Reverse Vesicouterine Fold Dissection

Procedures and Instruments

Reverse Vesicouterine Fold Dissection for Laparoscopic Hysterectomy After Prior Cesarean Deliveries

Camran Nezhat, MD, Lindsey A. Grace, MD, Gity M. Razavi, MD, Catalina Mihailide, and Holden Bamford

BACKGROUND: Cesarean delivery adhesions, during laparoscopic hysterectomy, can present surgical challenges, including distortion of anatomy, prolonged operating time, and inadvertent injury to nearby structures.

TECHNIQUE: At the time of laparoscopic hysterectomy, in patients with significant adhesions from prior cesarean deliveries, we use a reverse inferior to superior vesicouterine fold dissection to mobilize the scarred bladder. We use this as an alternative to the commonly practiced technique of mobilizing the bladder in a superior to inferior fashion at the time of laparoscopic hysterectomy.

EXPERIENCE: Fifty-two patients with a median age of 42.5 years are presented. Forty-eight patients were discharged within 3–6 hours postoperatively. Sixteen patients were discharged with Foley catheters, because they were unable to void within the protocol for a fast- track discharge. The catheters were removed between postoperative days 1 and 5. There were no gastrointestinal or genitourinary complications. One patient experienced a delayed vaginal cuff abscess and bleeding, which were managed conservatively.

CONCLUSION: Reverse vesicouterine fold dissection is a useful alternative technique for laparoscopic hysterectomy in women with a history of prior cesarean deliveries.

(Obstet Gynecol 2016;128:629–33) DOI: 10.1097/AOG.0000000000001593

From the Center for Special Minimally Invasive and Robotic Surgery and Stanford University, Palo Alto, and the University of California at Berkeley, Berkeley, California.

Corresponding author: Lindsey A. Grace, MD, Center for Special Minimally Invasive and Robotic Surgery, 900 Welch Road, Suite 403, Palo Alto, CA 94304; e-mail: lindseygrace@camrannezhatinstitute.com.

Financial Disclosure
The authors did not report any potential conflicts of interest.

© 2016 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/16

One of the most important steps in total laparoscopic hysterectomy, with and without robotic assistance, is adequately developing the vesicovaginal plane and mobilizing the urinary bladder. Adequate mobilization of the bladder allows space for proper closure of the vaginal cuff. This step is relatively straightforward in patients with no vesicouterine adhesions.

In individuals with prior cesarean deliveries, the plane between the bladder and the lower uterine segment and cervix can be scarred with dense adhesions (Appendix 1, available online). These adhesions create distorted anatomy, resulting in difficult dissections, prolonged operating time, and possible inadvertent injury to surrounding structures, specifically the urinary bladder. One study reported an odds ratio of 7.5 for incidental cystotomy at the time of laparoscopically assisted vaginal hysterectomy in women with a history of cesarean delivery.1 With the cesarean delivery birth rate approaching 33%, these adhesions are being encountered more frequently.

The traditional method of mobilizing the bladder involves a superior to inferior dissection. In using the superior to inferior dissection technique, the scarring can distort the planes and the dissection can be difficult, occasionally resulting in bladder injury. We describe an alternative approach to separating the bladder off the anterior uterus and cervix in women with a history of prior cesarean deliveries and dense uterine adhesions. By creating a place lateral and caudal to the vesicovaginal space and then using a reverse caudal to cephalad dissection, we develop the vesicovaginal space. This process facilitates complete mobilization of the bladder.

TECHNIQUE

Patients were determined to need laparoscopic hysterectomy after a thorough preoperative evaluation.

Indications for hysterectomy included pelvic pain, leiomyoma, adenomyosis, abnormal uterine bleeding, and endometriosis.

