OBG Management

In the United States, gynecologic surgeons remove approximately one uterus every minute of the year.¹ That rate translates to more than 525,000 hysterectomies annually in this country alone. Yet, despite the widespread availability of information on the benefits of a vaginal approach to hysterectomy, the great majority of these operations—close to 50%—are still performed via an open abdominal approach.²

As I pointed out last month in my “Update on Vaginal Hysterectomy,” the vaginal approach not only is more cosmetically pleasing than laparoscopic and robot-assisted hysterectomy (not to mention open abdominal surgery) but also has a lower complication rate.³

As I also noted, one reason for the low rate of vaginal hysterectomy may be the assumption, on the part of many gynecologic surgeons, that the techniques and tools they learned to use during training are still the only options available today. That assumption is wrong.

In this article, I describe the technique 
for vaginal hysterectomy using basic instru
mentation. This article is based on a master 
class in vaginal hysterectomy produced by 
the AAGL and co-sponsored by the Am
erican College of Obstetricians and Gynecologists and the Society of Gynecologic 
Surgeons. This master class offers continuing
 medical education credits and is avail
able at http://www.aagl.org/vaghystwebinar.

For a look at innovative tools for this procedure, see my “Update on Vaginal 
Hysterectomy” in the September 2015 issue of this journal at obgmanagement.com.

Vaginal hysterectomy has 
few contraindications

Many commonly cited contraindications to the vaginal approach are not, in fact, absolute contraindications. An open or laparoscopic approach is preferred when the patient has a known cancer, of course, and when deep infiltrating endometriosis is present at the rectovaginal septum. However, previous pelvic surgery, nulliparity, an enlarged uterus, or lack of a prior vaginal delivery need not exclude the vaginal approach. Nor does a narrow introitus necessarily mandate a laparoscopic or open abdominal approach. In fact, in this article, I describe my basic technique in a patient (a cadaver) with a very narrow pubic arch, and I offer strategies for gaining some needed mobility and avoiding complications (TABLES 1 and 2).

Next month, in the November issue of OBG Management, John B. Gebhart, MD, will describe his vaginal technique for right salpingectomy with ovarian preservation, as well as his technique for right salpingo-oophorectomy.

Proper patient positioning 
is key

You can simplify the operation by positioning the patient so that her buttocks are over the edge of the table fairly far—at least 1 inch beyond the edge of the table for optimal exposure and greater access. If the patient is thin, it then becomes important to pad the sacrum because, when she is positioned that far off the table, all her weight comes to rest on the sacrum. In overweight patients, this is not an issue, but for thin patients, I place a bit of egg crate or gel beneath the sacrum.

For the procedure, I prefer to place my instruments on a tray that is kept on my lap. This arrangement frees the scrub technician from having to hand tools over my shoulder—and it saves time. I use a narrow, covered Mayo stand, and I place a stepstool beneath my feet to keep my knees at right angles so that things don’t slip during the operation.

Surgical technique

Choose an appropriate retractor

In a woman with a narrow introitus, I find that a posterior weighted speculum takes up too much space. Once I place a clamp on the cervix with that speculum in place, I don’t have much room to work. However, if I substitute a small Deaver retractor, which is narrower, I gain more workspace.

Inject the uterosacral ligaments

Grasp the cervix using a Jacobs vulsellum tenaculum. Use of a single tenaculum allows for much more movement than the use of instruments placed anteriorly and posteriorly. The Jacobs tenaculum obtains a better purchase on the tissue than a single tooth and is considerably less likely to tear through the tissue.

Before beginning the hysterectomy, locate the uterosacral ligaments and inject each one at its junction with the cervix, aspirating slightly before infiltrating the ligament with 0.25% to 0.50% bupivacaine with epinephrine, with dilute vasopressin mixed in. (I place 1 unit in 20 mL of the local solution.) Injection of this solution achieves 2 goals:

• improved intraoperative hemostasis
• postoperative pain relief.

Use a short needle with a needle extender attached to a control syringe rather than a spinal needle for greater control.

Enter the posterior peritoneal cavity

Before entering the peritoneal cavity, create a right angle with the Jacobs tenaculum and Deaver retractor in relation to the surgical field (FIGURE 1). This right angle is difficult to achieve when you are using a weighted speculum in a tight vagina. Once you have a right angle, tent the vaginal tissue in the midline (FIGURE 2).

In a nulliparous patient or a woman with a tight pelvis, you may discover that the peritoneum is pulled up between the uterosacral ligaments. One common pitfall arises when the surgeon, having dissected the vaginal epithelium, continues cutting into the vaginal epithelium instead of reaching into the peritoneal cavity. Palpate the tissue to ensure that there is no bowel in the way and stay at right angles while confidently grasping the peritoneum with a toothed forceps.

I like to use a bit of electrosurgery to incise the vaginal wall. I don’t begin at the cervix but incise more distally into the vaginal epithelium approximately 2 cm from the cervicovaginal junction. This strategy prevents dissection into the cervix and/or rectovaginal septum rather than the posterior 
cul-de-sac (FIGURE 3).

Once the incision is made, it is possible to feel the posterior peritoneum. And as you tent the peritoneum, you can then very confidently extend the incision and enter the cavity posteriorly.

In a patient with significant adhesions such as this one, I feel around posteriorly to determine exactly where I am. One tactic I use is to release the tenaculum and regrasp the cervix with it. This allows for improved visualization and movement of the cervix as the procedure progresses. Depending on the case, it may be necessary to insert a sponge to hold bowel out of the way.

Avoid the bladder

Move the Deaver retractor to the anterior position, switch the Jacobs clamp to the anterior cervix, and pull straight down. Now that you have incised the vaginal epithelium posteriorly, the length of the cervix should be apparent to you, and you can easily determine the location of the bladder reflection.

Keep in mind that, in a postmenopausal patient, there will be fewer vaginal rugae to guide you. Place the Jacobs tenaculum as close to the midline as possible so that you can confidently grab the tissue without fear of grabbing the bladder. If you tilt the Jacobs clamp, you can feel the edge of the bladder reflection. Remember that postmenopausal patients with prolapse (or, occasionally, obese patients with cervical elongation but little actual descensus) may have altered anatomy.

You can create a bit more space in which to dissect by injecting the bupivacaine/ 
epinephrine solution into the vaginal epithelium. This technique also ensures that the vaginal epithelial incisions won’t bleed.

Now, tilt the Jacobs tenaculum downward and push the junction of the cervix with the bladder reflection toward you so that you have a good sense of how deeply to incise.

Once you’ve made the incision, reclamp the Jacobs tenaculum so that it holds all of that tissue, and repeat the maneuver, tilting the clamp downward and pushing the junction toward you. In this way, you create traction and countertraction, sweeping the tissue out of your way.

Always use sharp dissection. When adhesions are present, surgeons often get into trouble using blunt dissection and may inadvertently enter the bladder if they use a sponge-covered digit for dissection, because adhesions can be much denser than normal tissue. In such cases, the bladder tears open rather than the adhesions being swept away.

Consider this: You don’t need to enter the peritoneal cavity anteriorly in order to continue working on the procedure. You can safely protect the bladder throughout the case, until the very end, if necessary, in patients who have undergone multiple previous surgeries or cesarean deliveries.

Rather than enter the anterior peritoneum, I dissect as much of the vaginal epithelium as possible and place a second Deaver retractor posteriorly.

I massage the uterosacral ligament for about 10 seconds to lengthen it and create more descensus, then place a Ballantine Heaney clamp on the ligament.

Next, I cut the pedicle and suture it, maintaining a clamp on the uterosacral ligament suture so that I can use it later for repair of the vaginal cuff.

I recommend a vessel-sealing device to secure the major blood supply, but I do suture the uterosacral and round ligaments for attachment to the apex at the conclusion of the hysterectomy. I suggest that you place straight clamps to hold the uterosacral ligament sutures and curved clamps on the round ligament ties to help you keep track of what you’re doing.

I generally prefer to use a smaller vessel-sealing device, such as the LigaSure Max (Covidien), because it allows me to take very small bites of tissue. It is also less expensive because it uses a disposable electrode within a reusable Heaney-type clamp.

Many people have argued that we need to teach surgeons to suture vaginally and, for that reason, should avoid vessel sealing. My response: Why wouldn’t we want to use the very best technology available? Randomized trials have demonstrated a 50% reduction in pain relief postoperatively when we use vessel sealing.⁴ Less foreign material is left in the pelvis, lowering the risk of infection. And it really doesn’t matter which vessel-sealing technology you use, as long as you’re familiar with the specifics of the system you choose. Another advantage: There is no need to pass needles back and forth.

Take small bites of tissue

Because this patient has a very small uterus, a small bite of tissue will get you close to where you want to be. When you take a bite with the vessel sealer, try to protect the vaginal epithelium and vulva from the steam that is emitted. The clamp itself does not heat up, but the steam that is released from the tissue is 100° C, so place a finger between the clamp and the sidewall for protection. It is preferable to burn your own finger than to burn the patient.

Because you haven’t entered the peritoneal cavity anteriorly, it is important to ensure that you don’t take too big of a bite with the vessel sealer. Rather, stay where you know you’ve done your dissection, where things are safe.

One cardinal principle of surgery is that you shouldn’t operate where you can’t feel or see. One of the common errors in vaginal surgery is that surgeons start dissecting higher than they can see. It’s easy to get into trouble when you start pushing tissue or dissecting tissue that you can’t visualize.

At this point, the anterior Deaver retractor is not essential, so I remove it. If you don’t need it, don’t use it. I try to avoid metal when I can.

If I were using suture rather than vessel sealing, I would place a Heaney clamp on the uterosacral ligament and cut. Using a clamp-cut-tie technique, I would pull on the pedicle and cut just beyond the tip of the clamp to ensure that the suture will be secure 
(FIGURE 4). This approach would not be appropriate during use of a vessel sealer. In that case, you would want to cut to but not beyond the tip of the clamp.

One of the skills helpful in suturing is learning to move your elbow and wrist to achieve the proper angle. Determine where you want the suture to exit the tissue, and then angle your elbow and wrist so that the suture comes out where you want it. It’s easy to lose track of the needle tip, especially when you’re working in a limited space under the pubic symphysis, so use your shoulder, elbow, and wrist to control 
suture placement.

Protect the anterior epithelium

Because you have not yet entered the peritoneal cavity anteriorly, it is important to protect the anterior epithelium and bladder. Reinsert a narrow Deaver retractor anteriorly, remove the Jacobs clamp, and replace the clamp laterally so that the cervix can be pulled off to the side (FIGURE 5).

One nice thing about some vessel sealers is that the surgeon can twist them in any direction. It isn’t necessary to move your hand; you simply move the device itself.

Once you have taken at least the descending branch of the uterine artery, remove the posterior retractor and pull downward on the Jacobs tenaculum. You should have reached just about to the level of the uterine fundus, with the anatomy well visualized (FIGURE 6). Next, open the anterior peritoneum.

Pay attention to the surgical field

Now that you have entered the peritoneum anteriorly as well as posteriorly, identify the broad ligament, keeping in mind that the ureter is retroperitoneal, not intraperitoneal. If you were to place a clamp from the posterior leaf of the broad ligament across to the anterior leaf of the broad ligament, you would be grasping all the vessels but not the ureter. In fact, the anterior Deaver retractor is lifting both ureters up and out of the way. If you pull the cervix off to the opposite side, you create an additional couple of centimeters—a safe space for the vessel sealer 
(FIGURE 7).

In placing the vessel sealer, there is no need to move out laterally, as there is no need for space to place suture. Instead, hug the uterus. At this point, the main concern is the risk of damaging any small bowel behind the uterine fundus that might be coming down into the surgical field, obscured from vision. And because there may be steam emitted at the tip of the vessel-sealing clamp, keep a finger back there to protect anything that might be in the field.

