New Trends in Surgical Education The Ten Step Vaginal ... · The Ten Step Vaginal Hysterectomy“...

Michael Stark,

New European Surgical Academy (NESA)

Charité Berlin

16 – 17. September 2019

New Trends in Surgical Education

The Ten Step Vaginal Hysterectomy

Disclosure

Michael Stark is the President of the New

European Surgical Academy (NESA) and the

Scientific Adviser of the ELSAN Hospital Group in

France and a guest scientist at The Charité

University Hospital.

There is no conflict of interest nor any financial

interest

At the point where the scalpel touches the skin,

you will find the presentation of the

whole surgical culture.

• The Surgical Manifest, Stark M, 2019

„Less is More“

Ludwig Mies van der Rohe

„Nothing Missing, Nothing Superfluous“

• Leonardo da Vinci

Different methods were in use when

hysterectomy was indicated:

1. Abdominal hysterectomy

2. Vaginal hysterectomy

3. Endoscopic hysterectomy

4. Laparoscopic-assisted vaginal

hysterectomy

Hysterectomy until the 20th Century

Vaginal hysterectomy dates back to ancient

times. The procedure was performed by

Soranus of Ephesus 120 C.E.

Sutton, C. Hysterectomy. Baillière's Clinical

Obstetrics and Gynaecology Volume 11,

Issue 1, March 1997, Pages 1-22

The first abdominal

hysterectomy was

performed by Charles Clay

in Manchester, England

in 1843.

Sutton, C. Hysterectomy. Baillière's Clinical

Obstetrics and Gynaecology Volume 11, Issue 1,

March 1997, Pages 1-22

The first laparoscopic

hysterectomy (LH) was

performed in January 1988

by Harry Reich in

Pennsylvania

A.Perino, G.Cucinella, R.Venezia, et al. Total laparoscopic hysterectomy

versus total abdominal hysterectomy: an assessment of the learning curve in a

prospective randomized study, Human Reproduction, vol.14 no.12 pp.2996–

2999, 1999

1. Robotic hysterectomy

2. TransDouglas hysterectomy

Hysterectomy in the 21st Century

Transvaginal/transdouglas

hysterecomy is expected to be a

valid alternative to traditional

endoscopic procedures

Stark M, Benhidjeb T, Natural Orifice Surgery: Transdouglas

surgery – a new concept, in: JSLS, 2008, 12(3): 295-8

The vaginal route should always be

considered when hysterectomy is

indicated, due to

• quicker recovery

• lack of scars

• shorter hospital stay

Some common methods for

vaginal hysterectomy:

1. The Viennese School (Halban)

2. Falk

3. von Theobald

4. Heaney

5. Porges

6. The Chicago School

7. Joel-Cohen

Universal steps used in vaginal hysterectomy:

1. Suturing labiae majorae. (4 / 7)

2. Incision around cervix. (7 / 7)

3. Perpendicular incision toward urethra. (5 / 7)

4. Peeling away vaginal epithelium, exposing bladder. (7 / 7)

5. Cutting excessive vaginal epithelium. (7 / 7)

6. Separating bladder from uterus. (7 / 7)

7. Opening anterior peritoneum first. (5 / 7)

8. Opening posterior peritoneum first. (2 / 7)

9. Cutting and ligating sacro-uterine ligaments. (7 / 7)

10. Cutting and ligating paracervical tissues

in one or two steps. (7 / 7)

11. Cutting and ligating uterine arteries. (7 / 7)

12. Cutting and ligating round ligaments,

ovarian ligaments and blood vessels. (7 / 7)

13. Optional repair of enterocele.

14. Closing pelvic peritoneum. (7 / 7)

15. Binding lateral stumps, enforcing the pelvic floor. (7 / 7)

16. Closing vagina. (6 / 7)

The presented case shows hysterectomy with prolapse.

The Ten Step Vaginal Hysterectomy“

Step 1

Incision of the vaginal wall

Starting under the urethra, a drop-like incision around the cervix is done and the vaginal wall is separated from the uterus and the bladder

6 instruments: Speculum, 2 uterine forceps, scalpel, surgical forceps,

Allis forceps

Step 2

Detaching the bladder from the uterus

1 instrument: A swab only. Optionally a scalpel

Step 3

Opening the posterior peritoneum

2 instruments: Surgical forceps, scissors

Big curved scissors are introduced into peritoneal cavity

and pulled out open to enable the next step.

Step 4

Dissection of the lower part of the uterus

Cutting and ligating the sacro-uterine ligaments together with the paracervical tissues. The clamp is closed rotating towards the uterus, while contra-rotating the uterus

4 instruments: Wertheim or Heaney clamp, needle holder, surgical forceps, scissors (2 sutures)

Step 5

Cutting and ligating the uterine arteries

4 instruments: Wertheim or Heaney clamp, scissors, needle holder,

surgical forceps (2 sutures)

Step 6

Opening the anterior peritoneum

The uterus is pulled down rotating. The anterior peritoneum is lifted from behind and cut open.

