Alarge leiomyomatous polyp filling the vagina is best removed vaginally, even if the woman requires an abdominal hysterectomy for additional indications.1 But if its pedicle is very thick or cannot be reached vaginally, the polyp has to be removed abdominally, along with the uterus. A new method of division of its pedicle abdominally and its removal vaginally is presented. This avoids contamination of the peritoneal cavity by discharge on the surface of the polyp.

Between 1984 and 2003, a total of twelve women with large leiomyomatous polyps arising from the supravaginal cervix and filling the entire vagina presented for relief from symptoms like menorrhagia, leucorrhoea, retention of urine, and lump in abdomen. In all of them, there was no space available by the sides of the polyp to reach the pedicle with a clamp. The pedicles were also found to be very thick, so that the polyps could not be removed by twisting until the pedicles broke. Some of the polyps were friable due to degeneration, so that holding them with traumatic instruments for twisting would have aused lacerations and severe blood loss, which would have been dangerous in face of preexisting anaemia. Abdominopelvic ultrasonography was done in all cases to assess the size of the polyp and the thickness of the pedicle, besides assessment of other structures and the urinary tract. Renal function tests were done to diagnose renal decompensation due to backpressure changes, if any.These women were subjected to combined abdomino-vaginal polypectomy and abdominal hysterectomy under spinal or general anaesthesia. During an exploratory laparotomy, the round ligaments and the cornual structures were clamped, cut, and ligated by the conventional technique.2 The uterovesical fold of peritoneum was divided transversely and the urinary bladder was dissected off the distended cervix and vagina, and pushed downwards. The distended and stretched supravaginal cervix and upper vagina were cut longitudinally posteriorly in the midline using cutting unipolar electrocautery and scalpel as required. The pedicle was reached and examined by digital palpation. One stout curved clamp was placed on either side of the pedicle until the tips of the two clamps met in the midline beyond the pedicle, but still within the uterus. The clamps helped define the limits of the pedicle so that the structures beyond were protected while the pedicle was divided with cutting unipolar electrocautery and/or scalpel as seen in Fig. 1. They also stretched the pedicle backwards, making its division easier. After complete division of the pedicle, the polyp was held with a bulldog Vulsellum passed vaginally, and was removed vaginally by traction from below while pushing digitally from above. If it was found to be too large to pass through the introitus, it was bisected with a scalpel while still in the vagina. The traction was made on it vaginally by holding one of its half divided end, so that it unfolded and its transverse width reduced by 50%. The instruments used within the cervicovaginal cavity and the gloves were discarded, so as to avoid contamination of the peritoneal cavity. The divided edges of the cervix and the vagina were held together with an Allis forceps to restore near-normal shape. Then abdominal hysterectomy was completed by conventional technique.

The ages of the women ranged between 35 and 45 years average being 41.5 years. All the women were married and parous. Table 1 shows their presenting complaints.

A leiomyomatous polyp in the vagina is best removed by vaginal polypectomy.1 It is a short procedure that can be done under local anaesthesia with minimal complications. If the patient requires hysterectomy for additional uterine leiomyomas, it is better to perform a vaginal hysterectomy after the polypectomy, if at all possible. If not, an abdominal hysterectomy is performed. Vaginal removal of the polyp prior to abdominal hysterectomy is safer, because it avoids contamination of the peritoneum associated with abdominal removal of the polyp.1

If the pedicle of the polyp cannot be reached vaginally due to large size of the polyp, it cannot be clamped and cut. In such a case if the pedicle is thick, the polyp cannot be removed by twisting, because the pedicle does not break very easily. Such attempts are also associated with the risk of severe bleeding due to laceration of the polyp held with traumatic instruments. These difficulties are overcome by using the technique described by us. The pedicle can be reached very easily through a posterior cervico-vaginotomy. There is no risk of any injury to any adjacent structure because there is no structure nearby. An anterior cervico-vaginotomy could be associated with the risk of an injury to the urinary bladder. Division of the pedicle over two stout, curved pedicle clamps placed beyond it is associated with no risk of accidental injury to any structure beyond, because all the cutting is done within the cervico-vaginal cavity, and penetration of the wall beyond is prevented by the clamps, which function as back stops. Usually a large polyp cannot be delivered through the introitus, unless there is laxity of the perineum and gaping of the introitus. Our technique of dividing it into two half-way (hemi-bisection) permits unfolding of the polyp and reduction in its width associated with elongation, it can then be delivered vaginally by making traction on one divided end. Removal of the polyp shrinks the cervix and vagina, so that space is made available in the pelvis for applying clamps to pedicles below the level of the uterine vessels, and for cutting the vagina. Since the polyp never passes through the peritoneal cavity, the risk of contamination with the discharge on its surface and development of pelvic infection postoperatively is minimized. There is no significant bleeding during the procedure. The stretched cervix and the vagina do not bleed much after cervico-vaginotomy. The pedicle also does not usually bleed significantly, and if at all it does, electrocauterisation or figure-of-eight sutures before proceeding with hysterectomy can stop the bleeding immediately. We did not have to put haemostatic sutures on any pedicle of the polyp after its division.

The technique is a superior alternative to Rutherford Morrison’s technique of bisection of the uterine corpus and cervix to reach the cervical leiomyomatous polyp for its removal. That technique is associated with more bleeding, because the uterine vessels cannot be secured completely prior to the removal of the polyp.1 Our technique can further be extended for removal of the polyp and conserving the uterus. A vaginotomy for division of the pedicle heals well, and there would be no risk of its rupture in a future pregnancy. The uterus may not heal very well after bisection by Rutherford-Morrison’s technique, and is at a risk of rupture in a future pregnancy.3