Uterine (womb) surgeries are the most frequently performed procedures in gynecology. In particular, the removal of the uterus (Hysterectomy) can be performed for many different reasons and through various surgical routes. In this article, I will talk about the method of removing the uterus through the natural opening, the vagina (vaginal hysterectomy), which is perhaps a forgotten or, more accurately, an overlooked surgical method.
For which reasons is uterine removal necessary?
Uterine removal is a surgery required for many reasons. The most common reason is fibroids, which are found in 20-25% of women (and nearly 70% from age 35 onwards). Fibroids are benign tumors originating from the smooth muscle of the uterus. Other than fibroids, the most common conditions requiring hysterectomy are bleeding resistant to medical treatment, endometriosis/adenomyosis, uterine/cervical cancers, and uterine prolapse.
What is Vaginal Hysterectomy?
We call the process of removing the uterus by using the natural opening of the vagina "vaginal hysterectomy."
A bit of history…
Vaginal hysterectomy is the oldest of the uterine surgeries. According to historical documents, it was performed in 120 AD by SORANUS of Ephesus. In the Middle Ages, vaginal hysterectomy was generally performed due to uterine prolapse. The lack of anesthesia, hygiene, and bleeding control in those periods meant high mortality for this surgery, as for all types of surgery. Developments in anesthesia, the provision of aseptic/antiseptic environments, and the provision of bleeding controls have increased the success of these surgeries.
Abdominal hysterectomy (removal of the uterus via abdominal incision) was first performed in its modern sense in 1920 by Johanns Pfannenstiel, and laparoscopic-assisted hysterectomy was first performed in 1988 by Harry Reich.
With the widespread use of laparoscopy today, the laparoscopic route is preferred in most uterine surgeries, and unfortunately, the application of VAGINAL HYSTERECTOMY has begun to decrease. However, in laparoscopic uterine surgery, after the ligaments of the uterus are cut by entering through holes in the abdomen, the uterus is mostly removed from below, that is, vaginally. Then why not remove the uterus vaginally without opening any holes in the abdomen in "SUITABLE" cases?
Indeed, vaginal hysterectomy is considered one of the "MINIMALLY INVASIVE" uterine surgeries today.
How is vaginal hysterectomy performed?
The procedure is based on removing the uterus WITHOUT MAKING ANY INCISION on the skin, using the natural opening of the vagina (remembering that babies can come out from here during birth). Under either spinal/epidural or general anesthesia, in the gynecological position, the ligaments of the uterus are cut and sutured, and the uterus is removed. The ovaries and tubes can also be removed at the same time.
Which conditions are most suitable for vaginal hysterectomy?
It is quite suitable for those with small, prolapsed uteri, cervical cellular abnormalities (early-stage cancer), and those with other accompanying prolapses (since all surgeries will be performed from the lower part).
What are the advantages of vaginal hysterectomy?
The absence of an incision, much LESS postoperative pain and infection risk, LESS blood loss, and a faster return to normal daily life after surgery are the most important advantages of vaginal hysterectomy. Accompanying issues such as urinary prolapse, rectal prolapse, or vaginal prolapse can also be corrected.
Who is not suitable for vaginal hysterectomy?
Vaginal hysterectomy is not suitable for cases where the "pelvic" angles in the vaginal area are very narrow (for technical reasons), very large uteri (technical reason), very dense adhesions of the uterus inside the abdomen (technical reason), or cancer cases other than the early stages of cervical cancer (since the surgery would require much wider excisions).
Why is the application of vaginal hysterectomy being overlooked?
The emphasis on laparoscopic surgery and the reduced place for this surgery in the gynecological training process have unfortunately pushed it aside. However, experts in the field agree that for uteri that can be removed vaginally, it is more appropriate to perform a VAGINAL HYSTERECTOMY via the NATURAL OPENING rather than removing them abdominally or via laparoscopy.
The final word should be this: the type of uterine surgery should be determined by the joint decision of the physician and the patient, considering which surgeries can be applied to the individual and taking the patient's preferences into account.
Wishing you all days full of health and love…
Prof. Dr. Umit Inceboz
- Sutton C. Hysterectomy: a historical perspective. Baillieres Clin Obstet Gynaecol. 1997;11(1):1-22.
- ACOG CLINICAL Committee Opinion Number: 701, 2017