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6 Hysterectomy
69
abdominal hysterectomies come in with the lowest risk and have reported averages of 0.11% and
0.35%, respectively [26, 27]. Risk factors include
constipation, smoking, immunosuppression,
menopausal status, prior pelvic surgery, postoperative infection, and diabetes.
Prevention
There is no consensus on the best prevention
strategy for vaginal cuff dehiscence. Several
studies indicate that the incidence has increased
after the introduction of laparoscopic and
robotic surgery [23], although there is some
thought that this may be due to inexperience and
that this rate decreases signicantly in experienced surgeons’ hands [28]. Some advocate for
a two-layer laparoscopic vaginal cuff closure,
with one retrospective study showing 0.9% cuff
complication rate versus 2.6% in a single-layer
technique [25]. Barbed sutures have also been
shown in retrospective studies to reduce the risk
of dehiscence when compared to non-barbed
sutures; however, out of 11 studies looking at
this, only 2 found statistical signicance [23].
Another strategy that has been implemented by
many institutions has been delayed resumption
of intercourse after laparoscopic or robotic cuff
closure, our institution uses 9 weeks although
data are lacking. The approach to colpotomy has
been evaluated by looking at monopolar current
versus cut cautery or cold knife, and no studies
have been adequately powered to draw conclusions [23]. Another prevention technique has
been to close the cuff vaginally after a laparoscopic or robotic procedure. Three studies evaluating this approach showed an increase in the
risk of dehiscence with a transvaginal closure
than laparoscopic closure (2.7% vs 1%;
p = 0.01) [23, 29]. Some general strategies
include adequate mobilization of the bladder to
allow adequate cuff to suture, judicious use of
cautery to minimize thermal damage, approxi-
mation of the cuff without strangulation, and, in
selected cases, vertical closure.
Recognition
A delay in recognition and management can lead
to life-threatening complications such as bowel
perforation, peritonitis, sepsis, and even death
[23]. The presentation includes postcoital bleeding, other vaginal bleeding or watery discharge,
pelvic pressure or bulge, pelvic pain, and bowel
evisceration (Fig.6.6a–c). A high index of suspicion is critical with careful history taking and
immediate physical examination to visually
inspect and manually palpate the vaginal cuff.
Management
Although small or partial dehiscences may be
safely managed with pelvic rest, a true vaginal
cuff dehiscence is a surgical emergency and warrants a return to the operating room. If there is
any delay in taking the patient to the operating
room such as might occur if the patient needs to
be transferred from an outside hospital, it should
be requested that the patient remain supine or
even in slight Trendelenburg with placement of a
foley catheter and moist vaginal pack. If bowel is
eviscerated, a moist sterile towel should be
applied to cover the prolapsed bowel.
Cuff dehiscence can be closed vaginally
when possible, but may require abdominal
exploration (laparoscopy can be considered) in
cases of bowel evisceration to thoroughly
inspect the bowel and wash out the peritoneal
cavity. If the bowel is able to be inspected vaginally, it can sometimes be reduced without
trauma. However, if the bowel has become
edematous and does not easily reduce, an
exploratory laparotomy should be performed.
Any necrotic bowel should be resected by a surgeon trained in bowel surgery.
70
J. Selle and J. Gebhart
a
b
c
Fig. 6.6 (a) Vaginal bowel evisceration. She was taken to
the OR and repair was able to be performed vaginally.
Used with permission of Mayo Foundation for Medical
Education and Research, all rights reserved. (b) Vaginal
bowel evisceration with nonviable bowel, requiring resec-
tion. Copyright [2023] Journal of Gynecologic Surgery.
(c) Vaginal bowel evisceration requiring laparoscopy with
bowel reduction, abdominal washout, drain placement,
and transvaginal closure. Copyright [2023] Journal of
Gynecologic Surgery
6 Hysterectomy
71
References
1. Ramdhan RC, Loukas M, Tubbs RS. Anatomical
complications of hysterectomy: a review. Clin Anat.
2017;30(7):946–52.
2. Hammer A, etal. Global epidemiology of hysterectomy: possible impact on gynecological cancer rates.
Am J Obstet Gynecol. 2015;213(1):23–9.
