VAGINAL VAGINAL HYSTERECTOMY FOR HYSTERECTOMY FOR

BIG UTERIBIG UTERIDr. N. P. Pai-DhungatDr. N. P. Pai-Dhungat

D.G.O., D.N.B., M.R.C.O.G.D.G.O., D.N.B., M.R.C.O.G.Bombay Hospital Institute of Medical Bombay Hospital Institute of Medical

Sciences, MumbaiSciences, Mumbai

THANK YOUTHANK YOU

Dr. P B Pai-DhungatDr. P B Pai-Dhungat

Organisers Organisers

CAMPBELL 1946CAMPBELL 1946

The bulk of the uterus to be removed is The bulk of the uterus to be removed is not a contraindication to the vaginal route.not a contraindication to the vaginal route.

60 years later no need to change the 60 years later no need to change the dictumdictum

Why Vaginal hysterectomyWhy Vaginal hysterectomy

EVALUATE study EVALUATE study

Multicentre randomised controlled studyMulticentre randomised controlled study

Where possible vaginal route should be Where possible vaginal route should be preferredpreferred

Cochrane reviews confirms the sameCochrane reviews confirms the same

Evidence I BEvidence I B

Advantages of Vaginal Advantages of Vaginal HysterectomyHysterectomy

Shorter duration of hospital stayShorter duration of hospital stay

Speedier return to routine activitiesSpeedier return to routine activities

Fewer incidences of fever, infectionsFewer incidences of fever, infections

Morbidity significantly reduced.Morbidity significantly reduced.

Cost benefit analysisCost benefit analysis

Too much zeal for what is new and Too much zeal for what is new and contempt for what is oldcontempt for what is old

Laparoscopic HysterectomyLaparoscopic Hysterectomy

Benefits of vaginal hysterectomyBenefits of vaginal hysterectomy

Longer duration of surgeryLonger duration of surgery

Costlier equipmentCostlier equipment

Higher incidence of ureteral injuryHigher incidence of ureteral injury

Greater surgical expertiseGreater surgical expertise

Need for trainingNeed for training

Criteria for approachCriteria for approachSheth’sSheth’s

Clinical examinationClinical examination

Absence of contraindicationsAbsence of contraindications

Detailed Ultrasound studyDetailed Ultrasound study

Laxity/ rigidity of tissuesLaxity/ rigidity of tissues

Availability of uterus free spaceAvailability of uterus free space

Access to large fibroidAccess to large fibroid

ExperienceExperience

CriteriaCriteria

Good assistanceGood assistance

Good anaesthesiaGood anaesthesia

Good exposure—instruments, positionGood exposure—instruments, position

InstrumentsInstruments

Retractors- Jayle’s, Auvard’s, Soonawala, Retractors- Jayle’s, Auvard’s, Soonawala, Dever’s, Breisky- NavratilDever’s, Breisky- Navratil

ClampsClamps

Myoma ScrewMyoma Screw

TenaculumTenaculum

Bull dog vulsellumBull dog vulsellum

Size of FibroidsSize of Fibroids

Largest that we have removed is 1350 Largest that we have removed is 1350 gms.gms.

P C Mahapatra, A Magos, Paily, Sheth, V P C Mahapatra, A Magos, Paily, Sheth, V Shah, A Virkud routinely report removal of Shah, A Virkud routinely report removal of such large fibroids.such large fibroids.

Technical AspectsTechnical Aspects

Good cervical traction. Good cervical traction.

Open the posterior pouch even if anterior Open the posterior pouch even if anterior cannot be openedcannot be opened

Ligate and cut parametriumLigate and cut parametrium

Bladder DissectionBladder Dissection

Bladder has to be well retracted at all Bladder has to be well retracted at all times especially if anterior peritoneum is times especially if anterior peritoneum is not opened.not opened.

Fibroid higher than internal os.Fibroid higher than internal os.

Fibroid at or lower than internal osFibroid at or lower than internal os

Technical AspectsTechnical Aspects

Once the uterines are ligated, no reason Once the uterines are ligated, no reason why a fibroid of any size cannot be why a fibroid of any size cannot be removed.removed.

Difficult in cases of large cervical fibroid.Difficult in cases of large cervical fibroid.

Technical AspectTechnical Aspect

After the uterines are ligated and cut, After the uterines are ligated and cut, suture and cut the broad ligament.suture and cut the broad ligament.

Either reverse the uterusEither reverse the uterus

Start myomectomy or morcellation Start myomectomy or morcellation

Restart suturing and cutting the broad Restart suturing and cutting the broad ligament till the cornuals are reached.ligament till the cornuals are reached.