Last steps

Before taking the last bite of tissue on the right-hand side, place the round ligament in a Heaney clamp. Now that the round and utero-ovarian ligaments have been skeletonized, you can grasp the pedicle in a clamp. If the pedicle is especially thick, it may be beneficial to close the clamp, leave it on for a few seconds, and then reapply it. In that way, you obtain a better purchase.

Next, free the rest of the tissue with a vessel sealer, or cut it. I prefer to use a vessel sealer, and I again protect the adjacent tissue with my fingers anteriorly and posteriorly.

With the clamp remaining on the round ligament and utero-ovarian ligament 
(FIGURE 8), which will be sutured, push the uterine tissue out of the way, back into the pelvis, to make room for suturing.

Because a postmenopausal vulva may be cut by the suture, it’s important to take pains not to abrade that tissue. Once you have finished suturing the round/utero-ovarian pedicle, leave the needle on the suture so that you can reconnect the round ligament to the anterior pubocervical ring to reconstruct the vaginal apex. For safekeeping, clamp the needle out of the way and tuck it beneath the drape.

Switching to the other side, use a Lahey clamp to flip the uterus, then clamp the pedicle and use the vessel sealer to separate it, again protecting the tissue beneath and ahead of the clamp. Sometimes, with an especially thick pedicle, the vessel sealer will signal that the tissue hasn’t been completely sealed. In that case, get another purchase of the pedicle, protect the adjacent tissue, and seal again.

Once the uterus has been removed completely, suture the utero-ovarian and round ligament on this side.
One tip to aid in the placement of suture is to move your clamped tissue in such a way as to prevent inadvertent suturing of other tissue (FIGURE 9).

An additional strategy for pain relief at this point is to infiltrate the round ligaments with local anesthetic. We know that we’re working with higher-level fibers—T10 to T12—through the round ligaments. By infiltrating them with anesthetic, you achieve denser pain relief for post- 
operative management.

Uterine reduction strategies facilitate vaginal removal of tissue

When the uterus is too large to remove intact through the vagina, there are a number of techniques for coring, wedging, and morcellating the tissue. As always, a complete knowledge of anatomy is essential, as well as an understanding that fibroids can frequently distort the uterus, twisting it to the left or right. It is important to anticipate such distortion to avoid the inadvertent destruction of anatomic landmarks or damage to the adnexae.

One straight-forward strategy is to debulk the uterus using a knife to core it, removing the central portion. In cases in which you need to keep the entire endometrial cavity intact, you can core the central portion of the uterus while grasping the cervix so that you can remove the endometrium intact for the pathologist (FIGURE).

For this strategy it is important to protect the vaginal sidewalls with metal. You can use another retractor to do that, pulling down on the cervix and beginning the morcellation. I generally prefer to use a short knife handle only because I want to be sure I’m not tempted to cut any higher than I can see.

For more on coring and wedging techniques, see the introductory video for the ACOG/SGS/AAGL master class on vaginal hysterectomy at http://www.aagl.org/vaghystwebinar.

Close the vaginal cuff

The reconstruction of the vaginal cuff is a critical component of any hysterectomy. My approach is to reattach the uterosacral ligaments to the posterior cuff and the round ligaments to the anterior cuff, thereby re- 
creating an intact pubocervical ring. It is not necessary to include the peritoneum in the cuff closure. In fact, kinking of the ureters is more likely when the peritoneum is closed.

Attach one uterosacral ligament, then place a running, full-thickness stitch across the posterior cuff, and attach the uterosacral ligament on the opposite side. Use the needle you left attached to the round ligament to bring the right pedicle to the anterior cuff at 10 o’clock (be sure you grasp the full thickness of the vaginal epithelium without compromising the bladder). Attach the left round-ligament pedicle at the 2 o’clock position. Then close the cuff side to side down to the uterosacral ligaments. This completely reconstructs the pubocervical ring and provides excellent support at the apex.

Share your thoughts on this article! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

In the United States, gynecologic surgeons remove approximately one uterus every minute of the year.¹ That rate translates to more than 525,000 hysterectomies annually in this country alone. Yet, despite the widespread availability of information on the benefits of a vaginal approach to hysterectomy, the great majority of these operations—close to 50%—are still performed via an open abdominal approach.²

As I pointed out last month in my “Update on Vaginal Hysterectomy,” the vaginal approach not only is more cosmetically pleasing than laparoscopic and robot-assisted hysterectomy (not to mention open abdominal surgery) but also has a lower complication rate.³

As I also noted, one reason for the low rate of vaginal hysterectomy may be the assumption, on the part of many gynecologic surgeons, that the techniques and tools they learned to use during training are still the only options available today. That assumption is wrong.

In this article, I describe the technique 
for vaginal hysterectomy using basic instru
mentation. This article is based on a master 
class in vaginal hysterectomy produced by 
the AAGL and co-sponsored by the Am
erican College of Obstetricians and Gynecologists and the Society of Gynecologic 
Surgeons. This master class offers continuing
 medical education credits and is avail
able at http://www.aagl.org/vaghystwebinar.

For a look at innovative tools for this procedure, see my “Update on Vaginal 
Hysterectomy” in the September 2015 issue of this journal at obgmanagement.com.

Vaginal hysterectomy has 
few contraindications

Many commonly cited contraindications to the vaginal approach are not, in fact, absolute contraindications. An open or laparoscopic approach is preferred when the patient has a known cancer, of course, and when deep infiltrating endometriosis is present at the rectovaginal septum. However, previous pelvic surgery, nulliparity, an enlarged uterus, or lack of a prior vaginal delivery need not exclude the vaginal approach. Nor does a narrow introitus necessarily mandate a laparoscopic or open abdominal approach. In fact, in this article, I describe my basic technique in a patient (a cadaver) with a very narrow pubic arch, and I offer strategies for gaining some needed mobility and avoiding complications (TABLES 1 and 2).

Next month, in the November issue of OBG Management, John B. Gebhart, MD, will describe his vaginal technique for right salpingectomy with ovarian preservation, as well as his technique for right salpingo-oophorectomy.

Proper patient positioning 
is key

You can simplify the operation by positioning the patient so that her buttocks are over the edge of the table fairly far—at least 1 inch beyond the edge of the table for optimal exposure and greater access. If the patient is thin, it then becomes important to pad the sacrum because, when she is positioned that far off the table, all her weight comes to rest on the sacrum. In overweight patients, this is not an issue, but for thin patients, I place a bit of egg crate or gel beneath the sacrum.

For the procedure, I prefer to place my instruments on a tray that is kept on my lap. This arrangement frees the scrub technician from having to hand tools over my shoulder—and it saves time. I use a narrow, covered Mayo stand, and I place a stepstool beneath my feet to keep my knees at right angles so that things don’t slip during the operation.

Surgical technique

Choose an appropriate retractor

In a woman with a narrow introitus, I find that a posterior weighted speculum takes up too much space. Once I place a clamp on the cervix with that speculum in place, I don’t have much room to work. However, if I substitute a small Deaver retractor, which is narrower, I gain more workspace.

Inject the uterosacral ligaments

Grasp the cervix using a Jacobs vulsellum tenaculum. Use of a single tenaculum allows for much more movement than the use of instruments placed anteriorly and posteriorly. The Jacobs tenaculum obtains a better purchase on the tissue than a single tooth and is considerably less likely to tear through the tissue.

Before beginning the hysterectomy, locate the uterosacral ligaments and inject each one at its junction with the cervix, aspirating slightly before infiltrating the ligament with 0.25% to 0.50% bupivacaine with epinephrine, with dilute vasopressin mixed in. (I place 1 unit in 20 mL of the local solution.) Injection of this solution achieves 2 goals:

• improved intraoperative hemostasis
• postoperative pain relief.

Use a short needle with a needle extender attached to a control syringe rather than a spinal needle for greater control.

Enter the posterior peritoneal cavity

Before entering the peritoneal cavity, create a right angle with the Jacobs tenaculum and Deaver retractor in relation to the surgical field (FIGURE 1). This right angle is difficult to achieve when you are using a weighted speculum in a tight vagina. Once you have a right angle, tent the vaginal tissue in the midline (FIGURE 2).

In a nulliparous patient or a woman with a tight pelvis, you may discover that the peritoneum is pulled up between the uterosacral ligaments. One common pitfall arises when the surgeon, having dissected the vaginal epithelium, continues cutting into the vaginal epithelium instead of reaching into the peritoneal cavity. Palpate the tissue to ensure that there is no bowel in the way and stay at right angles while confidently grasping the peritoneum with a toothed forceps.

I like to use a bit of electrosurgery to incise the vaginal wall. I don’t begin at the cervix but incise more distally into the vaginal epithelium approximately 2 cm from the cervicovaginal junction. This strategy prevents dissection into the cervix and/or rectovaginal septum rather than the posterior 
cul-de-sac (FIGURE 3).

Once the incision is made, it is possible to feel the posterior peritoneum. And as you tent the peritoneum, you can then very confidently extend the incision and enter the cavity posteriorly.

In a patient with significant adhesions such as this one, I feel around posteriorly to determine exactly where I am. One tactic I use is to release the tenaculum and regrasp the cervix with it. This allows for improved visualization and movement of the cervix as the procedure progresses. Depending on the case, it may be necessary to insert a sponge to hold bowel out of the way.

Avoid the bladder

Move the Deaver retractor to the anterior position, switch the Jacobs clamp to the anterior cervix, and pull straight down. Now that you have incised the vaginal epithelium posteriorly, the length of the cervix should be apparent to you, and you can easily determine the location of the bladder reflection.

Keep in mind that, in a postmenopausal patient, there will be fewer vaginal rugae to guide you. Place the Jacobs tenaculum as close to the midline as possible so that you can confidently grab the tissue without fear of grabbing the bladder. If you tilt the Jacobs clamp, you can feel the edge of the bladder reflection. Remember that postmenopausal patients with prolapse (or, occasionally, obese patients with cervical elongation but little actual descensus) may have altered anatomy.

You can create a bit more space in which to dissect by injecting the bupivacaine/ 
epinephrine solution into the vaginal epithelium. This technique also ensures that the vaginal epithelial incisions won’t bleed.

Now, tilt the Jacobs tenaculum downward and push the junction of the cervix with the bladder reflection toward you so that you have a good sense of how deeply to incise.

Once you’ve made the incision, reclamp the Jacobs tenaculum so that it holds all of that tissue, and repeat the maneuver, tilting the clamp downward and pushing the junction toward you. In this way, you create traction and countertraction, sweeping the tissue out of your way.

Always use sharp dissection. When adhesions are present, surgeons often get into trouble using blunt dissection and may inadvertently enter the bladder if they use a sponge-covered digit for dissection, because adhesions can be much denser than normal tissue. In such cases, the bladder tears open rather than the adhesions being swept away.

Consider this: You don’t need to enter the peritoneal cavity anteriorly in order to continue working on the procedure. You can safely protect the bladder throughout the case, until the very end, if necessary, in patients who have undergone multiple previous surgeries or cesarean deliveries.

Rather than enter the anterior peritoneum, I dissect as much of the vaginal epithelium as possible and place a second Deaver retractor posteriorly.

I massage the uterosacral ligament for about 10 seconds to lengthen it and create more descensus, then place a Ballantine Heaney clamp on the ligament.

Next, I cut the pedicle and suture it, maintaining a clamp on the uterosacral ligament suture so that I can use it later for repair of the vaginal cuff.

I recommend a vessel-sealing device to secure the major blood supply, but I do suture the uterosacral and round ligaments for attachment to the apex at the conclusion of the hysterectomy. I suggest that you place straight clamps to hold the uterosacral ligament sutures and curved clamps on the round ligament ties to help you keep track of what you’re doing.

