Complications of vaginal hysterectomy - (Analysis of 1105 cases)Menna S Bhattacharya, SD Shinde, MR Narwekar
Department of Obstetrics & Gynaecology, K.E.M. Hospital, Parel, Bombay-400012, India
Eleven hundred and five cases of vaginal hysterectomy are analysed and their complications discussed.
Vaginal hysterectomy with or without repair of vagina and/or perineum is the commonest major gynaecological operation performed in our institute. Besides the cases having utero-vaginal prolapse, we prefer vaginal route for hysterectomy for all other non-malignant conditions as far as possible. Abdominal approach is selected only when the size of the uterus is larger than 12 weeks' size of pregnancy, when the mobility of the uterus is very much restricted due to adhesions or in the presence of palpable adnexal pathology with restricted uterine mobility. History of previous operation either vaginal or abdominal of any kind is not considered as a contraindication.
A total of 1105 cases of vaginal hysterectomy with or without repair, done at K.E.M. Hospital, Bombay, for nonmalignant conditions during January 1974 to March 1977, are analysed. Among these, plain vaginal hysterectomy was done in 615 cases while hysterectomy with repair of vagina and/or perineum was done in 490 cases.
[Table 1] shows the age distribution of patients. More than 90% o of the patients were between the age of 31 to 60 while 3.5% of them were less than 30 and 6.1% were above 60 years of age. The oldest patient was 82 years old. Majority of the patients were multiparous while only four were nulliparous and one of them required perineotomy due to nonavailability of space while performing the hysterectomy.
The choice of vaginal route for hysterectomy was not related to any systemic disease like hypertension or diabetes etc.
In 685 cases (62%), the hysterectomy was performed under general anaesthesia. Spinal anaesthesia was used in 388 cases whereas epidural route was utilized in 19 cases. In 13 cases hysterectomy was done under local anaesthesia.
Indications for hysterectomy are shown in [Table 2]. Prolapse was present in 51% of the cases while among the other indications, the major indication was dysfunctional uterine bleeding in 34.9% of the cases.
In all these cases the size of the uterus was less than 14 weeks of pregnancy. In most of these cases vaginal hysterectomy could be successfully performed, with bisection of the uterus in six and morcellation in two.
In 15 cases bilateral salpingo-oopherectomy had to be done as an additional measure because of the presence of undiagnosed small tubo-ovarian masses or hydrosalpinx.
There was a history of previous operation, either vaginal or abdominal, in 178 cases (15.2%). Only in one who had a previous caesarean section and sterilisation, vaginal hysterectomy could not be done successfully and had to be competed abdominally.
Out of these 1105 cases, only in four vaginal approach had to be abandoned, and the abdominal route was resorted to, to complete the operation. In one, vaginal hysterectomy could be carried out right upto the cornual structure but the uterus could not be delivered due to the presence of a thick fibrous band between the fundus of uterus and anterior abdominal wall, which was excised after opening the abdomen. In this case there was a history of previous caesarean section and abdominal sterilization.
In another case there was difficulty in opening the pouch of Douglas and the uterine vessels slipped while ligating. An attempt made to clamp them from below failed and hence the abdomen was opened to clamp the uterine vessels. On opening the abdomen, bilateral chocolate cysts of ovaries were also detected.
In two more cases the presence of undiagnosed tubo-ovarian masses made an abdominal approach mandatory.
The overall incidence of major complications in these 1105 cases of vaginal hysterectomy was 4%.
Accidental opening of bladder occurred in 13 cases (in 8 cases while doing plain vaginal hysterectomy and in 5 cases of vaginal hysterectomy with repair). In all these cases there was no history of any previous vaginal or abdominal surgery. The bladder injuries were recognised during the procedure in all of them and were managed by suturing the bladder in two layers and an indwelling catheter for two weeks postoperatively. None of them developed fistulae.
In one case rectum was opened accidentally while opening the posterior pouch, which was sutured immediately and the patient went home without any further problems. Haemorrhage, primary in 9 and secondary in 5, formed another important group of complications.
Primary haemorrhage occurred in 4 cases of plain vaginal hysterectomy and in 5 cases of vaginal hysterectomy with repair. Four of these 9 cases of primary haemorrhage could be managed simply by suturing the bleeding edges of vagina and packing, whereas in one case a simple packing was unable to control the haemorrhage and required suturing and packing twice. In four cases exploratory laparotomy was performed because no obvious bleeder was seen from below. Only in two cases broad ligamentary haematoma was detected and evacuated, while in one of the cases no particular bleeder could be identified and ligated and thus bilateral internal iliac ligation had to be resorted to.
There were 5 cases of secondary haemorrhage-3 following a plain vaginal and 2 following vaginal hysterectomy with repair. All of them responded to packing, adequate blood transfusion and higher antibiotics.