3. Committee Opinion No. 701. Summary: choosing
the route of hysterectomy for benign disease. Obstet
Gynecol. 2017;129(6):1149–50.
4. Occhino JA, Gebhart JB.Vaginal hysterectomy. In: Le
LV, Handa V, editors. Te Linde’s operative gynecology. Wolters Kluwer Health; 2023.
5. Aarts JW, etal. Surgical approach to hysterectomy for
benign gynaecological disease. Cochrane Database
Syst Rev. 2015;2015(8):Cd003677.
6. Elfazari T, et al. Surgical indication and approach
are associated with transfusion in hysterectomy for
benign disease. JSLS. 2022;26(2)
7. Baggish MS, Karram MM.Atlas of pelvic anatomy
and gynecologic surgery. 5th ed. Elsevier; 2021.
8. Hodges KR, Davis BR, Swaim LS. Prevention and
management of hysterectomy complications. Clin
Obstet Gynecol. 2014;57(1):43–57.
9. Tompeck AJ, etal. A comprehensive review of topical
hemostatic agents: the good, the bad, and the novel. J
Trauma Acute Care Surg. 2020;88(1):e1–e21.
10. Holub Z, Jabor A. Laparoscopic management of
bleeding after laparoscopic or vaginal hysterectomy.
JSLS. 2004;8(3):235–8.
11. Clarke-Pearson DL, Geller EJ.Complications of hysterectomy. Obstet Gynecol. 2013;121(3):654–73.
12. Johnson N, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane
Database Syst Rev. 2006;2:Cd003677.
13. Zelivianskaia AS, Bradley SE, Morozov VV. Best
practices for repair of iatrogenic bladder injury. AJOG
Glob Rep. 2022;2(3):100062.
14. Matthews CA, Gebhart JB.Avoiding and managing
lower urinary tract injuries during pelvic surgery. In:
Walters & Karram Urogynecology and reconstructive
pelvic surgery. Elsevier, Inc.; 2022. p.386–98.
15. Glaser LM, Milad MP. Bowel and bladder injury
repair and follow-up after gynecologic surgery. Obstet
Gynecol. 2019;133(2):313–22.
16. AAGL Advancing Minimally Invasive Gynecology
Worldwide. AAGL Practice Report: Practice
guidelines for intraoperative cystoscopy in laparoscopic hysterectomy. J Minim Invasive Gynecol.
2012;19(4):407–11.
17. Askew AL, Myers ER, Dieter AA.Cost-effectiveness
of agents used for evaluation of ureteral patency
during intraoperative cystoscopy in gynecologic
and urogynecologic surgery. Am J Obstet Gynecol.
2022;226(1):100.e1–6.
18. Shapiro R, etal. A comparative study of braided versus barbed suture for Cystotomy repair. Res Rep Urol.
2021;13:793–8.
19. Wolf JS Jr, etal. Best practice policy statement on
urologic surgery antimicrobial prophylaxis. J Urol.
2008;179(4):1379–90.
20. Zhu CR, etal. Risk factors for bowel injury in hysterectomy for benign indications. Obstet Gynecol.
2020;136(4)
21. Elbiss HM, Abu-Zidan FM. Bowel injury following
gynecological laparoscopic surgery. Afr Health Sci.
2017;17(4):1237–45.
22. Bhullar JS, et al. Delayed presentation of a bowel
Bovie injury after laparoscopic ventral hernia repair.
JSLS. 2013;17(3):495–8.
23. Uccella S, Zorzato PC, Kho RM. Incidence and
prevention of vaginal cuff dehiscence after laparoscopic and robotic hysterectomy: a systematic
review and meta-analysis. J Minim Invasive Gynecol.
2021;28(3):710–20.
24. Hur H-C, et al. Incidence and patient characteristics of vaginal cuff dehiscence after different modes
of hysterectomies. J Minim Invasive Gynecol.
2007;14(3):311–7.
25. Peters A, etal. Two-layer compared with one-layer
vaginal cuff closure at the time of Total laparoscopic hysterectomy to reduce complications. Obstet
Gynecol. 2021;138(1):59–65.
26. Kho RM, et al. Incidence and characteristics of
patients with vaginal cuff dehiscence after robotic
procedures. Obstet Gynecol. 2009;114(2 Pt 1):231–5.