I generally prefer to use a smaller vessel-sealing device, such as the LigaSure Max (Covidien), because it allows me to take very small bites of tissue. It is also less expensive because it uses a disposable electrode within a reusable Heaney-type clamp.

Many people have argued that we need to teach surgeons to suture vaginally and, for that reason, should avoid vessel sealing. My response: Why wouldn’t we want to use the very best technology available? Randomized trials have demonstrated a 50% reduction in pain relief postoperatively when we use vessel sealing.⁴ Less foreign material is left in the pelvis, lowering the risk of infection. And it really doesn’t matter which vessel-sealing technology you use, as long as you’re familiar with the specifics of the system you choose. Another advantage: There is no need to pass needles back and forth.

Take small bites of tissue

Because this patient has a very small uterus, a small bite of tissue will get you close to where you want to be. When you take a bite with the vessel sealer, try to protect the vaginal epithelium and vulva from the steam that is emitted. The clamp itself does not heat up, but the steam that is released from the tissue is 100° C, so place a finger between the clamp and the sidewall for protection. It is preferable to burn your own finger than to burn the patient.

Because you haven’t entered the peritoneal cavity anteriorly, it is important to ensure that you don’t take too big of a bite with the vessel sealer. Rather, stay where you know you’ve done your dissection, where things are safe.

One cardinal principle of surgery is that you shouldn’t operate where you can’t feel or see. One of the common errors in vaginal surgery is that surgeons start dissecting higher than they can see. It’s easy to get into trouble when you start pushing tissue or dissecting tissue that you can’t visualize.

At this point, the anterior Deaver retractor is not essential, so I remove it. If you don’t need it, don’t use it. I try to avoid metal when I can.

If I were using suture rather than vessel sealing, I would place a Heaney clamp on the uterosacral ligament and cut. Using a clamp-cut-tie technique, I would pull on the pedicle and cut just beyond the tip of the clamp to ensure that the suture will be secure 
(FIGURE 4). This approach would not be appropriate during use of a vessel sealer. In that case, you would want to cut to but not beyond the tip of the clamp.

One of the skills helpful in suturing is learning to move your elbow and wrist to achieve the proper angle. Determine where you want the suture to exit the tissue, and then angle your elbow and wrist so that the suture comes out where you want it. It’s easy to lose track of the needle tip, especially when you’re working in a limited space under the pubic symphysis, so use your shoulder, elbow, and wrist to control 
suture placement.

Protect the anterior epithelium

Because you have not yet entered the peritoneal cavity anteriorly, it is important to protect the anterior epithelium and bladder. Reinsert a narrow Deaver retractor anteriorly, remove the Jacobs clamp, and replace the clamp laterally so that the cervix can be pulled off to the side (FIGURE 5).

One nice thing about some vessel sealers is that the surgeon can twist them in any direction. It isn’t necessary to move your hand; you simply move the device itself.

Once you have taken at least the descending branch of the uterine artery, remove the posterior retractor and pull downward on the Jacobs tenaculum. You should have reached just about to the level of the uterine fundus, with the anatomy well visualized (FIGURE 6). Next, open the anterior peritoneum.

Pay attention to the surgical field

Now that you have entered the peritoneum anteriorly as well as posteriorly, identify the broad ligament, keeping in mind that the ureter is retroperitoneal, not intraperitoneal. If you were to place a clamp from the posterior leaf of the broad ligament across to the anterior leaf of the broad ligament, you would be grasping all the vessels but not the ureter. In fact, the anterior Deaver retractor is lifting both ureters up and out of the way. If you pull the cervix off to the opposite side, you create an additional couple of centimeters—a safe space for the vessel sealer 
(FIGURE 7).

In placing the vessel sealer, there is no need to move out laterally, as there is no need for space to place suture. Instead, hug the uterus. At this point, the main concern is the risk of damaging any small bowel behind the uterine fundus that might be coming down into the surgical field, obscured from vision. And because there may be steam emitted at the tip of the vessel-sealing clamp, keep a finger back there to protect anything that might be in the field.

Last steps

Before taking the last bite of tissue on the right-hand side, place the round ligament in a Heaney clamp. Now that the round and utero-ovarian ligaments have been skeletonized, you can grasp the pedicle in a clamp. If the pedicle is especially thick, it may be beneficial to close the clamp, leave it on for a few seconds, and then reapply it. In that way, you obtain a better purchase.

Next, free the rest of the tissue with a vessel sealer, or cut it. I prefer to use a vessel sealer, and I again protect the adjacent tissue with my fingers anteriorly and posteriorly.

With the clamp remaining on the round ligament and utero-ovarian ligament 
(FIGURE 8), which will be sutured, push the uterine tissue out of the way, back into the pelvis, to make room for suturing.

Because a postmenopausal vulva may be cut by the suture, it’s important to take pains not to abrade that tissue. Once you have finished suturing the round/utero-ovarian pedicle, leave the needle on the suture so that you can reconnect the round ligament to the anterior pubocervical ring to reconstruct the vaginal apex. For safekeeping, clamp the needle out of the way and tuck it beneath the drape.

Switching to the other side, use a Lahey clamp to flip the uterus, then clamp the pedicle and use the vessel sealer to separate it, again protecting the tissue beneath and ahead of the clamp. Sometimes, with an especially thick pedicle, the vessel sealer will signal that the tissue hasn’t been completely sealed. In that case, get another purchase of the pedicle, protect the adjacent tissue, and seal again.

Once the uterus has been removed completely, suture the utero-ovarian and round ligament on this side.
One tip to aid in the placement of suture is to move your clamped tissue in such a way as to prevent inadvertent suturing of other tissue (FIGURE 9).

An additional strategy for pain relief at this point is to infiltrate the round ligaments with local anesthetic. We know that we’re working with higher-level fibers—T10 to T12—through the round ligaments. By infiltrating them with anesthetic, you achieve denser pain relief for post- 
operative management.

Uterine reduction strategies facilitate vaginal removal of tissue

When the uterus is too large to remove intact through the vagina, there are a number of techniques for coring, wedging, and morcellating the tissue. As always, a complete knowledge of anatomy is essential, as well as an understanding that fibroids can frequently distort the uterus, twisting it to the left or right. It is important to anticipate such distortion to avoid the inadvertent destruction of anatomic landmarks or damage to the adnexae.

One straight-forward strategy is to debulk the uterus using a knife to core it, removing the central portion. In cases in which you need to keep the entire endometrial cavity intact, you can core the central portion of the uterus while grasping the cervix so that you can remove the endometrium intact for the pathologist (FIGURE).

For this strategy it is important to protect the vaginal sidewalls with metal. You can use another retractor to do that, pulling down on the cervix and beginning the morcellation. I generally prefer to use a short knife handle only because I want to be sure I’m not tempted to cut any higher than I can see.

For more on coring and wedging techniques, see the introductory video for the ACOG/SGS/AAGL master class on vaginal hysterectomy at http://www.aagl.org/vaghystwebinar.

Close the vaginal cuff

The reconstruction of the vaginal cuff is a critical component of any hysterectomy. My approach is to reattach the uterosacral ligaments to the posterior cuff and the round ligaments to the anterior cuff, thereby re- 
creating an intact pubocervical ring. It is not necessary to include the peritoneum in the cuff closure. In fact, kinking of the ureters is more likely when the peritoneum is closed.

Attach one uterosacral ligament, then place a running, full-thickness stitch across the posterior cuff, and attach the uterosacral ligament on the opposite side. Use the needle you left attached to the round ligament to bring the right pedicle to the anterior cuff at 10 o’clock (be sure you grasp the full thickness of the vaginal epithelium without compromising the bladder). Attach the left round-ligament pedicle at the 2 o’clock position. Then close the cuff side to side down to the uterosacral ligaments. This completely reconstructs the pubocervical ring and provides excellent support at the apex.

Share your thoughts on this article! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

In the United States, gynecologic surgeons remove approximately one uterus every minute of the year.¹ That rate translates to more than 525,000 hysterectomies annually in this country alone. Yet, despite the widespread availability of information on the benefits of a vaginal approach to hysterectomy, the great majority of these operations—close to 50%—are still performed via an open abdominal approach.²

As I pointed out last month in my “Update on Vaginal Hysterectomy,” the vaginal approach not only is more cosmetically pleasing than laparoscopic and robot-assisted hysterectomy (not to mention open abdominal surgery) but also has a lower complication rate.³

As I also noted, one reason for the low rate of vaginal hysterectomy may be the assumption, on the part of many gynecologic surgeons, that the techniques and tools they learned to use during training are still the only options available today. That assumption is wrong.

In this article, I describe the technique 
for vaginal hysterectomy using basic instru
mentation. This article is based on a master 
class in vaginal hysterectomy produced by 
the AAGL and co-sponsored by the Am
erican College of Obstetricians and Gynecologists and the Society of Gynecologic 
Surgeons. This master class offers continuing
 medical education credits and is avail
able at http://www.aagl.org/vaghystwebinar.

For a look at innovative tools for this procedure, see my “Update on Vaginal 
Hysterectomy” in the September 2015 issue of this journal at obgmanagement.com.

Vaginal hysterectomy has 
few contraindications

Many commonly cited contraindications to the vaginal approach are not, in fact, absolute contraindications. An open or laparoscopic approach is preferred when the patient has a known cancer, of course, and when deep infiltrating endometriosis is present at the rectovaginal septum. However, previous pelvic surgery, nulliparity, an enlarged uterus, or lack of a prior vaginal delivery need not exclude the vaginal approach. Nor does a narrow introitus necessarily mandate a laparoscopic or open abdominal approach. In fact, in this article, I describe my basic technique in a patient (a cadaver) with a very narrow pubic arch, and I offer strategies for gaining some needed mobility and avoiding complications (TABLES 1 and 2).

Next month, in the November issue of OBG Management, John B. Gebhart, MD, will describe his vaginal technique for right salpingectomy with ovarian preservation, as well as his technique for right salpingo-oophorectomy.

Proper patient positioning 
is key

You can simplify the operation by positioning the patient so that her buttocks are over the edge of the table fairly far—at least 1 inch beyond the edge of the table for optimal exposure and greater access. If the patient is thin, it then becomes important to pad the sacrum because, when she is positioned that far off the table, all her weight comes to rest on the sacrum. In overweight patients, this is not an issue, but for thin patients, I place a bit of egg crate or gel beneath the sacrum.

For the procedure, I prefer to place my instruments on a tray that is kept on my lap. This arrangement frees the scrub technician from having to hand tools over my shoulder—and it saves time. I use a narrow, covered Mayo stand, and I place a stepstool beneath my feet to keep my knees at right angles so that things don’t slip during the operation.

Surgical technique

Choose an appropriate retractor

In a woman with a narrow introitus, I find that a posterior weighted speculum takes up too much space. Once I place a clamp on the cervix with that speculum in place, I don’t have much room to work. However, if I substitute a small Deaver retractor, which is narrower, I gain more workspace.

Inject the uterosacral ligaments

Grasp the cervix using a Jacobs vulsellum tenaculum. Use of a single tenaculum allows for much more movement than the use of instruments placed anteriorly and posteriorly. The Jacobs tenaculum obtains a better purchase on the tissue than a single tooth and is considerably less likely to tear through the tissue.

Before beginning the hysterectomy, locate the uterosacral ligaments and inject each one at its junction with the cervix, aspirating slightly before infiltrating the ligament with 0.25% to 0.50% bupivacaine with epinephrine, with dilute vasopressin mixed in. (I place 1 unit in 20 mL of the local solution.) Injection of this solution achieves 2 goals:

• improved intraoperative hemostasis
• postoperative pain relief.

Use a short needle with a needle extender attached to a control syringe rather than a spinal needle for greater control.