Patients are positioned in the dorsal lithotomy position, prepped, and draped in a sterile fashion. Laparoscopic ports are introduced in the standard umbilical, right and left lower quadrants, and suprapubic locations.2 An evaluation of the upper abdomen and pelvis is performed and the mobility of the uterus is assessed. The round ligament is first dessicated and cut laterally near the inguinal region. Once the areolar tissue surrounding the obliterated umbilical artery opens from the pneumoperitoneum, the uteroovarian ligament or infundibulopelvic ligament (if the adnexa is going to be removed) is desiccated and cut. The tip of a closed vessel sealing-cutting device is used to open the space between the anterior and posterior leafs of the broad ligament (Fig. 1; Appendix 2 [Appendix 2 is available online at http://links.lww. com/AOG/A844]). Anteriorly the broad ligament is elevated using grasping forceps. The blunt dissection is continued in an inferior and medial direction, creating a space parallel and lateral to the cervix and vagina (Fig. 2) until first vesicovaginal and subsequently vesicocervical ligaments are identified medially. The medial part of the anterior leaf of the broad ligament is kept intact during the dissection to allow constant traction to facilitate locating the appropriate spaces. Next, the posterior leaf of the broad ligament is dissected. These techniques displace the ureter laterally and inferiorly, exposing the uterine vessels, which are ligated at this point. These steps are then repeated on the contralateral side.3

At this point we detail the dissection of the bladder off the uterus and cervix. The partially developed vesicovaginal space is entered inferiorly from the lateral dissection. The development of the avascular space occurs using blunt dissection with inferior to superior sweeping motions (Fig. 3A and B). This is performed bilaterally until both sides are connected together inferiorly, while superiorly, the vesicouterine adhesions are present. We are assured that we are in the appropriate plane when we encounter the following space and landmarks (Fig. 4).

Fig. 1. Lateral desiccation of the round ligament and opening of the broad ligament. Illustration by Sharon I. Teal. Reprinted with permission from Camran Nezhat, MD.

Nezhat. Dissection for Laparoscopic Hysterectomy After Prior Cesarean Delivery. Obstet Gynecol 2016.

Fig. 2. The blunt dissection is continued in an inferior and medial direction, creating a space parallel and lateral to the cervix and vagina. Illustration by Sharon I. Teal. Reprinted with permission from Camran Nezhat, MD.

Nezhat. Dissection for Laparoscopic Hysterectomy After Prior Cesarean Delivery. Obstet Gynecol 2016.

The space in the vesicovaginal plane is bordered medially by the vesicocervical–vaginal ligament or bladder pillar, distally by the bladder, anteriorly by the remaining anterior leaf of the broad ligament, laterally by the inner aspect of the obliterated umbilical artery, and posteriorly by the parametrium where the ureter traverses toward the bladder. The described space is present bilaterally (Fig. 4). To our knowledge, this space has not been described before, even in detailed dissections4,5; therefore, we refer to this space as a new space. We searched through the relevant anatomy textbooks as well as performed a search of PubMed and the National Institutes of Health using the terms “anatomy,” “vesicovaginal,” and “space” from 1950 to 2016. We found no reference of the new space we are describing. The pneumoperitoneum used at the time of laparoscopy allows for the clear demarcation of this space. We recognize laparoscopic views in live, young patients are different than anatomic spaces, including the vesicouterine space, described in cadavers, by laparotomy.4

In individuals with prior cesarean deliveries, adhesions are usually encountered above the new space. Thus, we describe the technique of the reverse vesicouterine fold dissection from this space. With this approach, the vesicovaginal and vesicocervical space is further developed using an inferior to superior sweeping motion with a blunt probe. This allows the lowest portion of the bladder to be dissected off of the vagina, cervix, and uterus from an unscarred plane. Developing the bladder flap from the inferior to superior direction mimics the technique used during a vaginal hysterectomy. The aforementioned technique is used until accurate delineation of the bladder adhesions is created.

Then, we proceed with the complete mobilization of the bladder. Using sharp dissection, without thermal heat, the remaining scarred bladder can be entirely dissected off the cervicouterine junction (Fig. 5A and B). We also mobilize the bladder inferiorly, 3 cm past the leading edge of the cervicovaginal junction, to allow adequate vaginal tissue to suture the cuff (Fig. 6).

The cervix is amputated from the vagina using a monopolar cautery. The vaginal cuff is closed either laparoscopically or vaginally with 0 Vicryl suture in a running or interrupted fashion. It is our practice to assure at least a 1.5-cm margin depth with each suture. Cystoscopy is routinely performed (Video 1, available online at http://links.lww.com/AOG/A845). All patients were managed in a fast-track model.6

Fig. 3. A. Once reaching the appropriate avascular space, an inferior to superior sweeping motion is used to approach the bladder adhesions from an unscarred plane. B. Lateral view of the inferior to superior sweeping motion to approach the bladder adhesions. Illustration by Sharon I. Teal. Reprinted with permission from Camran Nezhat, MD.

