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Vaginal hysterectomy.

Hysterectomy by the vaginal route is great for the patient but can be tough on the surgeon. Someone once said it's like an auto mechanic trying to remove a spark plug--through the exhaust pipe!

Here is our fourth set of pearls on this topic.

Silk on silk.

Many physicians struggle with anterior peritoneal entry. A year ago we had a pearl entitled "Behold the Thin White Line" aimed at making this step simple. Unfortunately, the thin white line--the curving lower edge of the peritoneal sac--is not always visible. Dr. Bruce Hilger of Marysville, Calif., has another trick: Put your index finger on the anterior cervix and feel for the slippery peritoneum sliding against the uterus. "Then I know it is 'down' and between my finger and the uterus," he says.

Dr. Miriam M. Yudkoff of Annapolis, Md., points out that this "silk on silk" or silk glove feeling also can be used to assist with entry into the posterior cul-de-sac.

V for victory.

John P. Puckett Jr. of Winter Haven, Fla., has a tip for vaginal hysterectomy when you also plan to do an anterior or posterior repair. Make your first incision high on the anterior portion of the cervix in an inverted "V" fashion. Stay shallow when you do this since you will be in bladder country.

Continue the incision around the cervix posteriorly also in an inverted V fashion. This technique will give you better visualization to enter the anterior and posterior cul-de-sac. After the hysterectomy, the first part of your anterior dissection will be done. After your repair, close the vagina from anterior to posterior, not transversely. The "V" incision also can be used on your posterior repair.

Loop it or lose it.

When performing vaginal hysterectomy with bilateral salpingo-oophorectomy, if the vagina is deep and narrow, it is sometimes difficult to pass the suture around the clamp holding the infundibulopelvic ligament, says Dr. Fady Collado of Brooklyn, N.Y. A way around this is to use the laparoscopic Endoloop and pass it around the tip of the clamp and tie it. A second Endoloop may then be placed or a suture attempted with more security because a tie is already there.

Dr. Saji C. Jacob of St. Louis and Dr. Robert A. DeSantis of Laurel, Miss., also sent in this pearl.

Try the dye.

Dr. Chris Jayne of Houston credits this wonderful pearl to Dr. Harold Miller at Baylor University in Houston. When performing a vaginal hysterectomy, after catheterizing the bladder, add 20 mL of saline mixed with indigo carmine and then either clamp or remove the catheter, thus leaving a small amount of dye in the bladder. The dye can help identify even the smallest cystotomy. Repair can be immediate, and patient care is not compromised.

Dr. Maura S. Welch, of Garden City, Kan., said the dye trick also helps identify a thin area of the bladder wall that has been denuded but not totally penetrated.

Send Us Your Clinical Pearls!

Please include your name, affiliation, and phone and fax numbers. Mail to:

Dr. Bruce L. Flamm

10445 Victoria Ave.

Riverside, CA 92503

Or send them by fax to 909-353-5625 or by e-mail to

DR. BRUCE L. FLAMM is area research chairman and a practicing ob.gyn. at the Kaiser Permanente Medical Center in Riverside, Calif.

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Title Annotation:Clinical Pearls
Author:Flamm, Bruce L.
Publication:OB GYN News
Date:Apr 15, 2004
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