Vaginal axis after abdominal,vaginal and laparoscopic hysterectomy: A preliminary study with perineal ultrasonography using contrast medium

Fifteen consecutive women (mean age 44.5 years) without pelvic relaxation underwent total abdominal (5), vaginal (5) and laparoscopic (5) hysterectomy for benign disease. The vaginal axes of the patients were examined prior to and on average 7 weeks (range 3–10) after the operation with perineal ultrasonography enhanced with an ultrasound contrast medium (SHU454/Echovist^®-300). Transabdominal and vaginal hysterectomies were performed in the classic manner, i.e. the round as well as cardinal and sacrouterine ligaments were attached to the vaginal vault, followed by peritonealization. In laparoscopic hysterectomy the round, broad and outer parts of the uterosacral and the upper parts of the cardinal ligaments were desiccated by bipolar electrocoagulation and cut with laparoscopic scissors. The vagina was closed by interrupted sutures with no specific fixation of the round, cardinal or uterosacral ligaments. Preoperative ultrasound findings showed that in all women the vagina was an angulated organ. The mean preoperative angle between the upper and lower vaginal portions was 108°, in both the supine and the standing positions. Postoperatively this angulated shape remained almost unchanged after vaginal (mean angle 117°) and laparoscopic hysterectomy (mean angle 130°), whereas after transabdominal hysterectomy the vaginal axis rotated anteriorly and became an almost straight tube (mean angle 158°). We conclude that the vaginal axis, at least at an early stage after vaginal and laparoscopic hysterectomy remained in almost the same position as preoperatively, in contrast to that after abdominal hysterectomy. A tight attachment of the round ligaments to the vaginal vault in the abdominal approach could explain the outcome of transabdominal hysterectomy, and should be called into question.EDITORIAL COMMENT: The investigators further explore the functional anatomic support of the vagina, looking specifically at differences in topography following abdominal, vaginal or laparoscopic hysterectomy. Although the number of patients included in the study is small and the length of follow-up short, clear differences in vaginal axis following hysterectomy performed via different routes can be seen. Vaginal and laparoscopic hysterectomy seem to maintain the normal preoperative position of the vagina, with the upper vagina horizontal to the levator plate and the vaginal apex positioned posteriorly towards the sacrum. In contrast, the abdominal hysterectomy technique used by the authors, which includes fixation of the round ligaments to the vaginal cuff, results in an anterior rotation of the vaginal axis and loss of the normal relationship between the upper vagina and levator plate; the vagina essentially becomes a vertically positioned tube. This difference in early postoperative upper vaginal position could predispose to the development of enterocele formation and vault prolapse. Continued investigation in this topic should help us understand postoperative pelvic support and devise methods by which to avoid posthysterectomy vault prolapse.