27. Hur HC, et al. Vaginal cuff dehiscence after different modes of hysterectomy. Obstet Gynecol.
2011;118(4):794–801.
28. Nezhat C, et al. Vaginal cuff dehiscence
and evisceration: a review. Obstet Gynecol.
2018;132(4):972–85.
29. Uccella S, et al. Laparoscopic vs transvaginal cuff
closure after total laparoscopic hysterectomy: a randomized trial by the Italian Society of Gynecologic
Endoscopy. Am J Obstet Gynecol. 2018;218(5):500.
e1–500.e13.
30. Gomez E, etal. CT of acute abdominopelvic hemorrhage: protocols, pearls, and pitfalls. Abdom Radiol
NY. 2022;47(1):475–84.
Genital Tract Prolapse
BrittanyL.Roberts andRebeccaG.Rogers
7
Intraoperative Injuries
General complications of surgery apply to pelvic
reconstructive surgeries as well. Overall, intraoperative complications are rare; however, it is
important to understand how to identify and manage complications. We will discuss hemorrhage
and injury to the urinary tract, gastrointestinal
tract, and nervous system specic to the most
common pelvic reconstructive surgeries.
Vascular Injury
Background
Hemorrhage related to pelvic organ prolapse surgery is uncommon and estimated to be 1.5% [1].
Although rare, excessive blood loss requiring
transfusion or formation of a hematoma may
occur in any pelvic reconstructive surgery.
Hemorrhage risk varies between procedures with
the highest risk of severe hemorrhage occurring
with sacrospinous ligament xation and sacral
colpopexy. The incidence of life-threatening
hemorrhage related to sacrospinous ligament
xation ranges from 0.2% to 2% [2, 3]. During a
B. L. Roberts · R. G. Rogers (*)
Department of Obstetrics and Gynecology,
Division of Urogynecology and Reconstructive
Pelvic Surgery Albany Medical Center,
Albany, NY, USA
e-mail: robertb5@amc.edu; rogersr2@amc.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Hoffman et al. (eds.), Major Complications of Female Pelvic Surgery,
https://doi.org/10.1007/978-3-031-66772-5_7
sacrospinous ligament xation, severe hemorrhage most commonly occurs with dissection
superior to the coccygeus muscle or lateral to the
ischial spine in the ischiorectal fossa. The inferior gluteal artery and its coccygeal branch are
most susceptible to injury [4, 5]. During sacrocolpopexy, the mesh is attached to the sacral
promontory. This is dened as the most superior
point on the anterior surface of S1 into the anterior longitudinal ligament. Figure 7.1 demonstrates the presacral space and the proximity of
vital structures. The reported hemorrhage or
transfusion rate for abdominal sacral colpopexies
is 4.4% [6]. There are several potential hemorrhage sources when dissecting the presacral
space including presacral vessels/venous complexes, the middle sacral vessels, and the left
common iliac vein.
Prevention
As the sacrospinous ligament dissection is typically performed without visualization, hemorrhage during the procedure may be difcult to
control. Since life-threatening hemorrhage is
rare, there are few guidelines on how to manage
hemorrhage. Utilization of the Capio device or
passage of the needle tip downward into the
ischiorectal space rather than passing the needle
tip superior toward vasculature is preferred [7].
73
74
Rectosigmoid
Right common
B. L. Roberts and R. G. Rogers
Inferior
vena cava
iliac artery
External
iliac artery
Lumbar fifth
vertebra
L5
S1
Uterus
Aorta
Middle sacral
artery
Left common
iliac vein
*
*
Internal
iliac artery
Sacral
sympathetic
chain
First sacral
vertebra
colon
Fig. 7.1 Presacral dissection: Dissection of the presacral space with surrounding organs, vasculature and nerves
A recent study was performed evaluating the
Recognition
relationship of critical structures to the sacral
suture during a robotic sacrocolpopexy [8]. A
vascular clip was placed at the level of the
sacral suture and 6weeks later, patients underwent imaging to evaluate the anatomy relative
to the sacral suture. The left common iliac vein
was an average of 26mm away from the sacral
suture, while the right common iliac artery was
18mm away. It is important to be mindful of
the proximity of these structures when performing the sacral dissection and placement of
sacral sutures.
