any residual bleeding vessels could be sealed by bipolar diathermy ensuring at the end of the procedure that the field was absolutely dry. Theoretically, this had 7the advantage of preventing secondary hemorrhages occurring a few days later and preventing subsequent hematoma formation but in reality this was not always achieved.
Advances in instrumentation such as the ultrasonic scalpel, more effective techniques to coagulate large vessels using plasma kinetic energy and ingenious uterine manipulators and vaginal tubes to delineate the vaginal fornices have led some surgeons to persevere with the total laparoscopic approach, and in recent years the time taken to perform these procedures has been considerably decreased, but nevertheless it remains a difficult procedure and one that can only really be performed by highly trained laparoscopic surgeons with a high skill level.
I will not enter into the debate about the place for robots in gynecological surgery because they do not appear to have an application in the vaginal approach and further ensures it will continue to be the cheapest method of removing the uterus.
The only instrumentation devised by modern technology that is applicable to vaginal hysterectomy is the introduction of fluid coupled electrosurgical energy.38
Some of these recently introduced electrosurgical devices that operate in a liquid field use the word plasma when describing their modus operandi but in reality use radiofrequency electrosurgery via specially designed bipolar electrode systems to seal vessels. Examples of this is the so-called PlasmaKinetic technology used in the Olympus (Gyrus ACMI) Plasma-Knife and the ArthroCareCoblation device, which only generates nonthermal plasma within the tiny bubbles formed in the fluid on the surface of their electrodes but in reality relies on basic electrosurgery for its tissue effect. Another new device, the Peak PlasmaBlade may generate a nonthermal plasma at the interface of the handpiece blade with the tissue or fluid medium in which it is used but, notwithstanding this, it is the rapid pulses of high-voltage energy that create the surgical effect. All of these devices allow rapid sealing of large vessels and allow a new generation of vaginal surgeons to dispense with the need for traditional sutures. It remains to be seen whether these new vessel sealing devices will have a wider application and increase the uptake of vaginal hysterectomy or if they are only used by laparoscopic surgeons because traditional abdominal and vaginal surgeons seem to have more faith in traditional sutures to seal vessels.
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