Nezhat. Dissection for Laparoscopic Hysterectomy After Prior Cesarean Delivery. Obstet Gynecol 2016.

Video 1. Demonstration of a total laparoscopic hysterectomy using the reverse vesicouterine fold dissection technique. The video shows a step-by-step illustration of a laparoscopic hysterectomy complicated by prior cesarean deliveries. Video created by Dr. Camran Nezhat. Used with permission.

EXPERIENCE

We report on 52 patients using the method described. The median age at the time of laparoscopic hysterectomy was 42.5 years (range 30–55 years). The average number of prior cesarean deliveries was 1.5 (range 1–5). The median weight of the removed uteri was 130 g (range 53–1,300 g). Forty-eight patients were discharged on the day of surgery, and the remaining four patients were discharged on postoperative day 1. Each case was evaluated for complications, including ureteral injury, bladder injury, and vaginal cuff dehiscence. Sixteen patients were discharged home with a transurethral Foley catheter after being unable to void at the time of fast-track discharge. The Foley catheters were removed between postoperative days 1 and 5. One patient experienced vaginal cuff abscess and bleeding; she responded well to antibiotics and incision and drainage.

Fig. 4. Boundaries of the new space after complete dissection into the avascular planes. Illustration by Sharon I. Teal. Reprinted with permission from Camran Nezhat, MD.

Nezhat. Dissection for Laparoscopic Hysterectomy After Prior Cesarean Delivery. Obstet Gynecol 2016.

DISCUSSION

Genitourinary injuries are a known complication of hysterectomy. A study of greater than 3,500 individuals shows the incidence of urinary tract injuries to be 1.30% during laparoscopic hysterectomy. Of these urinary injuries, 0.54% were ureteral, 0.71% were urinary bladder, and 0.06% involved both ureteral and bladder injuries.7 Prior cesarean delivery in- creases the risk of bladder injury during laparoscopic hysterectomy.1 Our study shows that the method of reverse vesicouterine fold dissection, using the techniques described, can minimize genitourinary injury during laparoscopic hysterectomy in patients with prior cesarean delivery.

The success of the described technique is multifactorial. Dissecting in the direction of the paravesical space first allows entry into the vesicovaginal space well below the level of the adhesions from a previously untouched plane. By approaching the dissection from this untouched avascular space, in the inferior to superior manner, bleeding is limited and bladder injury avoided. The new space we describe assures us that we are in this appropriate plane. Risk of thermal injury and delayed necrosis are minimized by the use of blunt and sharp dissection when separating the bladder from the cervicovaginal junction. Also, our technique of mobilizing the bladder to well below the site of colpotomy and incorporating adequate vaginal tissue in the cuff closure minimizes the risk of vaginal cuff dehiscence.

In addition to patients with prior cesarean deliveries, this approach can be used in patients with prior anterior myomectomy, ischiocele, or endometriosis that has scarred the anterior cul de sac. We caution those using this technique to use care when developing the spaces to avoid injuring the ureter.

In the setting of prior cesarean deliveries, different surgical techniques and spaces have been described to minimize iatrogenic injuries.8–10 Our technique, used as an alternative method, has proven to be beneficial to our patients.

Fig. 5. A. Sharp dissection of the skeletonized bladder adhesions off the uterine corpus. B. Lateral view demonstrating the final dissection of the bladder adhesions. Illustration by Sharon I. Teal. Reprinted with permission from Camran Nezhat, MD.

Nezhat. Dissection for Laparoscopic Hysterectomy After Prior Cesarean Delivery. Obstet Gynecol 2016.

Fig. 6. Degree of bladder dissection. Dashed line represents the site of the colpotomy.

Nezhat. Dissection for Laparoscopic Hysterectomy After Prior Cesarean Delivery. Obstet Gynecol 2016.

REFERENCES

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7. Tan-Kim J, Menefee SA, Reinsch CS, O’Day CH, Bebchuk J, Kennedy JS, et al. Laparoscopic hysterectomy and urinary tract injury: experience in a health maintenance organization. J Minim Invasive Gynecol 2015;22:1278–86.
8. Sinha R, Sundaram M, Lakhotia S, Hedge A, Kadam P. Total laparoscopic hysterectomy in women with previous cesarean sections. J Minim Invasive Gynecol 2010;17:513–7.
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