Enter the posterior peritoneal cavity

Before entering the peritoneal cavity, create a right angle with the Jacobs tenaculum and Deaver retractor in relation to the surgical field (FIGURE 1). This right angle is difficult to achieve when you are using a weighted speculum in a tight vagina. Once you have a right angle, tent the vaginal tissue in the midline (FIGURE 2).

In a nulliparous patient or a woman with a tight pelvis, you may discover that the peritoneum is pulled up between the uterosacral ligaments. One common pitfall arises when the surgeon, having dissected the vaginal epithelium, continues cutting into the vaginal epithelium instead of reaching into the peritoneal cavity. Palpate the tissue to ensure that there is no bowel in the way and stay at right angles while confidently grasping the peritoneum with a toothed forceps.

I like to use a bit of electrosurgery to incise the vaginal wall. I don’t begin at the cervix but incise more distally into the vaginal epithelium approximately 2 cm from the cervicovaginal junction. This strategy prevents dissection into the cervix and/or rectovaginal septum rather than the posterior 
cul-de-sac (FIGURE 3).

Once the incision is made, it is possible to feel the posterior peritoneum. And as you tent the peritoneum, you can then very confidently extend the incision and enter the cavity posteriorly.

In a patient with significant adhesions such as this one, I feel around posteriorly to determine exactly where I am. One tactic I use is to release the tenaculum and regrasp the cervix with it. This allows for improved visualization and movement of the cervix as the procedure progresses. Depending on the case, it may be necessary to insert a sponge to hold bowel out of the way.

Avoid the bladder

Move the Deaver retractor to the anterior position, switch the Jacobs clamp to the anterior cervix, and pull straight down. Now that you have incised the vaginal epithelium posteriorly, the length of the cervix should be apparent to you, and you can easily determine the location of the bladder reflection.

Keep in mind that, in a postmenopausal patient, there will be fewer vaginal rugae to guide you. Place the Jacobs tenaculum as close to the midline as possible so that you can confidently grab the tissue without fear of grabbing the bladder. If you tilt the Jacobs clamp, you can feel the edge of the bladder reflection. Remember that postmenopausal patients with prolapse (or, occasionally, obese patients with cervical elongation but little actual descensus) may have altered anatomy.

You can create a bit more space in which to dissect by injecting the bupivacaine/ 
epinephrine solution into the vaginal epithelium. This technique also ensures that the vaginal epithelial incisions won’t bleed.

Now, tilt the Jacobs tenaculum downward and push the junction of the cervix with the bladder reflection toward you so that you have a good sense of how deeply to incise.

Once you’ve made the incision, reclamp the Jacobs tenaculum so that it holds all of that tissue, and repeat the maneuver, tilting the clamp downward and pushing the junction toward you. In this way, you create traction and countertraction, sweeping the tissue out of your way.

Always use sharp dissection. When adhesions are present, surgeons often get into trouble using blunt dissection and may inadvertently enter the bladder if they use a sponge-covered digit for dissection, because adhesions can be much denser than normal tissue. In such cases, the bladder tears open rather than the adhesions being swept away.

Consider this: You don’t need to enter the peritoneal cavity anteriorly in order to continue working on the procedure. You can safely protect the bladder throughout the case, until the very end, if necessary, in patients who have undergone multiple previous surgeries or cesarean deliveries.

Rather than enter the anterior peritoneum, I dissect as much of the vaginal epithelium as possible and place a second Deaver retractor posteriorly.

I massage the uterosacral ligament for about 10 seconds to lengthen it and create more descensus, then place a Ballantine Heaney clamp on the ligament.

Next, I cut the pedicle and suture it, maintaining a clamp on the uterosacral ligament suture so that I can use it later for repair of the vaginal cuff.

I recommend a vessel-sealing device to secure the major blood supply, but I do suture the uterosacral and round ligaments for attachment to the apex at the conclusion of the hysterectomy. I suggest that you place straight clamps to hold the uterosacral ligament sutures and curved clamps on the round ligament ties to help you keep track of what you’re doing.

I generally prefer to use a smaller vessel-sealing device, such as the LigaSure Max (Covidien), because it allows me to take very small bites of tissue. It is also less expensive because it uses a disposable electrode within a reusable Heaney-type clamp.

Many people have argued that we need to teach surgeons to suture vaginally and, for that reason, should avoid vessel sealing. My response: Why wouldn’t we want to use the very best technology available? Randomized trials have demonstrated a 50% reduction in pain relief postoperatively when we use vessel sealing.⁴ Less foreign material is left in the pelvis, lowering the risk of infection. And it really doesn’t matter which vessel-sealing technology you use, as long as you’re familiar with the specifics of the system you choose. Another advantage: There is no need to pass needles back and forth.

Take small bites of tissue

Because this patient has a very small uterus, a small bite of tissue will get you close to where you want to be. When you take a bite with the vessel sealer, try to protect the vaginal epithelium and vulva from the steam that is emitted. The clamp itself does not heat up, but the steam that is released from the tissue is 100° C, so place a finger between the clamp and the sidewall for protection. It is preferable to burn your own finger than to burn the patient.

Because you haven’t entered the peritoneal cavity anteriorly, it is important to ensure that you don’t take too big of a bite with the vessel sealer. Rather, stay where you know you’ve done your dissection, where things are safe.

One cardinal principle of surgery is that you shouldn’t operate where you can’t feel or see. One of the common errors in vaginal surgery is that surgeons start dissecting higher than they can see. It’s easy to get into trouble when you start pushing tissue or dissecting tissue that you can’t visualize.

At this point, the anterior Deaver retractor is not essential, so I remove it. If you don’t need it, don’t use it. I try to avoid metal when I can.

If I were using suture rather than vessel sealing, I would place a Heaney clamp on the uterosacral ligament and cut. Using a clamp-cut-tie technique, I would pull on the pedicle and cut just beyond the tip of the clamp to ensure that the suture will be secure 
(FIGURE 4). This approach would not be appropriate during use of a vessel sealer. In that case, you would want to cut to but not beyond the tip of the clamp.

One of the skills helpful in suturing is learning to move your elbow and wrist to achieve the proper angle. Determine where you want the suture to exit the tissue, and then angle your elbow and wrist so that the suture comes out where you want it. It’s easy to lose track of the needle tip, especially when you’re working in a limited space under the pubic symphysis, so use your shoulder, elbow, and wrist to control 
suture placement.

Protect the anterior epithelium

Because you have not yet entered the peritoneal cavity anteriorly, it is important to protect the anterior epithelium and bladder. Reinsert a narrow Deaver retractor anteriorly, remove the Jacobs clamp, and replace the clamp laterally so that the cervix can be pulled off to the side (FIGURE 5).

One nice thing about some vessel sealers is that the surgeon can twist them in any direction. It isn’t necessary to move your hand; you simply move the device itself.

Once you have taken at least the descending branch of the uterine artery, remove the posterior retractor and pull downward on the Jacobs tenaculum. You should have reached just about to the level of the uterine fundus, with the anatomy well visualized (FIGURE 6). Next, open the anterior peritoneum.

Pay attention to the surgical field

Now that you have entered the peritoneum anteriorly as well as posteriorly, identify the broad ligament, keeping in mind that the ureter is retroperitoneal, not intraperitoneal. If you were to place a clamp from the posterior leaf of the broad ligament across to the anterior leaf of the broad ligament, you would be grasping all the vessels but not the ureter. In fact, the anterior Deaver retractor is lifting both ureters up and out of the way. If you pull the cervix off to the opposite side, you create an additional couple of centimeters—a safe space for the vessel sealer 
(FIGURE 7).

In placing the vessel sealer, there is no need to move out laterally, as there is no need for space to place suture. Instead, hug the uterus. At this point, the main concern is the risk of damaging any small bowel behind the uterine fundus that might be coming down into the surgical field, obscured from vision. And because there may be steam emitted at the tip of the vessel-sealing clamp, keep a finger back there to protect anything that might be in the field.

Last steps

Before taking the last bite of tissue on the right-hand side, place the round ligament in a Heaney clamp. Now that the round and utero-ovarian ligaments have been skeletonized, you can grasp the pedicle in a clamp. If the pedicle is especially thick, it may be beneficial to close the clamp, leave it on for a few seconds, and then reapply it. In that way, you obtain a better purchase.

Next, free the rest of the tissue with a vessel sealer, or cut it. I prefer to use a vessel sealer, and I again protect the adjacent tissue with my fingers anteriorly and posteriorly.

With the clamp remaining on the round ligament and utero-ovarian ligament 
(FIGURE 8), which will be sutured, push the uterine tissue out of the way, back into the pelvis, to make room for suturing.

Because a postmenopausal vulva may be cut by the suture, it’s important to take pains not to abrade that tissue. Once you have finished suturing the round/utero-ovarian pedicle, leave the needle on the suture so that you can reconnect the round ligament to the anterior pubocervical ring to reconstruct the vaginal apex. For safekeeping, clamp the needle out of the way and tuck it beneath the drape.

Switching to the other side, use a Lahey clamp to flip the uterus, then clamp the pedicle and use the vessel sealer to separate it, again protecting the tissue beneath and ahead of the clamp. Sometimes, with an especially thick pedicle, the vessel sealer will signal that the tissue hasn’t been completely sealed. In that case, get another purchase of the pedicle, protect the adjacent tissue, and seal again.

Once the uterus has been removed completely, suture the utero-ovarian and round ligament on this side.
One tip to aid in the placement of suture is to move your clamped tissue in such a way as to prevent inadvertent suturing of other tissue (FIGURE 9).

An additional strategy for pain relief at this point is to infiltrate the round ligaments with local anesthetic. We know that we’re working with higher-level fibers—T10 to T12—through the round ligaments. By infiltrating them with anesthetic, you achieve denser pain relief for post- 
operative management.

Uterine reduction strategies facilitate vaginal removal of tissue

When the uterus is too large to remove intact through the vagina, there are a number of techniques for coring, wedging, and morcellating the tissue. As always, a complete knowledge of anatomy is essential, as well as an understanding that fibroids can frequently distort the uterus, twisting it to the left or right. It is important to anticipate such distortion to avoid the inadvertent destruction of anatomic landmarks or damage to the adnexae.

One straight-forward strategy is to debulk the uterus using a knife to core it, removing the central portion. In cases in which you need to keep the entire endometrial cavity intact, you can core the central portion of the uterus while grasping the cervix so that you can remove the endometrium intact for the pathologist (FIGURE).

For this strategy it is important to protect the vaginal sidewalls with metal. You can use another retractor to do that, pulling down on the cervix and beginning the morcellation. I generally prefer to use a short knife handle only because I want to be sure I’m not tempted to cut any higher than I can see.

For more on coring and wedging techniques, see the introductory video for the ACOG/SGS/AAGL master class on vaginal hysterectomy at http://www.aagl.org/vaghystwebinar.

Close the vaginal cuff

The reconstruction of the vaginal cuff is a critical component of any hysterectomy. My approach is to reattach the uterosacral ligaments to the posterior cuff and the round ligaments to the anterior cuff, thereby re- 
creating an intact pubocervical ring. It is not necessary to include the peritoneum in the cuff closure. In fact, kinking of the ureters is more likely when the peritoneum is closed.

Attach one uterosacral ligament, then place a running, full-thickness stitch across the posterior cuff, and attach the uterosacral ligament on the opposite side. Use the needle you left attached to the round ligament to bring the right pedicle to the anterior cuff at 10 o’clock (be sure you grasp the full thickness of the vaginal epithelium without compromising the bladder). Attach the left round-ligament pedicle at the 2 o’clock position. Then close the cuff side to side down to the uterosacral ligaments. This completely reconstructs the pubocervical ring and provides excellent support at the apex.

