Colpotomy

Colpotomy

Definition

A colpotomy, also known as a vaginotomy, is a procedure by which an incision is made in the vagina.

Purpose

A colpotomy is performed either to visualize pelvic structures or to perform surgery on the fallopian tubes or ovaries.

Role of colpotomy in gynecologic surgery

Several gynecologic surgery protocols require a colpotomy as part of the overall surgical procedure. It is performed whenever the surgeon needs to access the vagina. Several of these surgeries include:

• Tubal sterilization. Sterilization is a procedure that can be performed using either abdominal or vaginal procedures. When a vaginal procedure is selected by the surgeon, he performs a colpotomy and may also insert a culdoscope to locate the tubes (culdoscopy), and close them off.
• Removal of myomas. Myomas are fibroid tumors of the muscle tissue of the uterus and they are sometimes removed vaginally by colpotomy.
• Removal of pelvic cysts and masses. In one treatment variant, patients may undergo a laparoscopy followed by a colpotomy for the vaginal extraction of the pelvic cyst or mass.
• Hysterectomy . One technique used to surgically remove the uterus combines three steps, an initial laparoscopic stage, followed by a vaginal stage, and a final laparoscopic stage. The colpotomy is performed during the second step to deliver the uterus into the vagina.
• Dysmenorrhea. Separation of the uterosacral ligaments via colpotomy is an approach that has been used for the relief of dysmenorrhea (painful menstruation).
• Complications in pregnancy and childbirth. Colpotomy may be used in the management of difficult pregnancies and childbirths.

Demographics

According to Professor V. Base-Smith at the University of Cincinnati College of Nursing, removal of the uterus is the second most commonly performed surgical procedure in the United States after cesarean delivery. Analysis of the demographics show that:

• 650,000 hysterectomies are performed annually, expected to reach approximately 834,000 by 2005.
• 6.1–8.6 per 1,000 women undergo hysterectomy per year.
• In the United States, the Northeast has the lowest hysterectomy rate, while the South has the highest rate.
• African-American women experience hysterectomy more frequently than European-American women.

The ratio of abdominal to vaginally performed hysterectomies is 3:1, meaning that colpotomy is performed in one out of four hysterectomy procedures.

Female sterilization is a common contraception method. About 20,000 female sterilizations are carried out each year in Canada and nearly 10% of North American women 30 years or older have been sterilized in a procedure that involved colpotomy.

Description

The patient is placed in a supine position on the operating table with her legs in stirrups and the incision site is prepared. An antiseptic solution, such as chlorhexidine, is applied to the skin using highly disinfected forceps and gauze swabs. The patient is covered with surgical drapes with the window positioned directly over the incision site. Throughout the procedure, the vital signs of the patient are monitored (blood pressure, pulse, respiratory rate) as well as her level of consciousness and blood loss. Pain management depends on the surgery that requires the colpotomy, and may involve local, regional, or general anesthesia. The incision is only made as large as necessary for the requirements of the overall surgery.

For example, when a decision has been made to remove a myoma by colpotomy, the procedure may proceed as follows:

• A small myoma screw is inserted into the myoma and a grasper with locking mechanism is placed on the lower edge of the wound.
• The myoma is directed toward the cul-de-sac using the myoma screw.
• A colpotomy is performed.
• The myoma is grasped and removed vaginally. During this part of the procedure, the surgeon examines whether the myoma extends into the uterine cavity.
• If it does, the uterus is guided to the colpotomy site. T-clamps are placed on the edges of the wounds and the fundus of the uterus is delivered, via the colpotomy incision, into the vagina.
• The uterus is sutured in three layers (endometrial, myometrial and serosal).
• The repaired uterus is returned to the abdominal cavity.
• The colpotomy incision is sutured.

Preparation

The procedure is explained to the patient within the broader context of the surgery that includes the colpotomy. Preoperative preparation includes whatever is required for the overall surgical procedure that will be performed.

Aftercare

Aftercare for colpotomy is associated with the overall surgery that required the colpotomy.