1 instrument: scissors

Step 7

Dissection of the upper part of the uterus

Clamping, cutting and suturing the round

ligaments and blood vessels

(oophorectomy is optional)

4 instruments: Wertheim or Heaney clamp, scissors, needle holder, surgical forceps (4 sutures)

Step 8

A „non-stage“

Peritoneum is left open (enterocele repair is

optional)

▪ Suturing the peritoneal layers is unnecessary

▪ Peritoneum does not heal by approximation

of its edges

▪ New peritoneum is formed within 24 – 48 h

from the coelum cells

▪ Sutures are providing focal points for adhesions

Ellis H. Internal overhealing: the problem of intraperitoneal adhesions. World J Surg

1980; 4: 303-306

ADHESIONS IN REPEATED OPERATIONS

Peritoneum

previously

left open

No. %

16

147

Adhesions

1 6,3

35 23,8

Stark M. World J Surg 1993; 17 (3): 419

Peritoneum

closed previously

Closing the peritoneum in a vaginal hysterectomy

is not necessary:

Lipscomb GH, Ling FW, Stovall TG, Summitt RL jr.

Peritoneal closure at vaginal hysterectomy : a reassessment.

Obstet Gynecol 1996; 87 (1): 40-43

Janschek EC, Hohlagschwandtner M, Nather A, Schindl M, Joura EA.

A study of non-closure of the peritoneum at vaginal hysterectomy.

Arch Gynecol Obstet 2003; 267 (4): 213-216

Step 9

Reconstruction of the pelvic floor

Sacrofixation or mesh where indicated.

Sacro-uterine ligaments, paracervical tissues

(from step 4) and ovarian ligaments

(from step 7) are ligated to each other

Step 10

Suturing the vaginal wall

4 instruments: Allis forceps, needle holder, surgical forceps, scissors (1 suture)

1 speculum

2 uterine forceps

1 Allis forceps

1 scalpel

1 surgical forceps

1 big curved scissors

1 Wertheim or Heaney clamp

1 needle holder

1 straight scissors

10 coated Vicryl sutures

10 instruments, 10 sutures

Instruments and sutures

10 instruments, 10 sutures:

Stark M/Di Renzo GC/Gerli S, in: Progress in Obstetrics and Gynaecology 2006,

Vol. 17, 358-368

The Ten-Step Vaginal Hysterectomy –

A Newer and Better Approach

Bina I, Akhter. Journal of Bangladesh College of Physicians and Surgeons.

30 (2), 2012, 71-7

The Ten-Step Vaginal Hysterectomy –

A Newer and Better Approach

Bina I, Akhter. Journal of Bangladesh College of Physicians and Surgeons.

30 (2), 2012, 71-7

Ten-step hysterectomy Heaney method

Mean value±SD Median (25th-

75th percentile)

Mean value±SD Median (25th-

75th percentile)

Statistical

significance

(p<0,05)

Operation time

(min.)

30±5 30(25-35) 43±7,7 45(38-48) <0,001

Need for

analgesics (hours)

28±10,4 30(25-35) 40,8±12,8 40(32-48) 0,001

Hospital stay

(days)

7,5±0,8 7(7-8) 9,5±2 9(8-10) <0,001

Comparison of operation time, use of analgesics and hospital stay

Comparison of a re-analyzed vaginal hysterectomy

to a classical one (in 66 cases)

Davor Zoričić, Dragan Belci, Dino Bečić, Michael Stark

In a study of 49 patients who underwent the Ten-Step

Vaginal Hysterectomy (TSVH) method or the Heaney

method, the TSVH group had a significantly shorter

operation time (P = 0.001), shorter hospital stay (P = 0.020)

and shorter time of analgesics requirement (P = 0.006).

Ü. GÖRKEM, C. TOĞRUL, H.A. İNAL, T. GÜNGÖR. Comparison of conventional Heaney’s technique

and ten-step vaginal hysterectomy technique. Turkısh Journal of Clinics and Laboratory Volum 6

Number 3 p: 91-95

The advantages ...

▪ Makes sense anatomically and physiologically

▪ Requires less pain killers

▪ Is easy to learn, perform and teach

▪ Saves theatre time

We expect any new presented surgical method to

bring upon added value to the existing ones, but

no evaluation can be done without standardization

of the compared groups.

Key Messages

1. In an optimal Vaginal Hysterectomy, no superfluous step should be taken, and no step should be lacking.

2. There is direct correlation between any surgical step to the clinical outcome.

3. Only standardized method will enable meta-analyzis and comparison among surgeons and institutions.

Thank you for your attention!

Non vi sed arte