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Michael Stark,
New European Surgical Academy (NESA)
Charité Berlin
16 – 17. September 2019
New Trends in Surgical Education
The Ten Step Vaginal Hysterectomy
Disclosure
Michael Stark is the President of the New
European Surgical Academy (NESA) and the
Scientific Adviser of the ELSAN Hospital Group in
France and a guest scientist at The Charité
University Hospital.
There is no conflict of interest nor any financial
interest
At the point where the scalpel touches the skin,
you will find the presentation of the
whole surgical culture.
• The Surgical Manifest, Stark M, 2019
„Less is More“
Ludwig Mies van der Rohe
„Nothing Missing, Nothing Superfluous“
• Leonardo da Vinci
Different methods were in use when
hysterectomy was indicated:
1. Abdominal hysterectomy
2. Vaginal hysterectomy
3. Endoscopic hysterectomy
4. Laparoscopic-assisted vaginal
hysterectomy
Hysterectomy until the 20th Century
Vaginal hysterectomy dates back to ancient
times. The procedure was performed by
Soranus of Ephesus 120 C.E.
Sutton, C. Hysterectomy. Baillière's Clinical
Obstetrics and Gynaecology Volume 11,
Issue 1, March 1997, Pages 1-22
The first abdominal
hysterectomy was
performed by Charles Clay
in Manchester, England
in 1843.
Sutton, C. Hysterectomy. Baillière's Clinical
Obstetrics and Gynaecology Volume 11, Issue 1,
March 1997, Pages 1-22
The first laparoscopic
hysterectomy (LH) was
performed in January 1988
by Harry Reich in
Pennsylvania
A.Perino, G.Cucinella, R.Venezia, et al. Total laparoscopic hysterectomy
versus total abdominal hysterectomy: an assessment of the learning curve in a
prospective randomized study, Human Reproduction, vol.14 no.12 pp.2996–
2999, 1999
1. Robotic hysterectomy
2. TransDouglas hysterectomy
Hysterectomy in the 21st Century
Transvaginal/transdouglas
hysterecomy is expected to be a
valid alternative to traditional
endoscopic procedures
Stark M, Benhidjeb T, Natural Orifice Surgery: Transdouglas
surgery – a new concept, in: JSLS, 2008, 12(3): 295-8
The vaginal route should always be
considered when hysterectomy is
indicated, due to
• quicker recovery
• lack of scars
• shorter hospital stay
Some common methods for
vaginal hysterectomy:
1. The Viennese School (Halban)
2. Falk
3. von Theobald
4. Heaney
5. Porges
6. The Chicago School
7. Joel-Cohen
Universal steps used in vaginal hysterectomy:
1. Suturing labiae majorae. (4 / 7)
2. Incision around cervix. (7 / 7)
3. Perpendicular incision toward urethra. (5 / 7)
4. Peeling away vaginal epithelium, exposing bladder. (7 / 7)
5. Cutting excessive vaginal epithelium. (7 / 7)
6. Separating bladder from uterus. (7 / 7)
7. Opening anterior peritoneum first. (5 / 7)
8. Opening posterior peritoneum first. (2 / 7)
9. Cutting and ligating sacro-uterine ligaments. (7 / 7)
10. Cutting and ligating paracervical tissues
in one or two steps. (7 / 7)
11. Cutting and ligating uterine arteries. (7 / 7)
12. Cutting and ligating round ligaments,
ovarian ligaments and blood vessels. (7 / 7)
13. Optional repair of enterocele.
14. Closing pelvic peritoneum. (7 / 7)
15. Binding lateral stumps, enforcing the pelvic floor. (7 / 7)
16. Closing vagina. (6 / 7)
The presented case shows hysterectomy with prolapse.
The Ten Step Vaginal Hysterectomy“
Step 1
Incision of the vaginal wall
Starting under the urethra, a drop-like incision around the cervix is done and the vaginal wall is separated from the uterus and the bladder
6 instruments: Speculum, 2 uterine forceps, scalpel, surgical forceps,
Allis forceps
Step 2
Detaching the bladder from the uterus
1 instrument: A swab only. Optionally a scalpel
Step 3
Opening the posterior peritoneum
2 instruments: Surgical forceps, scissors
Big curved scissors are introduced into peritoneal cavity
and pulled out open to enable the next step.
Step 4
Dissection of the lower part of the uterus
Cutting and ligating the sacro-uterine ligaments together with the paracervical tissues. The clamp is closed rotating towards the uterus, while contra-rotating the uterus
4 instruments: Wertheim or Heaney clamp, needle holder, surgical forceps, scissors (2 sutures)
Step 5
Cutting and ligating the uterine arteries
4 instruments: Wertheim or Heaney clamp, scissors, needle holder,
surgical forceps (2 sutures)
Step 6
Opening the anterior peritoneum
The uterus is pulled down rotating. The anterior peritoneum is lifted from behind and cut open.