For example, if a colpotomy is performed for tubal ligation (female sterilization), the procedure takes only 15–30 minutes and women usually go home the same day. It may take a few days at home to recover. Sexual intercourse is usually postponed until the colpotomy incision is completely healed, and as advised by the doctor. The healing process usually requires several weeks and there are no visible scars. In the case of a colpotomy performed for myoma removal, aftercare is more elaboate with the patient's vital signs monitored in the recovery room until she regains consciousness.

Risks

Complications such as bleeding, infection, or reaction to the anesthetic, may occur as with any type of gynecological surgery.

Normal results

Colpotomy results are considered normal when the incision performed allows the surgeon to meet the goal of the overall surgical protocol.

Morbidity and mortality rates

Colpotomy morbidity rates are not reported. This is because the procedure represents one surgical process in an operation that involves other surgical peocedures. In the case of colpotomy performed in the context of tubal sterilization, morbidity with tubal ligation is 5%; mortality is less than 4 in 100,000 cases.

As for hysterectomies, a higher morbidity and mortality rate is associated with abdominal than with vaginal hysterectomy surgery, the latter procedure being the only one to involve colpotomy.

Alternatives

In the case of colpotomy used for tubal ligation procedures, laparoscopy or laparotomy procedures are currently the preferred technique, since fewer and fewer U.S. surgeons are trained to use colpotomy as an approach for sterilization.

See also Laparotomy, exploratory.

Resources

books

masterson, b. j. manual of gynecologic surgery (comprehensive manuals of surgical specialties). new york: springer verlag, 1986.

reiffenstahl, g., w. platzer, and p.-g. knapstein. vaginal operations. philadelphia: lippincott, williams & wilkins, 1996.

stewart, e. g., and p. spencer. the v book: a doctor's guide to complete vulvovaginal health. new york: bantam doubleday dell publishers, 2002.

periodicals

diakomanolis, e., a. rodolakis, z. boulgaris, g. blachos, and s. michalas. "treatment of vaginal intraepithelial neoplasia with laser ablation and upper vaginectomy." gynecologic and obstetric investigation 54 (2002): 17-20, 419-427.

ghezzi, f., l. raio, m. d. mueller, t. gyr, m. buttarelli, and m. franchi. "vaginal extraction of pelvic masses following operative laparoscopy." surgical endoscopy 16 (december 2002): 1691-1696.

goodlin, r. c. "in defense of the anterior vaginotomy." journal of reproductive medicine 47 (august 2002): 693-694.

gortzak-uzan, l., a. walfisch, y. gortzak, m. katz, m. mazor, and m. hallak. "accidental vaginal incision during cesarean section. a report of four cases." journal of reproductive medicine 46 (november 2001): 1017-1020.

ou, c. s., a. harper, y. h. liu, and r. rowbotham. "laparoscopic myomectomy technique. use of colpotomy and the harmonic scalpel." journal of reproductive medicine 47 (october 2002): 849-853.

organizations

american association of gynecological laparoscopists. 13021 east florence avenue, sante fe springs, ca 90670-4505. (800) 554-2245. <www.aagl.com/>.

american college of obstetricians and gynecologists. 409 12th street, sw, washington, dc 20024-2188. e-mail: resources@acog.org. <www.acog.org/>.

american society for colposcopy and cervical pathology. 20 west washington street, suite 1, hagerstown, md 21740. (301) 733-3640 or (800) 787-7227. <www.asccp.org>.

national association for women's health. 300 w. adams street, suite 328, chicago, il 60606-5101. (312) 786-1468. <www.nawh.org/>.

other

"culdocentesis and colpotomy." managing complications of pregnancy and childbirth: a guide for midwives and doctors. world health organization. [cited may 14, 2003]. <http://www.who.int/reproductive-health/impac/procedures/culdocentesis_p69_p70.html>.

national women's health information center. u.s. department of health and human services. [cited may 14, 2003]. <http://www.4woman.org/>.

Monique Laberge, Ph.D.

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

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A colpotomy is performed by a gynecological surgeon either in an outpatient clinic or in a hospital setting, depending on the overall surgical procedure of which the colpotomy is a part.

QUESTIONS TO ASK THE DOCTOR

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• Why is a colpotomy required?
• What are the risks involved?
• How many such procedures do you perform in a year?
• How soon can I have sexual intercourse again?
• Is the procedure painful?