Share your thoughts on this article! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Clinicians work to maximize the quality of life and longevity of every patient. For women with moderate to severe menopausal symptoms, oral estrogen therapy can improve quality of life, but at the cost of significant adverse effects. The Women’s Health Initiative
 (WHI) reported that for postmenopausal women with a uterus, 
conjugated estrogen plus medroxyprogesterone acetate (CEE+MPA) hormone therapy (HT) versus placebo 
significantly increased the risk of 
cardiovascular events (relative risk 
[RR], 1.13), breast cancer (RR, 1.24), 
stroke (RR, 1.37), deep vein thrombosis (RR, 1.87), and pulmonary 
embolism (RR, 1.98).¹ In postmeno
pausal women without a uterus, CEE 
HT did not increase the risk of breast 
cancer (RR, 0.79), compared with 
placebo, but it did significantly in
crease the risk of cardiovascular 
events (RR, 1.11), stroke (RR, 1.35), 
deep vein thrombosis (RR, 1.48), and 
pulmonary embolism (RR, 1.35).¹

Clinicians prescribing estrogen must individualize therapy according
 to its benefits and risks. An important issue that has received insufficient at
tention is, “What is the effect of HT 
on mortality in recently menopausal women?” Here, I examine this issue.

HT reduces mortality in 
recently menopausal women

Pooling the results of the WHI CEE+MPA and CEE-only trials 
reveals that there were 70 deaths in the HT-treated groups and 98 deaths in the placebo groups among women aged 50 to 59 years.¹ With 4,706 and 4,259 women alive at the conclusion of the study in the HT and placebo groups, respectively, the women in the placebo group had significantly more deaths than the women in the HT-treated groups (Fisher exact test, P = .0194, χ² test with Yates correction, P = .0226).

Using pooled data from the WHI, the RR of death in the HT versus placebo group was estimated at 0.70 (95% confidence interval [CI], 0.51−0.96), representing approximately 5 fewer deaths per 
1,000 women per 5 years of therapy.² In women aged 60 to 69 years and 70 to 79 years there were no significant differences in death rates between the HT- and placebo-treated women.

My interpretation of these results is that HT likely is associated with a reduced risk of death in recently menopausal women, but not in 
women distant from menopause onset.

Cochrane review of 
HT and mortality

Consistent with the WHI findings, authors of a recent Cochrane 
meta-analysis of 19 randomized trials including 40,410 menopausal women reported that HT significantly increased the risk of stroke (RR, 1.24; 95% CI, 1.10−1.41), venous thromboembolism (RR, 1.92; 95% CI, 1.36−2.69), and pulmonary emboli (RR, 1.81; 95% CI, 1.32−2.48).³ However, among women treated with oral HT within 10 years after the start of menopause, there was a reduced risk of coronary heart disease (RR, 0.52; 95% CI, 0.29−0.96). Using data from 5 clinical trials, the Cochrane meta-analysis researchers reported that, compared with placebo, HT reduced mortality (RR, 0.70; 95% CI, 0.52−0.95).³

Results of the Cochrane meta-analysis are consistent with those of a previous meta-analysis of 
19 randomized trials involving 16,000 women. In this analysis, investigators found a reduced risk of death in recently menopausal women treated with hormone therapy (RR, 0.73; 95% CI, 0.52−0.96).⁴

Early menopause, 
HT, and mortality

Authors of multiple large epidemiologic studies have reported that early menopause is associated with an increased risk of death if HT is not initiated.⁵⁻⁷ For example, results of a study of women in Olmsted County, Minnesota, conducted from 1950 to 1987, indicated that, for women younger than age 45 years who underwent bilateral oophorectomy, the risk of death was increased among those who did not initiate HT, compared with women who did not undergo oophorectomy (hazard ratio [HR], 1.84; 95% CI, 1.27−2.68; 
P = .001).⁷

By contrast, women younger than 45 years who underwent bilateral oophorectomy and initiated estrogen therapy did not have an increased risk of death compared with women who did not undergo oophorectomy (HR, 0.65; 95% CI, 0.30−1.41; P = .28).⁷ An excess number of cardiovascular events appeared to account for the increased mortality among women with early surgical menopause who did not initiate HT.

The “timing hypothesis” proposes that the initiation of HT soon after the onset of menopause is associated with beneficial cardiovascular effects, but initiation more than 10 years after the onset of menopause is not associated with beneficial cardiovascular effects. The timing hypothesis is supported by the finding that, in recently menopausal women, HT is associated with reduced carotid intima-media thickness (CIMT), compared with placebo.⁸ Greater CIMT thickness is associated with an increased risk of cardiovascular events.

In my experience, few primary care clinicians are aware of these data. Often, these clinicians over-emphasize the risks and withhold HT in this vulnerable group of women.

HT: Minimizing the risks 
of stroke, deep vein thrombosis, pulmonary embolism, and 
breast cancer

Results of multiple studies have shown that certain HT regimens increase the risk of stroke, deep vein thrombosis, pulmonary embolism, and breast cancer. Is it possible to prescribe HT in a way that reduces these risks?

Results of observational studies indicate that, compared with oral estrogen therapy, transdermal HT is associated with a lower risk of stroke, deep vein thrombosis, pulmonary embolism, and breast cancer 
(TABLE).⁹⁻¹⁵

Reducing the risk of stroke caused by HT is an important goal. In a study of 15,710 women who had stroke and 59,958 control women aged 50 to 79 years, transdermal estradiol at a dose of 50 µg or less daily was not associated with an increased risk of stroke, compared with HT nonuse (rate ratio, 0.81; 95% CI, 0.62−1.05).⁹ Compared with HT nonuse, the use of oral estrogen (rate ratio, 1.28; 95% CI, 1.15−1.42) or transdermal estradiol 50 µg or greater daily (rate ratio, 1.89; 95% CI, 1.15−3.11) was associated with an increased risk of stroke.⁹

Reducing the risks of deep venous thromboembolism (VTE) and pulmonary embolism caused by HT is an important goal. In a meta-analysis of the risk of VTE with HT, compared with nonusers, oral estrogen therapy was associated with a significantly increased risk of VTE (odds ratio [OR], 2.5; 95% CI, 1.9−3.4). Compared with nonuse, transdermal estrogen therapy was not associated with an increased risk of VTE (OR, 1.2; 95% CI, 0.9−1.7).¹¹ In a study comparing oral versus transdermal estradiol, transdermal estradiol was associated with a reduced risk of pulmonary embolism (0.46 [95% CI, 0.22−0.97]).¹³

Reducing the risk of breast cancer caused by HT is an important goal. Results of one study showed that the combination of oral estrogen plus synthetic progestin was associated with an increased risk of breast cancer, compared with nonuse (RR, 1.5; 95% CI, 1.1−1.9). By contrast, the combination of transdermal estradiol plus micronized progesterone was not associated with an increased risk of breast cancer, compared with nonuse (RR, 0.9; 95% CI, 0.7−1.2).¹⁵

INSTANT POLL
Many health insurers use pharmacy benefit managers to control the cost of prescription medicines. These managers often develop formulary algorithms that favor the use of oral estrogen and medroxyprogesterone acetate over transdermal estradiol and micronized progesterone. When you prescribe transdermal estradiol and micronized progesterone, have your patients had difficulty filling the prescription?

Tell us! Send your Letter to the Editor!

The bottom line

In recently menopausal women with moderate to severe hot flashes, HT improves quality of life and appears to decrease mortality. However, HT with oral estrogen plus synthetic progestin is associated with an increased risk of stroke, deep vein thrombosis, pulmonary embolism, and breast cancer. Compared with oral estrogen, transdermal estradiol treatment is associated with a lower risk of stroke, deep vein thrombosis, and pulmonary embolism. Compared with oral estrogen plus a synthetic progestin, transdermal estradiol plus micronized progesterone is associated with a lower risk of breast cancer. The benefits of HT are likely maximized by initiating therapy in the perimenopause transition or early in the postmenopause, and the risks are minimized by using transdermal estradiol.¹⁶⁻¹⁸

Share your thoughts on this article! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Clinicians work to maximize the quality of life and longevity of every patient. For women with moderate to severe menopausal symptoms, oral estrogen therapy can improve quality of life, but at the cost of significant adverse effects. The Women’s Health Initiative
 (WHI) reported that for postmenopausal women with a uterus, 
conjugated estrogen plus medroxyprogesterone acetate (CEE+MPA) hormone therapy (HT) versus placebo 
significantly increased the risk of 
cardiovascular events (relative risk 
[RR], 1.13), breast cancer (RR, 1.24), 
stroke (RR, 1.37), deep vein thrombosis (RR, 1.87), and pulmonary 
embolism (RR, 1.98).¹ In postmeno
pausal women without a uterus, CEE 
HT did not increase the risk of breast 
cancer (RR, 0.79), compared with 
placebo, but it did significantly in
crease the risk of cardiovascular 
events (RR, 1.11), stroke (RR, 1.35), 
deep vein thrombosis (RR, 1.48), and 
pulmonary embolism (RR, 1.35).¹

Clinicians prescribing estrogen must individualize therapy according
 to its benefits and risks. An important issue that has received insufficient at
tention is, “What is the effect of HT 
on mortality in recently menopausal women?” Here, I examine this issue.

HT reduces mortality in 
recently menopausal women

Pooling the results of the WHI CEE+MPA and CEE-only trials 
reveals that there were 70 deaths in the HT-treated groups and 98 deaths in the placebo groups among women aged 50 to 59 years.¹ With 4,706 and 4,259 women alive at the conclusion of the study in the HT and placebo groups, respectively, the women in the placebo group had significantly more deaths than the women in the HT-treated groups (Fisher exact test, P = .0194, χ² test with Yates correction, P = .0226).

Using pooled data from the WHI, the RR of death in the HT versus placebo group was estimated at 0.70 (95% confidence interval [CI], 0.51−0.96), representing approximately 5 fewer deaths per 
1,000 women per 5 years of therapy.² In women aged 60 to 69 years and 70 to 79 years there were no significant differences in death rates between the HT- and placebo-treated women.

My interpretation of these results is that HT likely is associated with a reduced risk of death in recently menopausal women, but not in 
women distant from menopause onset.

Cochrane review of 
HT and mortality

Consistent with the WHI findings, authors of a recent Cochrane 
meta-analysis of 19 randomized trials including 40,410 menopausal women reported that HT significantly increased the risk of stroke (RR, 1.24; 95% CI, 1.10−1.41), venous thromboembolism (RR, 1.92; 95% CI, 1.36−2.69), and pulmonary emboli (RR, 1.81; 95% CI, 1.32−2.48).³ However, among women treated with oral HT within 10 years after the start of menopause, there was a reduced risk of coronary heart disease (RR, 0.52; 95% CI, 0.29−0.96). Using data from 5 clinical trials, the Cochrane meta-analysis researchers reported that, compared with placebo, HT reduced mortality (RR, 0.70; 95% CI, 0.52−0.95).³

Results of the Cochrane meta-analysis are consistent with those of a previous meta-analysis of 
19 randomized trials involving 16,000 women. In this analysis, investigators found a reduced risk of death in recently menopausal women treated with hormone therapy (RR, 0.73; 95% CI, 0.52−0.96).⁴

Early menopause, 
HT, and mortality

Authors of multiple large epidemiologic studies have reported that early menopause is associated with an increased risk of death if HT is not initiated.⁵⁻⁷ For example, results of a study of women in Olmsted County, Minnesota, conducted from 1950 to 1987, indicated that, for women younger than age 45 years who underwent bilateral oophorectomy, the risk of death was increased among those who did not initiate HT, compared with women who did not undergo oophorectomy (hazard ratio [HR], 1.84; 95% CI, 1.27−2.68; 
P = .001).⁷

By contrast, women younger than 45 years who underwent bilateral oophorectomy and initiated estrogen therapy did not have an increased risk of death compared with women who did not undergo oophorectomy (HR, 0.65; 95% CI, 0.30−1.41; P = .28).⁷ An excess number of cardiovascular events appeared to account for the increased mortality among women with early surgical menopause who did not initiate HT.

