Schuchardt Incision When vaginal exposure is difficult, the Schuchardt incision may be used. If the surgeon is right handed, the incision is made on the patient’s left side. To decrease blood loss, the area can be infiltrated with lidocaine-containing epinephrine. The incision follows a curved line from the 4-o’clock position at the hymenal margin to a point halfway between the anus and the ischial tuberosity. The incision may be continued into the vaginal vault as high as necessary to gain exposure. The depth of the incision is the medial portion of the pubococcygeus muscle, which may be divided in extreme cases. The incision must be closed in layers at the completion of the procedure.
Injury to the urinary bladder is one of the most common intraoperative complications associated with hysterectomy. If the bladder is inadvertently entered, repair should be performed when the injury is discovered and not delayed until completion of surgery. When bladder injury is recognized, the edges of the wound should be mobilized to assess the full extent of the injury and allow repair without tension. This assessment should include visualization of the trigone to exclude injury to that area. The bladder may be repaired with a single-or double-layered closure with a small-caliber absorbable suture. Methylene blue, indigo carmine, or a dye of sterile milk formula can be instilled into the bladder to ensure that the repair is adequate.
Because patients with suspected pelvic adhesions or obvious pelvic disease are excluded as candidates for vaginal hysterectomy, bowel injuries do not occur often. Bowel injuries are associated with the performance of a posterior colporrhaphy and are usually confined to the rectum.
If the rectum is entered, the injury is repaired with a single-or double-layer closure using a small-caliber absorbable suture, followed by copious irrigation. Postoperatively, the patient should be given a stool softener and a low-residue diet.
Intraoperative hemorrhage invariably is the result of failure to ligate securely a significant blood vessel, bleeding from the vaginal cuff, slippage of a previously placed ligature, or avulsion of tissue before clamping. Most intraoperative bleeding can be avoided with adequate exposure and good surgical technique. Using square knots with attention to proper knot-tying mechanisms will prevent bleeding in most cases. The use of Heaney-type sutures may minimize ligature slippage and subsequent bleeding from bulky pedicles. When bleeding does occur, blind clamping, which may endanger the ureter, should be avoided. The bleeding vessel should be identified and precisely ligated, with visualization of the ureter if necessary. If the location of the ureter is in question, it should be visualized before suturing a bleeding vessel.
Perioperative Care Bladder Drainage Postoperative bladder drainage should be employed after any procedure in which spontaneous, complete voiding is not anticipated. Reasons to consider closed bladder drainage include significant local pain, additional vaginal reparative procedures, surgery for stress incontinence, the use of a vaginal pack, and patient anxiety.
After vaginal hysterectomy without additional repair, most patients can void spontaneously, and catheter drainage is not required. The relative amount of pain after a vaginal hysterectomy is less than with abdominal hysterectomy and, in the absence of additional repairs or a pack, no obstructive effect should be present.
If the patient does not tolerate pain well postoperatively or is extremely anxious, the transurethral insertion of a 16-Fr. catheter after completing surgery is warranted. This catheter may be inserted postoperatively if the patient is unable to void spontaneously on two attempts. Closed-catheter drainage after vaginal hysterectomy usually is not necessary for longer than 24 hours. The catheter is removed without clamping, and there is no need to obtain a urine specimen for culture and sensitivity.