1 instrument: scissors
Step 7
Dissection of the upper part of the uterus
Clamping, cutting and suturing the round
ligaments and blood vessels
(oophorectomy is optional)
4 instruments: Wertheim or Heaney clamp, scissors, needle holder, surgical forceps (4 sutures)
Step 8
A „non-stage“
Peritoneum is left open (enterocele repair is
optional)
▪ Suturing the peritoneal layers is unnecessary
▪ Peritoneum does not heal by approximation
of its edges
▪ New peritoneum is formed within 24 – 48 h
from the coelum cells
▪ Sutures are providing focal points for adhesions
Ellis H. Internal overhealing: the problem of intraperitoneal adhesions. World J Surg
1980; 4: 303-306
ADHESIONS IN REPEATED OPERATIONS
Peritoneum
previously
left open
No. %
16
147
Adhesions
1 6,3
35 23,8
Stark M. World J Surg 1993; 17 (3): 419
Peritoneum
closed previously
Closing the peritoneum in a vaginal hysterectomy
is not necessary:
Lipscomb GH, Ling FW, Stovall TG, Summitt RL jr.
Peritoneal closure at vaginal hysterectomy : a reassessment.
Obstet Gynecol 1996; 87 (1): 40-43
Janschek EC, Hohlagschwandtner M, Nather A, Schindl M, Joura EA.
A study of non-closure of the peritoneum at vaginal hysterectomy.
Arch Gynecol Obstet 2003; 267 (4): 213-216
Step 9
Reconstruction of the pelvic floor
Sacrofixation or mesh where indicated.
Sacro-uterine ligaments, paracervical tissues
(from step 4) and ovarian ligaments
(from step 7) are ligated to each other
Step 10
Suturing the vaginal wall
4 instruments: Allis forceps, needle holder, surgical forceps, scissors (1 suture)
1 speculum
2 uterine forceps
1 Allis forceps
1 scalpel
1 surgical forceps
1 big curved scissors
1 Wertheim or Heaney clamp
1 needle holder
1 straight scissors
10 coated Vicryl sutures
10 instruments, 10 sutures
Instruments and sutures
10 instruments, 10 sutures:
Stark M/Di Renzo GC/Gerli S, in: Progress in Obstetrics and Gynaecology 2006,
Vol. 17, 358-368
The Ten-Step Vaginal Hysterectomy –
A Newer and Better Approach
Bina I, Akhter. Journal of Bangladesh College of Physicians and Surgeons.
30 (2), 2012, 71-7
The Ten-Step Vaginal Hysterectomy –
A Newer and Better Approach
Bina I, Akhter. Journal of Bangladesh College of Physicians and Surgeons.
30 (2), 2012, 71-7
Ten-step hysterectomy Heaney method
Mean value±SD Median (25th-
75th percentile)
Mean value±SD Median (25th-
75th percentile)
Statistical
significance
(p<0,05)
Operation time
(min.)
30±5 30(25-35) 43±7,7 45(38-48) <0,001
Need for
analgesics (hours)
28±10,4 30(25-35) 40,8±12,8 40(32-48) 0,001
Hospital stay
(days)
7,5±0,8 7(7-8) 9,5±2 9(8-10) <0,001
Comparison of operation time, use of analgesics and hospital stay
Comparison of a re-analyzed vaginal hysterectomy
to a classical one (in 66 cases)
Davor Zoričić, Dragan Belci, Dino Bečić, Michael Stark
In a study of 49 patients who underwent the Ten-Step
Vaginal Hysterectomy (TSVH) method or the Heaney
method, the TSVH group had a significantly shorter
operation time (P = 0.001), shorter hospital stay (P = 0.020)
and shorter time of analgesics requirement (P = 0.006).
Ü. GÖRKEM, C. TOĞRUL, H.A. İNAL, T. GÜNGÖR. Comparison of conventional Heaney’s technique
and ten-step vaginal hysterectomy technique. Turkısh Journal of Clinics and Laboratory Volum 6
Number 3 p: 91-95
The advantages ...
▪ Makes sense anatomically and physiologically
▪ Requires less pain killers
▪ Is easy to learn, perform and teach
▪ Saves theatre time
We expect any new presented surgical method to
bring upon added value to the existing ones, but
no evaluation can be done without standardization
of the compared groups.
Key Messages
1. In an optimal Vaginal Hysterectomy, no superfluous step should be taken, and no step should be lacking.
2. There is direct correlation between any surgical step to the clinical outcome.
3. Only standardized method will enable meta-analyzis and comparison among surgeons and institutions.
Thank you for your attention!
Non vi sed arte