With the increasing rate of cesarean sections, it is imperative that the the number of cases with the scar on the uterus are going to increase.Cases who have had a scar on the uterus secondary to some surgery on the uterus ,for example,myomectomy also contribute.
Adhesions are the commonest consequence of any surgery on the uterus .And when we contemplate hysterectomy in such cases,taking care of these adhesions is a task.
These adhesions are
1) Between the bladder and the uterus (Commonest) .Generally an area of 2-3 cms over the lower uterine segment ,or just over the superior surface of the cervix and the lower part of the body of the uterus,at the level of uterine artery pedicle ,is the site where the adhesion of the bladder is the densest.To dissect the bladder away,one has to go through the lateral utero-vesical window or Sheths space.After taking the semilunar incision on the cervix,one can enter this space by either a finger or an artery forcep from the either of the corner angles of the incision,anteriorly.One would find a space which is devoid of any adhesions. Using this as a guide,start the sharp dissection of the scar close to the surface of the uterus ,bit by bit.till one opens the anterior pouch.
2) Parietal adhesions
These are the consequence of any surgery of the abdomen.Omentum and at times the bowel is stuck to the parietal surface obscuring the approach to the uterus. Many a times the bladder is pulled up and adherent to the anterior abdominal wall,making it difficult to separate.
3) Adhesions between the rectum and the uterus post surgery are rare.
Now when we consider the route of hysterectomy in such cases,it is my firm opinion that vaginal route is the best route ,because
a) one does not have to encounter the parietal adhesions before actually reaching the uterus,as one has to by abdominal or the laparoscopic route. These parietal adhsions are well settled ones and there is no need to disturb them.
b) one just has to dissect about 2 to 2.5 inches of the surface of the uterus to push the bladder away. This is closest and easiest by the vaginal route.
I believe the use of laparoscope is limited to tackle any band of adhesion which is pulling the uterus up
In case the bladder is accidentally nicked ,it is important to identify it on table and suture it off in 2 layers with 3-0 delayed absorbable suture.