During sacrospinous ligament xation, sudden
signicant bleeding may be encountered during
the dissection or following placement of the
sacrospinous sutures. Hemorrhage is most likely
to occur at the time of dissection of the presacral
space during sacrocolpopexy. When bleeding
occurs at the presacral vessels, hemostasis can be
difcult to achieve because of the venous network both beneath and on the surface of the periosteum. Vessels retract beneath the surface of the
anterior sacrum and recede into the bone, including sacral foramina.
7 Genital Tract Prolapse
75
Management
Initial management of hemorrhage includes compression of the sacrospinous ligament. This is
performed by applying pressure with a sponge on
the sacrospinous ligament at the insertion of the
ischial spine. Although there is limited evidence
on the length of time to hold pressure, a minimum compression time of 10min has been suggested [9]. If bleeding continues, application of
hemostatic agents can be applied. This is most
helpful for venous bleeding or capillary oozing.
If despite these measures bleeding continues, a
narrow malleable or Breisky retractor may be
used to attempt visualization of the injured vessel. If visualized, suture ligation or placement of
vascular clips may be performed. Conversion to
laparotomy is not recommended as does not
allow for visualization of the hemorrhage source.
Packing of the presacral space may temporarily control bleeding, but it may recur once packing is removed. Packing must be done cautiously
and without undue pressure to avoid tearing the
delicate venous network. Agents for hemostasis
may include sutures, metallic clips, cautery, and
bone wax. If not successful, stainless steel thumbtacks can be placed on a retracted bleeding presacral vein or into the associated foramen to treat a
life-threatening hemorrhage [10]. If performing a
laparoscopic or robotic sacrocolpopexy, conversion to laparotomy may be performed depending
on the vasculature injured, poor control of the
hemorrhage, or inadequate visualization.
Urinary Tract Injury
Background
Urinary tract injury at the time of prolapse surgery varies depending on the procedure being
performed. Cystotomy and ureteral injuries are
often diagnosed at the time of surgical procedures secondary to the utilization of intraoperative cystoscopy [11]. Specic to pelvic
reconstructive surgery, the rate of cystotomy is
around 3.2% [12] and ureteral obstruction and/or
injury ranges from 0.3 to 11% of cases [13, 14].
Uterosacral ligament suspension (USLS) is the
most common procedure associated with ureteral
injury [15]. One of the most common complications associated with uterosacral ligament suspension is ureteral injury or kinking (risk up to
11% [13]). This risk is high because of ureteral
proximity to the uterosacral ligament. The ureter
may also be injured directly with the placement
of the stitch. This injury is typically identied
following the needle placement with leakage of
urine into the posterior cul-de-sac. It is often
helpful to administer phenazopyridine in the preoperative period versus methylene blue for easy
identication.
Prevention
The ureter is located lateral and ventral to the
uterosacral ligament along its course. The distance from the ureter to the uterosacral ligament
is estimated to be 0.9cm in the cervical portion,
2.3cm in the intermediate portion, and 4.1cm in
the sacral portion. [16] The optimal xation site
is the intermediate portion of the uterosacral ligament, 1cm posterior to its most anterior palpable
margin, at the level of the ischial spine or above
[16]. Identication of the uterosacral ligament is
paramount in performing this procedure safely. If
a USLS is being performed at the time of the
vaginal hysterectomy, keeping the ligament
tagged at the time of suture ligation is useful to
aid in later identication. Adequate visualization
of the pelvis is then achieved with the packing of
the bowel and use of retractors. An Allis or
Babcock clamp may then be placed at the vaginal
portion of the uterosacral ligament, and gentle
traction is utilized to aide in identication. If this
is performed in a patient who is post- hysterectomy,
the clamps may be placed at 4 and 8 o clock [17].
The sutures should be placed from ventral to dorsal, avoiding peritoneum lateral to the ligament,
to minimize the risk of ureteral entrapment or
kinking.
76
B. L. Roberts and R. G. Rogers
Recognition
It is imperative to perform an intraoperative cystoscopy to ensure ureteral patency with these procedures. If ureteral efux is weak or not observed,
the suspension on that side should be removed
suture by suture with repetitive re-evaluation.