Vault sepsis was one of the commonest problem encountered during post operative period. There were 28 cases of vault sepsis which responded to systemic and local antibiotics and drainage.
Four had a pelvic abscess with peritonitis. Two of them responded to drainage and intensive management but the other two succumbed.
Myocardial infarction occurred in 4 cases within 48 hours of the operation. These patients were between the age of 45 to 52 and none of them had any preoperative cardiovascular problems. One of these patients died on the third day. Postmortem report confirmed the cause of the death as myocardial infarction.
The other interesting complications were deep vein thrombosis of leg veins in one and femoral artery embolism in another. The patient who had femoral artery embolism was a 50 year old obese hypertensive and diabetic woman. Excrutiating pain and absence of pulsations, on the 10th day drew our attention to the presence of femoral artery embolism. A 10 th long embolus was removed by the Vascular Surgeons.
One patient developed psychosis after two weeks of operation and was managed by major and massive doses of tranquilizers.
Post operative paraparesis developed in 6 cases requiring prolonged physiotherapy.
One patient developed signs and symptoms of intestinal obstruction on the 6th postoperative day. Exploration showed loops of small bowel adherent to the vaginal vault causing subacute intestinal obstruction. Patient went home after 3 weeks.
There were four deaths in this series of 1105 cases of vaginal hysterectomy. The causes of death were myocardial infarction in one, acute viral enteritis with paralytic ileus in another. These two were obviously not directly related to the surgery. Two cases developed severe peritonitis on the 3rd and 6th day of the operation and died due to terminal bronchopneumonia and endotoxic shock respectively. Hence the corrected mortality rate is 0.018%.
Hysterectomy by the vaginal route has become increasingly popular. It is always preferable to perform a hysterectomy by the vaginal route whenever technically feasible. Advantages of vaginal route are too well known to be enumerated. However a careful selection and a proper reexamination of the patient under anaesthesia before starting the surgery is essential to avoid complications.
Accidental injury to the bladder during hysterectomy has been a common occurrence (1.17%) in our series. None of them had any history of previous vaginal surgery and none of them developed fistulae. Sheth and Ashar,  in their study from the same institute of 687 cases of vaginal hysterectomy, reported bladder injury in 6 cases with fistula developing in one. Tatra  from Austria in his massive series of 3482 cases of vaginal hysterectomy had only 13 (0.36%) cases of bladder injury. However the incidence of urinary fistulae was 0.3% (12 cases) Seven of these were vesico-vaginal and 5 uretero-vaginal. Gray  reported an unusually high incidence of uretero-vaginal fistulae in 7 out of 810 cases of vaginal hysterectomy with repair.
Vault sepsis has been the commonest complication (2.7%;) of our series. But this is a relatively minor complication in the sense that mere digital separation of vaginal edges followed by vaginal pessaries could control the infection in majority of the cases. Lash  in his series of 2007 cases reported a 35% incidence of post-operative low-grade infection of the vault which was brought down to 7-10% by the use of vaginal suppositories. du Toit  from S. Africa has reported an 11% incidence of vault sepsis in a study of 367 cases. Four out of these developed pelvic peritonitis. Incidence of vault sepsis can be minimised by keeping the vault open.
Immediate and late haemorrhage is still of major concern to the gynaecologist. Our incidence of primary haemorrhage was 0.81% and that of secondary haemorrhage was 0.45%. Papaloucas et al  in their series of 360 cases had 4 cases of haemorrhage Secondary haemorrhage was reported in 26 cases out of 3482 cases of Tatra.  Gray  reported an overall incidence of 2.4% of postoperative haemorrhage. Lash  advocates immediate exploratory laparotomy with ligation of uterine or ovarian vessels for primary haemorrhage and internal iliac ligation in presence of broad ligament haematomas. Secondary haemorrhage can be tackled by vessel ligation and vaginal packing.
Deep vein thrombosis and pulmonary emboli are reported more frequently in the western literature. We had only one case of deep vein thrombosis. Walsh  et al in their study of 100 vaginal hysterectomies showed a 7% incidence of deep vein thrombosis. These were, however, detected by using labelled fibrinogen phlebography.
Mortality rate following vaginal hysterectomy varies from 0.03% (Lewis  ) to 0.38% (Lash  ). No mortality has been reported by Sheth and Ashar  in their series of 687 cases. Hawksworth  himself has performed 1000 cases of vaginal hysterectomy without a single death.
Hence there is a tremendous scope for improvement by careful pre-operative assessment, meticulous surgical techniques and proper post-operative care in order to reduce the complication rate further.
We take this opportunity to thank Dr. C. K. Deshpande, Dean, K.E.M. Hospital & Seth G.S. Medical College and Dr. V. N. Purandare, Hon. Prof. & Head, Department of Obstetrics and Gynaecology, for allowing us to publish the hospital data.
[Table 1], [Table 2]