The “timing hypothesis” proposes that the initiation of HT soon after the onset of menopause is associated with beneficial cardiovascular effects, but initiation more than 10 years after the onset of menopause is not associated with beneficial cardiovascular effects. The timing hypothesis is supported by the finding that, in recently menopausal women, HT is associated with reduced carotid intima-media thickness (CIMT), compared with placebo.⁸ Greater CIMT thickness is associated with an increased risk of cardiovascular events.

In my experience, few primary care clinicians are aware of these data. Often, these clinicians over-emphasize the risks and withhold HT in this vulnerable group of women.

HT: Minimizing the risks 
of stroke, deep vein thrombosis, pulmonary embolism, and 
breast cancer

Results of multiple studies have shown that certain HT regimens increase the risk of stroke, deep vein thrombosis, pulmonary embolism, and breast cancer. Is it possible to prescribe HT in a way that reduces these risks?

Results of observational studies indicate that, compared with oral estrogen therapy, transdermal HT is associated with a lower risk of stroke, deep vein thrombosis, pulmonary embolism, and breast cancer 
(TABLE).⁹⁻¹⁵

Reducing the risk of stroke caused by HT is an important goal. In a study of 15,710 women who had stroke and 59,958 control women aged 50 to 79 years, transdermal estradiol at a dose of 50 µg or less daily was not associated with an increased risk of stroke, compared with HT nonuse (rate ratio, 0.81; 95% CI, 0.62−1.05).⁹ Compared with HT nonuse, the use of oral estrogen (rate ratio, 1.28; 95% CI, 1.15−1.42) or transdermal estradiol 50 µg or greater daily (rate ratio, 1.89; 95% CI, 1.15−3.11) was associated with an increased risk of stroke.⁹

Reducing the risks of deep venous thromboembolism (VTE) and pulmonary embolism caused by HT is an important goal. In a meta-analysis of the risk of VTE with HT, compared with nonusers, oral estrogen therapy was associated with a significantly increased risk of VTE (odds ratio [OR], 2.5; 95% CI, 1.9−3.4). Compared with nonuse, transdermal estrogen therapy was not associated with an increased risk of VTE (OR, 1.2; 95% CI, 0.9−1.7).¹¹ In a study comparing oral versus transdermal estradiol, transdermal estradiol was associated with a reduced risk of pulmonary embolism (0.46 [95% CI, 0.22−0.97]).¹³

Reducing the risk of breast cancer caused by HT is an important goal. Results of one study showed that the combination of oral estrogen plus synthetic progestin was associated with an increased risk of breast cancer, compared with nonuse (RR, 1.5; 95% CI, 1.1−1.9). By contrast, the combination of transdermal estradiol plus micronized progesterone was not associated with an increased risk of breast cancer, compared with nonuse (RR, 0.9; 95% CI, 0.7−1.2).¹⁵

INSTANT POLL
Many health insurers use pharmacy benefit managers to control the cost of prescription medicines. These managers often develop formulary algorithms that favor the use of oral estrogen and medroxyprogesterone acetate over transdermal estradiol and micronized progesterone. When you prescribe transdermal estradiol and micronized progesterone, have your patients had difficulty filling the prescription?

Tell us! Send your Letter to the Editor!

The bottom line

In recently menopausal women with moderate to severe hot flashes, HT improves quality of life and appears to decrease mortality. However, HT with oral estrogen plus synthetic progestin is associated with an increased risk of stroke, deep vein thrombosis, pulmonary embolism, and breast cancer. Compared with oral estrogen, transdermal estradiol treatment is associated with a lower risk of stroke, deep vein thrombosis, and pulmonary embolism. Compared with oral estrogen plus a synthetic progestin, transdermal estradiol plus micronized progesterone is associated with a lower risk of breast cancer. The benefits of HT are likely maximized by initiating therapy in the perimenopause transition or early in the postmenopause, and the risks are minimized by using transdermal estradiol.¹⁶⁻¹⁸

Share your thoughts on this article! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Clinicians work to maximize the quality of life and longevity of every patient. For women with moderate to severe menopausal symptoms, oral estrogen therapy can improve quality of life, but at the cost of significant adverse effects. The Women’s Health Initiative
 (WHI) reported that for postmenopausal women with a uterus, 
conjugated estrogen plus medroxyprogesterone acetate (CEE+MPA) hormone therapy (HT) versus placebo 
significantly increased the risk of 
cardiovascular events (relative risk 
[RR], 1.13), breast cancer (RR, 1.24), 
stroke (RR, 1.37), deep vein thrombosis (RR, 1.87), and pulmonary 
embolism (RR, 1.98).¹ In postmeno
pausal women without a uterus, CEE 
HT did not increase the risk of breast 
cancer (RR, 0.79), compared with 
placebo, but it did significantly in
crease the risk of cardiovascular 
events (RR, 1.11), stroke (RR, 1.35), 
deep vein thrombosis (RR, 1.48), and 
pulmonary embolism (RR, 1.35).¹

Clinicians prescribing estrogen must individualize therapy according
 to its benefits and risks. An important issue that has received insufficient at
tention is, “What is the effect of HT 
on mortality in recently menopausal women?” Here, I examine this issue.

HT reduces mortality in 
recently menopausal women

Pooling the results of the WHI CEE+MPA and CEE-only trials 
reveals that there were 70 deaths in the HT-treated groups and 98 deaths in the placebo groups among women aged 50 to 59 years.¹ With 4,706 and 4,259 women alive at the conclusion of the study in the HT and placebo groups, respectively, the women in the placebo group had significantly more deaths than the women in the HT-treated groups (Fisher exact test, P = .0194, χ² test with Yates correction, P = .0226).

Using pooled data from the WHI, the RR of death in the HT versus placebo group was estimated at 0.70 (95% confidence interval [CI], 0.51−0.96), representing approximately 5 fewer deaths per 
1,000 women per 5 years of therapy.² In women aged 60 to 69 years and 70 to 79 years there were no significant differences in death rates between the HT- and placebo-treated women.

My interpretation of these results is that HT likely is associated with a reduced risk of death in recently menopausal women, but not in 
women distant from menopause onset.

Cochrane review of 
HT and mortality

Consistent with the WHI findings, authors of a recent Cochrane 
meta-analysis of 19 randomized trials including 40,410 menopausal women reported that HT significantly increased the risk of stroke (RR, 1.24; 95% CI, 1.10−1.41), venous thromboembolism (RR, 1.92; 95% CI, 1.36−2.69), and pulmonary emboli (RR, 1.81; 95% CI, 1.32−2.48).³ However, among women treated with oral HT within 10 years after the start of menopause, there was a reduced risk of coronary heart disease (RR, 0.52; 95% CI, 0.29−0.96). Using data from 5 clinical trials, the Cochrane meta-analysis researchers reported that, compared with placebo, HT reduced mortality (RR, 0.70; 95% CI, 0.52−0.95).³

Results of the Cochrane meta-analysis are consistent with those of a previous meta-analysis of 
19 randomized trials involving 16,000 women. In this analysis, investigators found a reduced risk of death in recently menopausal women treated with hormone therapy (RR, 0.73; 95% CI, 0.52−0.96).⁴

Early menopause, 
HT, and mortality

Authors of multiple large epidemiologic studies have reported that early menopause is associated with an increased risk of death if HT is not initiated.⁵⁻⁷ For example, results of a study of women in Olmsted County, Minnesota, conducted from 1950 to 1987, indicated that, for women younger than age 45 years who underwent bilateral oophorectomy, the risk of death was increased among those who did not initiate HT, compared with women who did not undergo oophorectomy (hazard ratio [HR], 1.84; 95% CI, 1.27−2.68; 
P = .001).⁷

By contrast, women younger than 45 years who underwent bilateral oophorectomy and initiated estrogen therapy did not have an increased risk of death compared with women who did not undergo oophorectomy (HR, 0.65; 95% CI, 0.30−1.41; P = .28).⁷ An excess number of cardiovascular events appeared to account for the increased mortality among women with early surgical menopause who did not initiate HT.

The “timing hypothesis” proposes that the initiation of HT soon after the onset of menopause is associated with beneficial cardiovascular effects, but initiation more than 10 years after the onset of menopause is not associated with beneficial cardiovascular effects. The timing hypothesis is supported by the finding that, in recently menopausal women, HT is associated with reduced carotid intima-media thickness (CIMT), compared with placebo.⁸ Greater CIMT thickness is associated with an increased risk of cardiovascular events.

In my experience, few primary care clinicians are aware of these data. Often, these clinicians over-emphasize the risks and withhold HT in this vulnerable group of women.

HT: Minimizing the risks 
of stroke, deep vein thrombosis, pulmonary embolism, and 
breast cancer

Results of multiple studies have shown that certain HT regimens increase the risk of stroke, deep vein thrombosis, pulmonary embolism, and breast cancer. Is it possible to prescribe HT in a way that reduces these risks?

Results of observational studies indicate that, compared with oral estrogen therapy, transdermal HT is associated with a lower risk of stroke, deep vein thrombosis, pulmonary embolism, and breast cancer 
(TABLE).⁹⁻¹⁵

Reducing the risk of stroke caused by HT is an important goal. In a study of 15,710 women who had stroke and 59,958 control women aged 50 to 79 years, transdermal estradiol at a dose of 50 µg or less daily was not associated with an increased risk of stroke, compared with HT nonuse (rate ratio, 0.81; 95% CI, 0.62−1.05).⁹ Compared with HT nonuse, the use of oral estrogen (rate ratio, 1.28; 95% CI, 1.15−1.42) or transdermal estradiol 50 µg or greater daily (rate ratio, 1.89; 95% CI, 1.15−3.11) was associated with an increased risk of stroke.⁹

Reducing the risks of deep venous thromboembolism (VTE) and pulmonary embolism caused by HT is an important goal. In a meta-analysis of the risk of VTE with HT, compared with nonusers, oral estrogen therapy was associated with a significantly increased risk of VTE (odds ratio [OR], 2.5; 95% CI, 1.9−3.4). Compared with nonuse, transdermal estrogen therapy was not associated with an increased risk of VTE (OR, 1.2; 95% CI, 0.9−1.7).¹¹ In a study comparing oral versus transdermal estradiol, transdermal estradiol was associated with a reduced risk of pulmonary embolism (0.46 [95% CI, 0.22−0.97]).¹³

Reducing the risk of breast cancer caused by HT is an important goal. Results of one study showed that the combination of oral estrogen plus synthetic progestin was associated with an increased risk of breast cancer, compared with nonuse (RR, 1.5; 95% CI, 1.1−1.9). By contrast, the combination of transdermal estradiol plus micronized progesterone was not associated with an increased risk of breast cancer, compared with nonuse (RR, 0.9; 95% CI, 0.7−1.2).¹⁵

INSTANT POLL
Many health insurers use pharmacy benefit managers to control the cost of prescription medicines. These managers often develop formulary algorithms that favor the use of oral estrogen and medroxyprogesterone acetate over transdermal estradiol and micronized progesterone. When you prescribe transdermal estradiol and micronized progesterone, have your patients had difficulty filling the prescription?

Tell us! Send your Letter to the Editor!

The bottom line

In recently menopausal women with moderate to severe hot flashes, HT improves quality of life and appears to decrease mortality. However, HT with oral estrogen plus synthetic progestin is associated with an increased risk of stroke, deep vein thrombosis, pulmonary embolism, and breast cancer. Compared with oral estrogen, transdermal estradiol treatment is associated with a lower risk of stroke, deep vein thrombosis, and pulmonary embolism. Compared with oral estrogen plus a synthetic progestin, transdermal estradiol plus micronized progesterone is associated with a lower risk of breast cancer. The benefits of HT are likely maximized by initiating therapy in the perimenopause transition or early in the postmenopause, and the risks are minimized by using transdermal estradiol.¹⁶⁻¹⁸

Share your thoughts on this article! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Click here to download the PDF.
Every surgeon knows that, if you operate, complications will follow. Surgeons are perfectionists and strive to reduce complications through years of diligent personal training and continuous quality improvement. Surgeons hate complications, especially those that might be preventable (such as retained foreign bodies, wrong site surgery, and medication errors).

