Knowing how to navigate the vesicocervical space during vaginal hysterectomy makes all the difference, according to Dr.
"This little space scares gynecologic surgeons into abdominal hysterectomy" because the proximity of C-section scar tissue to the bladder narrows the vesicocervical space and makes it trickier to cut into the peritoneum without hitting the bladder," he said at a conference on vaginal surgery sponsored by the Society of Pelvic Reconstructive Surgeons.
Kovac advocated a particular method of entering the peritoneum using sharp dissection rather than the more common blunt dissection into the vesicocervical (or adventitial) space, which separates the lower uterine segment from the bladder.
With the more common blunt dissection during vaginal hysterectomy, the surgeon pushes the supravaginal septum and vesicocervical space upward with a finger on a piece of gauze or with a sponge stick in an attempt to expose or enter the anterior peritoneum.
After the supravaginal septum is cut, the vesicocervical space is easily entered and more space is created by spreading the scissors laterally.
Once the upper part of the vesicocervical space is entered, the peritoneum becomes exposed so that it may be entered with scissors under direct dissection.