The use of Hegar's dilator for finding correct planes around the uterus

Introduction

During laparoscopy-assisted and open surgery, finding the correct planes between the uterus, bladder and rectum can be difficult. There could also be significant blood loss. We describe how the 15F Hegar's dilator could be used to find the correct planes.

Materials and method

During laparoscopic surgery to enter the pouch of Douglas the 15F Hegar's dilator should be placed in the posterior fornix while the uterus is pushed superiorly and anteriorly with a smaller dilator in the uterus (placed earlier). The vaginal wall over the 15F dilator can be incised using a hook and, once the dilator comes inside the abdomen in the correct plane, the rest of the dissection can be carried out comfortably (Figure 1).

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Figure 1

Finding the plane in the posterior fornix

While carrying out Wertheim's hysterectomy, or a difficult hysterectomy, the patient should be positioned on a table with the legs spread out and the 15F Hegar's dilator can then be used to get the anterior vaginal wall dissected after separating it from the bladder. Pushing with the dilator helps to dissect the bladder off the vaginal wall and enables the surgeon to avoid cutting into the cervix (Figure 2).

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Figure 2

Finding the anterior plane during difficult hysterectomy

Discussion

Entry into the correct plane in the posterior fornix is required for surgery such as: laparoscopy-assisted hysterectomies; the removal of a larger specimen through the posterior fornix in surgery such as laparoscopic ovarian cystectomy; and the removal of other lumps during laparoscopic surgery. This method has the advantages of:

Reaching the correct plane of dissection;