In this special issue of OBG Management, world-renowned experts focus on topical issues in safety in minimally invasive gynecologic surgery (MIGS). In a roundtable, Drs. Neal Lonky, John Gebhart, Rosanne Kho, and Malcolm Munro discuss important issues in MIGS, including the need to prioritize the vaginal and laparoscopic routes of hysterectomy and the role of single-port surgery. In a concise yet detailed discussion of safety issues related to radiofrequency and ultrasound energy devices, Dr. Munro alerts us to the dangers of heat injury and direct and capacitative coupling. Drs. Andrew Sokol and Katelyn Smithling provide guidance on preventing apical prolapse of the vagina following hysterectomy. And Dr. Antonio Gargiulo explores the rapidly expanding role of simulation training with computer-assisted (robotic) surgical simulators and predicts that, instead of learning surgery on patients, future trainees will gain skills in a simulation environment.

We thank the master surgeons who participated in this special issue for providing guidance and helping us to reduce complications. Our patients are the beneficiaries of the wisdom provided herein.

>>Robert L. Barbieri, MD
Editor in Chief, OBG Management

To view the video, "McCall" culdoplasty technique by Mickey Karram, MD, that accompanies the article by Sokol et al in this supplement, click here.

Click here to download the PDF.
Every surgeon knows that, if you operate, complications will follow. Surgeons are perfectionists and strive to reduce complications through years of diligent personal training and continuous quality improvement. Surgeons hate complications, especially those that might be preventable (such as retained foreign bodies, wrong site surgery, and medication errors).

In this special issue of OBG Management, world-renowned experts focus on topical issues in safety in minimally invasive gynecologic surgery (MIGS). In a roundtable, Drs. Neal Lonky, John Gebhart, Rosanne Kho, and Malcolm Munro discuss important issues in MIGS, including the need to prioritize the vaginal and laparoscopic routes of hysterectomy and the role of single-port surgery. In a concise yet detailed discussion of safety issues related to radiofrequency and ultrasound energy devices, Dr. Munro alerts us to the dangers of heat injury and direct and capacitative coupling. Drs. Andrew Sokol and Katelyn Smithling provide guidance on preventing apical prolapse of the vagina following hysterectomy. And Dr. Antonio Gargiulo explores the rapidly expanding role of simulation training with computer-assisted (robotic) surgical simulators and predicts that, instead of learning surgery on patients, future trainees will gain skills in a simulation environment.

We thank the master surgeons who participated in this special issue for providing guidance and helping us to reduce complications. Our patients are the beneficiaries of the wisdom provided herein.

>>Robert L. Barbieri, MD
Editor in Chief, OBG Management

To view the video, "McCall" culdoplasty technique by Mickey Karram, MD, that accompanies the article by Sokol et al in this supplement, click here.

Click here to download the PDF.
Every surgeon knows that, if you operate, complications will follow. Surgeons are perfectionists and strive to reduce complications through years of diligent personal training and continuous quality improvement. Surgeons hate complications, especially those that might be preventable (such as retained foreign bodies, wrong site surgery, and medication errors).

In this special issue of OBG Management, world-renowned experts focus on topical issues in safety in minimally invasive gynecologic surgery (MIGS). In a roundtable, Drs. Neal Lonky, John Gebhart, Rosanne Kho, and Malcolm Munro discuss important issues in MIGS, including the need to prioritize the vaginal and laparoscopic routes of hysterectomy and the role of single-port surgery. In a concise yet detailed discussion of safety issues related to radiofrequency and ultrasound energy devices, Dr. Munro alerts us to the dangers of heat injury and direct and capacitative coupling. Drs. Andrew Sokol and Katelyn Smithling provide guidance on preventing apical prolapse of the vagina following hysterectomy. And Dr. Antonio Gargiulo explores the rapidly expanding role of simulation training with computer-assisted (robotic) surgical simulators and predicts that, instead of learning surgery on patients, future trainees will gain skills in a simulation environment.

We thank the master surgeons who participated in this special issue for providing guidance and helping us to reduce complications. Our patients are the beneficiaries of the wisdom provided herein.

>>Robert L. Barbieri, MD
Editor in Chief, OBG Management

To view the video, "McCall" culdoplasty technique by Mickey Karram, MD, that accompanies the article by Sokol et al in this supplement, click here.

An OBG Management reader recently requested assistance finding an app or Web site that would be helpful for International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10) coding, particularly for practicing ObGyns. It is not surprising that I have received this question, as we already are seeing a ton of smartphone apps that promise to search through the code descriptions quickly. None of these apps are ObGyn-specific but, given the vast amount, deciding which one is the best option to purchase and download can be a challenge.

Purchase considerations

Before you buy, decide what features you are looking for and make sure the app you have chosen can deliver what you need. Pay special attention to any reviews to learn the app’s pros and the cons. For instance, some apps offer code conversion from ICD-9 to ICD-10. Keep in mind, however, that not all conversions are accurate, and your search may just lead you to another unspecified code. Some apps will offer a decision tree, which is ideal. What you would like to avoid is an app that generates a list of 200 codes from a single search term.

A useful resource that I have found is this Buyers Guide to Mobile ICD-10 Apps from mHealthNews.¹ This guide compares and contrasts the available apps (as of March 2014) for Android and Apple products. Some, you will note, are free; others are not. Try out a few before choosing. While several companies have developed products geared for ICD-10, many are not geared for mobile use and may have a substantial purchase price. Many of them also seem to be geared toward coders, not toward physician users.

My picks

ICD-10 Search was developed by e-MDs.² It appears that this search program is part of a more extensive product that e-MDs sells, but for the time being, is free. This app deserves a look, especially because the decision tree format quickly gets you to the most specific code.

ICD-10 Code Lookup is the official offering from the Centers for Medicare & Medicaid Services (CMS).³ After you type in the term you are looking for, you get the search results in code order. The more specific your search terms, the closer you will get to the needed code. One caveat: the search mode is not set up to accept all clinical terms. For instance, I typed in "menorrhagia" and got 0 results; I typed in “menstruation, frequent” and I received 2 codes.

I hope this information is helpful, and I wish you an easy transition from ICD-9 to ICD-10.

WE WANT TO HEAR FROM YOU!
Drop us a line and let us know what you think about current articles, which topics you'd like to see covered in future issues, and what challenges you face in daily practice. Tell us what you think by emailing us at: obg@frontlinemedcom.com

An OBG Management reader recently requested assistance finding an app or Web site that would be helpful for International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10) coding, particularly for practicing ObGyns. It is not surprising that I have received this question, as we already are seeing a ton of smartphone apps that promise to search through the code descriptions quickly. None of these apps are ObGyn-specific but, given the vast amount, deciding which one is the best option to purchase and download can be a challenge.

Purchase considerations

Before you buy, decide what features you are looking for and make sure the app you have chosen can deliver what you need. Pay special attention to any reviews to learn the app’s pros and the cons. For instance, some apps offer code conversion from ICD-9 to ICD-10. Keep in mind, however, that not all conversions are accurate, and your search may just lead you to another unspecified code. Some apps will offer a decision tree, which is ideal. What you would like to avoid is an app that generates a list of 200 codes from a single search term.

A useful resource that I have found is this Buyers Guide to Mobile ICD-10 Apps from mHealthNews.¹ This guide compares and contrasts the available apps (as of March 2014) for Android and Apple products. Some, you will note, are free; others are not. Try out a few before choosing. While several companies have developed products geared for ICD-10, many are not geared for mobile use and may have a substantial purchase price. Many of them also seem to be geared toward coders, not toward physician users.

My picks

ICD-10 Search was developed by e-MDs.² It appears that this search program is part of a more extensive product that e-MDs sells, but for the time being, is free. This app deserves a look, especially because the decision tree format quickly gets you to the most specific code.

ICD-10 Code Lookup is the official offering from the Centers for Medicare & Medicaid Services (CMS).³ After you type in the term you are looking for, you get the search results in code order. The more specific your search terms, the closer you will get to the needed code. One caveat: the search mode is not set up to accept all clinical terms. For instance, I typed in "menorrhagia" and got 0 results; I typed in “menstruation, frequent” and I received 2 codes.

I hope this information is helpful, and I wish you an easy transition from ICD-9 to ICD-10.

WE WANT TO HEAR FROM YOU!
Drop us a line and let us know what you think about current articles, which topics you'd like to see covered in future issues, and what challenges you face in daily practice. Tell us what you think by emailing us at: obg@frontlinemedcom.com

An OBG Management reader recently requested assistance finding an app or Web site that would be helpful for International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10) coding, particularly for practicing ObGyns. It is not surprising that I have received this question, as we already are seeing a ton of smartphone apps that promise to search through the code descriptions quickly. None of these apps are ObGyn-specific but, given the vast amount, deciding which one is the best option to purchase and download can be a challenge.

Purchase considerations

Before you buy, decide what features you are looking for and make sure the app you have chosen can deliver what you need. Pay special attention to any reviews to learn the app’s pros and the cons. For instance, some apps offer code conversion from ICD-9 to ICD-10. Keep in mind, however, that not all conversions are accurate, and your search may just lead you to another unspecified code. Some apps will offer a decision tree, which is ideal. What you would like to avoid is an app that generates a list of 200 codes from a single search term.

A useful resource that I have found is this Buyers Guide to Mobile ICD-10 Apps from mHealthNews.¹ This guide compares and contrasts the available apps (as of March 2014) for Android and Apple products. Some, you will note, are free; others are not. Try out a few before choosing. While several companies have developed products geared for ICD-10, many are not geared for mobile use and may have a substantial purchase price. Many of them also seem to be geared toward coders, not toward physician users.

My picks

ICD-10 Search was developed by e-MDs.² It appears that this search program is part of a more extensive product that e-MDs sells, but for the time being, is free. This app deserves a look, especially because the decision tree format quickly gets you to the most specific code.

ICD-10 Code Lookup is the official offering from the Centers for Medicare & Medicaid Services (CMS).³ After you type in the term you are looking for, you get the search results in code order. The more specific your search terms, the closer you will get to the needed code. One caveat: the search mode is not set up to accept all clinical terms. For instance, I typed in "menorrhagia" and got 0 results; I typed in “menstruation, frequent” and I received 2 codes.

I hope this information is helpful, and I wish you an easy transition from ICD-9 to ICD-10.

WE WANT TO HEAR FROM YOU!
Drop us a line and let us know what you think about current articles, which topics you'd like to see covered in future issues, and what challenges you face in daily practice. Tell us what you think by emailing us at: obg@frontlinemedcom.com

Postpartum preeclampsia, mother dies: $6.9M settlement
Four days after delivery of a healthy child, a 31-year-old mother went to the emergency department (ED) reporting tightness in her chest, difficulty breathing, and swelling in her lower extremities. Pulmonary embolism was ruled out and she was discharged. When she returned 3 days later, her legs were more swollen than before and her systolic blood pressure was 160 mm Hg. She was sent home again. Four days later, she suffered a seizure at home, in the ambulance during transport, and at the hospital. She was transferred to another facility a few days later where she died a week after transfer.

Estate’s Claim The ED physicians and hospital staff were negligent in not diagnosing and treating postpartum preeclampsia. This led to seizures, brain damage, and death. Antihypertensive and antiseizure medications would have prevented her death.

Defendant’s defense The actions taken were reasonable because she had no symptoms of preeclampsia during pregnancy or delivery.