Management
As the ureter is in closest proximity to the uterosacral ligament distally, the distal suture on the
ipsilateral side of the suspension should be
removed rst (lateral to medial). The suture can
be replaced more medially.
Bowel Injury
Background
Bowel injury during general gynecologic surgery
is rare and ranges from 0.13 to 0.54% [18]. The
majority of these injuries occur during vaginal or
abdominal entry and adhesiolysis [18, 19]. Bowel
injuries in pelvic reconstructive surgery are similar, and the same general principles of early diagnosis and repair apply. Sacrospinous ligament
xation and sacrocolpopexy have features that
may elicit bowel injury specic to these reconstructive procedures. The global rate of rectal
injury during sacrospinous ligament xation is
0.4% [20]. Injury to the rectum is higher if a previous colporrhaphy was performed [21].
The incidence of bowel injury during sacrocolpopexy ranges from 0 to 1.6% [22–24]. As
with general gynecologic surgery, injuries typically occur with entry. Rectal injury may occur
during the development of the rectovaginal space,
especially in patients with cul-de-sac adhesions.
Prevention
Although rare, rectal injury is most likely to
occur during entry of the ischiorectal fossa while
gaining access to the sacrospinous ligament. If
retractors are necessary to aid in visualization of
the ligament or to increase the space of dissection, careful placement is necessary to avoid rectal injury. This may be accomplished by
displacing the rectum with a nger and placing
the retractor over your nger.
During sacrocolpopexy, utilization of an
endoanal sizer may aid in delineation of the rectum and development of the rectovaginal space.
Recognition
A rectal examination should be performed after
placement of the sutures because of the close
proximity of the rectum to the sacrospinous ligament [7].
Management
If a rectal injury is identied during sacrospinous
ligament xation, it can be repaired
transvaginally.
Limited evidence exists on whether or not a
mesh sacrocolpopexy should be completed following a bowel injury. A recent review of the literature utilizing the Delphi process recommended
that if there is an uncomplicated small bowel
injury, the sacrocolpopexy should be completed.
If a large bowel injury occurs, the sacrocolpopexy should be deferred [25]. Alternatively, consideration can be given to completing the
procedure with native tissue such as rectus
fascia.
Nerve Injury
Background
The incidence of postoperative neuropathy in
pelvic surgery is estimated to range from 1.1
to 1.9% [26–28]. The procedure with the highest risk of nerve related injury in prolapse surgery is sacrospinous ligament fixation. An
estimated 55–84% of patients experience some
gluteal or thigh pain immediately postop [29,
Ext
Pudendal nerve
)
Inferior gluteal artery
7 Genital Tract Prolapse
77
30]. This decreases to around 3–16% by
6weeks [2, 29, 30].
Although rare, nerve injuries can occur with
USLS [31]. There have been conicting literature
describing the anatomy of the uterosacral ligaments. Several studies have demonstrated that the
uterosacral ligaments insert directly into the
sacrum [16, 32], while others have demonstrated
that most of the ligaments insert into the sacrospinous and coccygeus muscle complex [33].
Cadaveric studies have demonstrated that entrapment of S1–S4 nerves is most likely implicated in
neuropathic pain after USLS [34–36].
Prevention
Postoperative pain is secondary to the proximity
of the sciatic nerve to the sacrospinous ligament.
Cadaver studies have demonstrated that branches
from S3 and/or S4 course between the sacrospinous and sacrotuberous ligaments and are most
likely to be affected in this procedure [37].
Figure 7.2 demonstrates the sacrospinous ligament and the proximity to vital structures. To
minimize entrapment, it is recommended that the
sutures be placed 2–3cm from the ischial spine at
the mid-section of the ligament [38].
The anatomic studies also indicate that there
may be signicant variability in the anatomy of
the uterosacral ligament. One theory is that nerve
entrapment most likely occurs when the uterosacral suture is placed too lateral and deep [31].
Recognition
Nerve injury at the time of pelvic reconstructive
surgery is rare and is typically not diagnosed in
the operating room. Injuries are identied postoperatively based on patient symptoms. If there is
severe or persistent pain following a sacrospinous ligament xation, this may indicate a pudendal nerve entrapment. USLS nerve entrapment
from the S1 to S4 distribution may include sharp
pain radiating from the buttocks into the posterior
leg, resulting in difculty sitting and walking
[39].
