Morcellation of the Large Uterus Uterine morcellation is a well-known but underutilized surgical procedure whereby the uterus is removed piecemeal. Several methods of uterine morcellation were described, including hemisection or bivalving, wedge or “V” incisions, and intramyometrial coring (53). Before beginning any morcellation procedure, the uterine vessels must be ligated, and the peritoneal cavity must be entered. When uterine hemisection or bivalving is performed, the cervix is split at the midline, and the uterus is cut into halves, which are removed separately (53). This method seems best suited for fundal, midline leiomyomas.
Wedge morcellation is best suited for anterior or posterior fibroids or for fibroids in the other broad ligaments (i.e., when the fibroids are away from the midline). The cervix is amputated, and the myometrium is grasped with clamps. Wedge-shaped portions of myometrium are removed from the anterior or posterior uterine wall. The apex of the wedge is kept in the midline, thereby reducing the bulk of the myometrium. This process is repeated until the uterus can be removed or until a pseudocapsule of a fibroid can be grasped with a Leahy clamp or towel clip. Traction is applied, and a “myomectomy” is performed.
When the intramyometrial coring technique is used, the myometrium above the site of the ligated vessels is incised parallel to the axis of the uterine cavity and serosa of the uterus. This incision is continued around the full circumference of the myometrium in a symmetrical fashion beneath the uterine serosa. Traction is maintained on the cervix, and the avascular myometrium is cut to allow the undisturbed endometrial cavity, with a thick layer of myometrium, to be delivered with the cervix. As a result, the inside of the uterus with its unopened endometrial cavity is brought closer to the operator. Incision of the lateral portions of the myometrium medial to the remaining attachment of the broad ligament results in considerable additional descent of the uterus and greatly increases the mobility of the uterine fundus. The uterus is converted from a globular to an elongated tissue mass. The cored uterus is removed by clamping the utero-ovarian pedicle and fallopian tubes.
In a retrospective comparison of 383 patients undergoing abdominal hysterectomy or vaginal hysterectomy with uterine morcellation, length of stay and perioperative complications were significantly increased with abdominal hysterectomy. It appears that vaginal hysterectomy with uterine morcellation is safe and allows an increased number of women to undergo vaginal hysterectomy (54).
McCall Culdoplasty Although McCall culdoplasty is thought to help decrease future enterocele formation, the accuracy of this belief remains open to debate. An absorbable suture is placed through the full thickness of the posterior vaginal wall at the point of the highest portion of the vaginal vault. The patient’s left uterosacral ligament pedicle is grasped and sutured. The suture incorporates the posterior peritoneum, between the uterosacral ligaments and the right uterosacral ligament. The suture is completed by passing the needle from the inside to the outside at the same point at which it was begun. The suture is tied, thereby approximating the uterosacral ligaments and the posterior peritoneum.