Verdict A $6.9 million Illinois settlement was reached.

Ovary not removed; cyst develops
A 38-year-old woman underwent what was planned as total hysterectomy with bilateral salpingo-oophorectomy. The procedure was prophylactic: she had been treated for stage 3 breast cancer and her family history put her at high risk for developing ovarian cancer. Two days after surgery, the pathology report noted only 1 ovary.

Two months later, the patient went to the ED with right lower quadrant pain. It was determined that she had an ovarian cyst. She underwent additional surgery to remove the right ovary.

Patient’s claim The gynecologist was negligent in failing to remove the patient’s right ovary.

Physician’s defense Failure to remove the ovary was due to the patient’s abnormal anatomy.

Verdict A $250,000 Missouri verdict was returned.

Microcephaly not detected before birth
At 19 weeks’ gestation, an ultrasonographic anatomy scan showed that both hands of the fetus were clenched tightly. Amniocentesis results were reported as normal. No further fetal testing was ordered.

At birth, the baby was found to have Dandy Walker Variant, a severe brain malformation. The child has difficulty moving, is cognitively impaired, and requires a feeding tube and 24-hour care.

Parents’ claim Seen on ultrasonography, the fetus’ clenched fists were a sign of possible fetal abnormality. The maternal-fetal medicine (MFM) specialist who evaluated the ultrasound and amniocentesis and the ObGyn should have recommended fetal magnetic resonance imaging, which would have shown the microcephaly. If the parents had known of the abnormality, they would have terminated the pregnancy.

Defendant’s defense The case was settled during trial.

Verdict A $6 million New Jersey settlement was reached, including 
$5 million from the MFM and 
$1 million from the ObGyn.

Injury during hydrothermal ablation
When a 41-year-old woman underwent hydrothermal ablation to treat menorrhagia, her uterus was perforated and hot saline solution injured her intestines. During repair surgery, 21 inches of bowel were resected and a colostomy was created, which was reversed 8 months later.

Patient’s claim The gynecologist was negligent in performing the ablation. The manufacturer produced a poorly designed device.

Defendant’s defense The rupture was spontaneous. The procedure was properly performed. The device is safe.

Verdict A $2 million Kansas verdict was returned. The gynecologist was found 60% at fault and the manufacturer was 40% at fault. The patient’s net recovery was $322,300 due to the state cap.
 

Postpartum preeclampsia, mother dies: $6.9M settlement
Four days after delivery of a healthy child, a 31-year-old mother went to the emergency department (ED) reporting tightness in her chest, difficulty breathing, and swelling in her lower extremities. Pulmonary embolism was ruled out and she was discharged. When she returned 3 days later, her legs were more swollen than before and her systolic blood pressure was 160 mm Hg. She was sent home again. Four days later, she suffered a seizure at home, in the ambulance during transport, and at the hospital. She was transferred to another facility a few days later where she died a week after transfer.

Estate’s Claim The ED physicians and hospital staff were negligent in not diagnosing and treating postpartum preeclampsia. This led to seizures, brain damage, and death. Antihypertensive and antiseizure medications would have prevented her death.

Defendant’s defense The actions taken were reasonable because she had no symptoms of preeclampsia during pregnancy or delivery.

Verdict A $6.9 million Illinois settlement was reached.

Ovary not removed; cyst develops
A 38-year-old woman underwent what was planned as total hysterectomy with bilateral salpingo-oophorectomy. The procedure was prophylactic: she had been treated for stage 3 breast cancer and her family history put her at high risk for developing ovarian cancer. Two days after surgery, the pathology report noted only 1 ovary.

Two months later, the patient went to the ED with right lower quadrant pain. It was determined that she had an ovarian cyst. She underwent additional surgery to remove the right ovary.

Patient’s claim The gynecologist was negligent in failing to remove the patient’s right ovary.

Physician’s defense Failure to remove the ovary was due to the patient’s abnormal anatomy.

Verdict A $250,000 Missouri verdict was returned.

Microcephaly not detected before birth
At 19 weeks’ gestation, an ultrasonographic anatomy scan showed that both hands of the fetus were clenched tightly. Amniocentesis results were reported as normal. No further fetal testing was ordered.

At birth, the baby was found to have Dandy Walker Variant, a severe brain malformation. The child has difficulty moving, is cognitively impaired, and requires a feeding tube and 24-hour care.

Parents’ claim Seen on ultrasonography, the fetus’ clenched fists were a sign of possible fetal abnormality. The maternal-fetal medicine (MFM) specialist who evaluated the ultrasound and amniocentesis and the ObGyn should have recommended fetal magnetic resonance imaging, which would have shown the microcephaly. If the parents had known of the abnormality, they would have terminated the pregnancy.

Defendant’s defense The case was settled during trial.

Verdict A $6 million New Jersey settlement was reached, including 
$5 million from the MFM and 
$1 million from the ObGyn.

Injury during hydrothermal ablation
When a 41-year-old woman underwent hydrothermal ablation to treat menorrhagia, her uterus was perforated and hot saline solution injured her intestines. During repair surgery, 21 inches of bowel were resected and a colostomy was created, which was reversed 8 months later.

Patient’s claim The gynecologist was negligent in performing the ablation. The manufacturer produced a poorly designed device.

Defendant’s defense The rupture was spontaneous. The procedure was properly performed. The device is safe.

Verdict A $2 million Kansas verdict was returned. The gynecologist was found 60% at fault and the manufacturer was 40% at fault. The patient’s net recovery was $322,300 due to the state cap.
 

Postpartum preeclampsia, mother dies: $6.9M settlement
Four days after delivery of a healthy child, a 31-year-old mother went to the emergency department (ED) reporting tightness in her chest, difficulty breathing, and swelling in her lower extremities. Pulmonary embolism was ruled out and she was discharged. When she returned 3 days later, her legs were more swollen than before and her systolic blood pressure was 160 mm Hg. She was sent home again. Four days later, she suffered a seizure at home, in the ambulance during transport, and at the hospital. She was transferred to another facility a few days later where she died a week after transfer.

Estate’s Claim The ED physicians and hospital staff were negligent in not diagnosing and treating postpartum preeclampsia. This led to seizures, brain damage, and death. Antihypertensive and antiseizure medications would have prevented her death.

Defendant’s defense The actions taken were reasonable because she had no symptoms of preeclampsia during pregnancy or delivery.

Verdict A $6.9 million Illinois settlement was reached.

Ovary not removed; cyst develops
A 38-year-old woman underwent what was planned as total hysterectomy with bilateral salpingo-oophorectomy. The procedure was prophylactic: she had been treated for stage 3 breast cancer and her family history put her at high risk for developing ovarian cancer. Two days after surgery, the pathology report noted only 1 ovary.

Two months later, the patient went to the ED with right lower quadrant pain. It was determined that she had an ovarian cyst. She underwent additional surgery to remove the right ovary.

Patient’s claim The gynecologist was negligent in failing to remove the patient’s right ovary.

Physician’s defense Failure to remove the ovary was due to the patient’s abnormal anatomy.

Verdict A $250,000 Missouri verdict was returned.

Microcephaly not detected before birth
At 19 weeks’ gestation, an ultrasonographic anatomy scan showed that both hands of the fetus were clenched tightly. Amniocentesis results were reported as normal. No further fetal testing was ordered.

At birth, the baby was found to have Dandy Walker Variant, a severe brain malformation. The child has difficulty moving, is cognitively impaired, and requires a feeding tube and 24-hour care.

Parents’ claim Seen on ultrasonography, the fetus’ clenched fists were a sign of possible fetal abnormality. The maternal-fetal medicine (MFM) specialist who evaluated the ultrasound and amniocentesis and the ObGyn should have recommended fetal magnetic resonance imaging, which would have shown the microcephaly. If the parents had known of the abnormality, they would have terminated the pregnancy.

Defendant’s defense The case was settled during trial.

Verdict A $6 million New Jersey settlement was reached, including 
$5 million from the MFM and 
$1 million from the ObGyn.

Injury during hydrothermal ablation
When a 41-year-old woman underwent hydrothermal ablation to treat menorrhagia, her uterus was perforated and hot saline solution injured her intestines. During repair surgery, 21 inches of bowel were resected and a colostomy was created, which was reversed 8 months later.

Patient’s claim The gynecologist was negligent in performing the ablation. The manufacturer produced a poorly designed device.

Defendant’s defense The rupture was spontaneous. The procedure was properly performed. The device is safe.

Verdict A $2 million Kansas verdict was returned. The gynecologist was found 60% at fault and the manufacturer was 40% at fault. The patient’s net recovery was $322,300 due to the state cap.
 

Menopause experts Andrew M. Kaunitz, MD, and JoAnn E. Manson, MD, DrPH, provide a comprehensive review of various treatments for menopausal symptoms in an article recently published ahead of print in Obstetrics and Gynecology.¹ They discuss hormonal and nonhormonal options to treat vasomotor symptoms, genitourinary syndrome of menopause (GSM), and considerations for the use of hormone therapy in special populations: women with early menopause, women with a history of breast cancer and those who carry the BRCA gene mutation, and women with a history of venous thrombosis.¹

The authors write that, “given the lower rates of adverse events on HT among women close to menopause onset and at lower baseline risk of cardiovascular disease, risk stratification and personalized risk assessment appear to represent a sound strategy for optimizing the benefit–risk profile and safety of HT.”¹ They suggest that instead of stopping systemic HT at age 65 years, the length of treatment be individualized based on a woman’s risk profile and preferences. The authors encourage gynecologists and other clinicians to use benefit–risk profile tools for both hormonal and nonhormonal options to help women make sound decisions on treating menopausal symptoms.¹

Readthe full Clinical Expert Series here.

Menopause experts Andrew M. Kaunitz, MD, and JoAnn E. Manson, MD, DrPH, provide a comprehensive review of various treatments for menopausal symptoms in an article recently published ahead of print in Obstetrics and Gynecology.¹ They discuss hormonal and nonhormonal options to treat vasomotor symptoms, genitourinary syndrome of menopause (GSM), and considerations for the use of hormone therapy in special populations: women with early menopause, women with a history of breast cancer and those who carry the BRCA gene mutation, and women with a history of venous thrombosis.¹

The authors write that, “given the lower rates of adverse events on HT among women close to menopause onset and at lower baseline risk of cardiovascular disease, risk stratification and personalized risk assessment appear to represent a sound strategy for optimizing the benefit–risk profile and safety of HT.”¹ They suggest that instead of stopping systemic HT at age 65 years, the length of treatment be individualized based on a woman’s risk profile and preferences. The authors encourage gynecologists and other clinicians to use benefit–risk profile tools for both hormonal and nonhormonal options to help women make sound decisions on treating menopausal symptoms.¹

Readthe full Clinical Expert Series here.

Menopause experts Andrew M. Kaunitz, MD, and JoAnn E. Manson, MD, DrPH, provide a comprehensive review of various treatments for menopausal symptoms in an article recently published ahead of print in Obstetrics and Gynecology.¹ They discuss hormonal and nonhormonal options to treat vasomotor symptoms, genitourinary syndrome of menopause (GSM), and considerations for the use of hormone therapy in special populations: women with early menopause, women with a history of breast cancer and those who carry the BRCA gene mutation, and women with a history of venous thrombosis.¹

The authors write that, “given the lower rates of adverse events on HT among women close to menopause onset and at lower baseline risk of cardiovascular disease, risk stratification and personalized risk assessment appear to represent a sound strategy for optimizing the benefit–risk profile and safety of HT.”¹ They suggest that instead of stopping systemic HT at age 65 years, the length of treatment be individualized based on a woman’s risk profile and preferences. The authors encourage gynecologists and other clinicians to use benefit–risk profile tools for both hormonal and nonhormonal options to help women make sound decisions on treating menopausal symptoms.¹

Readthe full Clinical Expert Series here.