Re: Vaginal Hysterectomy closure/Vaginal BSO
From: Andrew Folley (agfolley@hotmail.com)
Fri Jan 6 08:07:12 2006
What does it mean to "massage the uterosacrals"?? andy
>From: "Richard Chudacoff, MD" <rchudacoff@mylinuxisp.com>
>Reply-To: ob-gyn-l@obgyn.net
>To: Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.net>
>Subject: RE: Vaginal Hysterectomy closure/Vaginal BSO
>Date: Thu, 5 Jan 2006 08:58:40 -0600
>
>Nichols described uterosacral ligament massage prior to the posterior
>colpotomy, which have been doing for years. It allows me to define the
>uterosacral ligaments and increases the descent of the uterus. Anyone else
>doing this? Also, he mentioned palpating the ureter after the posterior
>colpotomy. Easy to do, and helps define lateral placement of the clamps.
>
>I also use Marcaine with epi, and reef the posterior cuff prior to
>placement
>of the long duck billed/ski slope retractor.
>
>Richard Chudacoff, MD, FACOG
>
> _____
>
>From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Atkinson,
>Samuel M
>Sent: Wednesday, January 04, 2006 8:16 PM
>To: Multiple recipients of list OB-GYN-L
>Subject: RE: Vaginal Hysterectomy closure/Vaginal BSO
>
>I have looked at several threads on this subject. As I published the
>series
>of vag hysts for sterilization 35 yrs ago I offer some observations. My
>series had the shortest OR time and LOS at that time I offer the following.
>
>Last year, an adhesion prevention authority gave grand rounds here at at
>ECU
>and stated "All good vaginal surgeons reperitonealize". Nuff said..
>
>To enter posteriorly, do a classical posterior colpotomy incision by using
>large scissors such as Sims or Mayo Harrington with long handles. Regular
>Mayos are too short and your hand blocks visibility. Pull down hard on the
>posterior lip of the cervix, open the scissors wide, push them cephalad and
>cut boldly. You will enter the peritoneum. I have never entered rectum
>doing this in a non prev PID or pelvic surgery pt. Try not push the
>mucosa
>away. The more you do, the more bleeding, the more sutures to dry it up. I
>do not put fingers in the culdesac and rip. Take your favorite Hyst clamp
>and place it inside the peritoneal cavity on the uterosacral. Do no try to
>get the Cardinal in this bite. If you do you will lose the peritoneum, a
>key to this surgery and closure. Suture,tie tag. Get the other one and do
>likewise. Then put your ski slope in.
>
>If you use zylocaine and adrenaline as an hemostatic agent, the cuff won't
>bleed for 45 minutes and won't need sutures till you close the cuff(HINT
>HINT!!)
>
>Most surgeons separate the round ligament abdominally..why shouldn't we do
>it vaginally before attempting to get the ovarian pedicle..I use the
>Herrick
>renal pedicle clamp rather than the Satinsky..the satinsky is too fragile
>to
>my taste. Use a Vanderbilt, long Kelly or long right angle to carry a free
>tie up to the top of the clamp.
>
>Back in the dark ages of Gyn (CHROMIC CATGUT) there was so much inflamation
>the culdesac and uterosacrals were fused and rarely did an enterocele
>occur.
>There is an epidemic of enteroceles now that everyone uses polyglycolic
>sutures.
>
>Thus uterosacrals must be plicated...whether ;you use the MdCall, a
>Moskowitz or the Atkinson(I use a delayed absorbable such as PDS or maxon
>and reperitonealize and plicate U-S in the midline with the same suture).
>
>Close the cuff..no catgut..From an historical standpoint, when CCG was used
>to close you got just as much granulation as you did leaving the cuff open.
>Since clearing up granulation is one of those free post op warranty deeds,
>why not close the cuff and not have pts c/o spotting and discharge. ?
>
>FWIW
>
>sam a MD, Brody SOM, East Carolins Univ
>
> _____
>
>From: ob-gyn-l@obgyn.net on behalf of Garry E. Siegel, M.D.
>Sent: Tue 1/3/2006 10:54 PM
>To: Multiple recipients of list OB-GYN-L
>Subject: Gyn: Vaginal Hysterectomy closure/Vaginal BSO
>
>I am listening to an ACOG update about choosing the best approach for a
>hysterectomy, and the beginning deals with TVH.
>
>The panel discusses TVH as the preferred approach (mine, too) in many
>circumstances, and then they chat about BSO. They discussed how this
>can be made easier (a la Ballard and Walters, ObGyn 1996; 87: 35-39,
>which I reviewed online via ACOG) by ligating the round ligament
>separately after the uterosacrals, cardinal, and uterines are done.
>Then, after ligating the rounds, you can sequentially divide the
>mesosalpinx sequentially until you work your way up to the
>infundibulo-pelvic ligament.
>
>I've never tried to ligate the round separately, nor have I ever tried
>to palpate the ureter vaginally after doing so.
>
>Any tips?
>
>This may be hard to do online without pictures.
>
>Also, in looking this up in texts (Wheeless Atlas of Pelvic Surgery and
>TeLinde), I saw how both texts (older versions) suggested an elaborate
>cuff closure incorporating some of the anterior and posterior peritoneum
>along with distal bites of the pedicles anchored to the vagina. This is
>way more than I was taught years ago.
>
>How do you guys close the cuff at TVH, in general?
>
>I learned to leave the peritoneum open ,and maybe incorporate the
>posterior edge if I ran and locked the posterior cuff, or closed the
>cuff anterior to posteriorly in a running lock fashion.
>
>Do you tie the uterosacrals together? Place an McCall's type stitch?
>
>Thanks to all--this may be a nice relief from circumcision and Ob stuff.
>
>Lastly, thanks to Ashley who helped me with vaginal suspension to the
>uterosacrals.
>
>Garry
>
>--
>Garry E. Siegel, M.D.
>Private Practice
>Roswell, GA
>
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