Nerve injuries related to position should be
considered in any surgery. For pelvic organ prolapse surgery, the patients are positioned in the
dorsal lithotomy or high lithotomy position. The
ernal iliac artery
Posterior trunk of
Internal iliac artery
Anterior trunk of
internal iliac artery
Sciatic nerve
Ischial spine
Internal pudendal
artery
Fig. 7.2 Sacrospinous anatomy: Depiction of the sacrospinous ligament and important surrounding structures
S1
S2
S3
*
*
S4
internal iliac artery
Piriformis muscle
Lateral sacral arteries
Coccygeus muscle (cut
Sacrospinous ligament
Nerves to coccygeus,
levator ani and external
anal sphincter
78
B. L. Roberts and R. G. Rogers
most common injuries include the common peroneal and femoral nerves. Positional injuries may
be avoided by ensuring padding over bony prominences and avoiding excessive exion and external rotation of the hip.
Management
In such instances, prompt suture removal should
be considered [40]. Uterosacral nerve entrapment
may be managed similarly to that of sacrospinous
neuropathy. Conservative management may
include physical therapy, stretching exercises,
and medical management with neuroleptics, such
as Gabapentin. If not alleviated by conservative
management, surgical intervention with suture
removal should be considered.
Postoperative Considerations
Postoperative complications of pelvic reconstructive surgery are rare and may consist of
infection, urinary retention, bleeding, and pain.
For the purposes of this chapter, we will discuss
specic complications in the most common prolapse surgeries.
The treatment of mesh complications is unique
in pelvic reconstructive surgery. Mesh complications may include exposure, pain, dyspareunia,
infection, and erosion. The mesh exposure rate
for abdominal sacrocolpopexy is estimated to be
3% [41]. If mesh exposures are less than 0.5cm
and the patient is asymptomatic, they may be
managed with topical estrogen or observation. If
the patient is symptomatic, the exposure is persistent, or a multilament mesh was used,
removal is recommended [42]. Typically, vaginal
excision of the visualized mesh may be performed. If infected, the recommendation is for
the removal of the entire mesh. If there is concern
for an infection, a pelvic MRI to evaluate the
entire length of the mesh and the sacral promontory is recommended. If a patient complains of
persistent back pain, an MRI to evaluate the
promontory should be performed to evaluate for
osteomyelitis. While the incidence is less than
1/1000 sacrocolpopexy cases [43], the sequelae
from this can be devastating. Mesh erosion into
the bowel or bladder is extremely rare and is typically managed with an interdisciplinary team
depending on the organ affected.
Reperitonealization following sacrocolpopexy
is often recommended to hypothetically prevent
small bowel obstruction. Recent studies have
found that bowel complications are similar in
women who undergo reperitonealization of mesh
versus those who do not [44, 45].
Prolapse Recurrence
Approximately 11% of women will undergo surgery for prolapse or stress urinary incontinence
in their lifetime [46]. Unfortunately, one of the
most common complications related to prolapse
repair is recurrent prolapse. Reoperation for prolapse recurrence ranges from 2.2 to 4.4% for
sacrocolpopexy [47, 48] and 3–6.5% for native
tissue repair [49, 50] at 2years postoperatively.
Epidemiologic studies report that a 20-year risk
of repeat operation is 11% overall with younger
(<50years of age) women having higher risk of
repeat surgery compared to women >/= 50
(26.9% vs.10.1%) [51]. Recurrent prolapse as
measured by POPQ criteria is more common
after native tissue than mesh augmented repairs,
such as sacrocolpopexy. Dened as recurrent
stage 2 prolapse on pelvic examination, an estimated 23% of women have recurrent prolapse
after sacral colpopexy and around 41% after
native tissue procedures at 1–2years following
surgery [41]. Although the recurrence rate is
higher in native tissue procedures, this risk is balanced against the risk of mesh complications.
Conclusion
Pelvic reconstructive surgery procedures are generally low risk with low morbidity. The most
common complication is recurrence of prolapse.
Other complications of these surgeries are rare,
although if not managed appropriately can be
catastrophic.
7 Genital Tract Prolapse
79
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