WarningWarning

However difficult and however big the However difficult and however big the uterus never dissect lateral to the uterine uterus never dissect lateral to the uterine ligatures.ligatures.

If you start dissecting lateral to the If you start dissecting lateral to the uterines you are on the lateral pelvic wall uterines you are on the lateral pelvic wall with risk of injury to the ureter or uterines with risk of injury to the ureter or uterines where it is difficult to ligate themwhere it is difficult to ligate them

AIM : To remove large AIM : To remove large fibroids but cause fibroids but cause minimal damage to pelvis minimal damage to pelvis and vagina.and vagina.

Removal in toto-- Removal in toto-- myomectomymyomectomy

MorcellationMorcellation

Lash techniqueLash technique

Bisection of the uterusBisection of the uterus

CoringCoring

MorcellationMorcellation

Successive chunks of the fibroid are held Successive chunks of the fibroid are held and cut outand cut out

Large wedges of tissue are removed.Large wedges of tissue are removed.

Lash techniqueLash technique

Circumferential incisions given just below Circumferential incisions given just below the serosa and parallel to it.the serosa and parallel to it.

Strong cervical tractionStrong cervical traction

Enlarged fundus delivers as an elongated Enlarged fundus delivers as an elongated mass.mass.

BisectionBisection

Cut in the midline from below upwards.Cut in the midline from below upwards.

Try to reach upto the fundus by Try to reach upto the fundus by successively applying clamps.successively applying clamps.

Offers more space to apply the clamps.Offers more space to apply the clamps.

Often combined with morcellation or Often combined with morcellation or myomectomy.myomectomy.

Anterior FibroidAnterior Fibroid

If low down and upto 7 cms, may reach it If low down and upto 7 cms, may reach it from anterior aspectfrom anterior aspect

Be careful of BladderBe careful of Bladder

Bissect the uterus to reach the fibroidBissect the uterus to reach the fibroid

Cut through the posterior wallCut through the posterior wall

Posterior FibroidPosterior Fibroid

Easier accessEasier access

Myomectomy or morcellateMyomectomy or morcellate

Technical aspectsTechnical aspects

Disconnect from one side upto cornuals Disconnect from one side upto cornuals and then reverse or morcellateand then reverse or morcellate

Schukhardt’s incisions.Schukhardt’s incisions.

AdjunctsAdjuncts

Use of harmonicUse of harmonic

Use of BiclampUse of Biclamp

Laparoscopy pre vaginal or post vaginalLaparoscopy pre vaginal or post vaginal

USGUSG

MRIMRI

UrographyUrography

Ureteric catherizationUreteric catherization

DrainageDrainage

Use of Foley’s drain.Use of Foley’s drain.

Minimizes collectionMinimizes collection

Helps monitor the Helps monitor the patient.patient.

ContraindicationsContraindications

Except malignancy with large uteri, there Except malignancy with large uteri, there should be no contraindication.should be no contraindication.Endometriosis, suspected adhesions may Endometriosis, suspected adhesions may be tackled with Laparoscopy followed by be tackled with Laparoscopy followed by vaginal hysterectomyvaginal hysterectomyLarge subserous fibroid may need to be Large subserous fibroid may need to be confirmed with laparoscopy after confirmed with laparoscopy after hysterectomy.hysterectomy.Previous scars relative contraindicationPrevious scars relative contraindication

ContraindicationsContraindications

Citadel uterusCitadel uterus

Very little space to workVery little space to work

Sudden bulging of the uterus at the anglesSudden bulging of the uterus at the angles

Our experienceOur experience

2005 to 20082005 to 2008

500-1000 gms 42 cases500-1000 gms 42 cases

>1000 gms 5 cases>1000 gms 5 cases

Our SeriesOur Series

0%

1%

1%

2%

2%

3%

Fever BloodTrans

Uretericinjury

Bladderinjury

Prolongedvaginal

Discharge

vaginalhysterectomy

DurationDuration

< 60 mins

1-2 hrs

> 2hrs

Hospital StayHospital Stay

0

5

10

15

20

25

30

35

40

45

48 hrs 72 hrs >96 hrs

Column 1

ComplicationComplication

Neuropraxia of Femoral NerveNeuropraxia of Femoral Nerve

Weakness at knee jointWeakness at knee joint

Parasthesia over the knee jointParasthesia over the knee joint

Avoid exaggerated lithotomy for prolonged Avoid exaggerated lithotomy for prolonged periodsperiods

PhysiotherapyPhysiotherapy

TrainingTraining

Start with easy casesStart with easy cases

Build up confidenceBuild up confidence

Good assistance, anaesthesiaGood assistance, anaesthesia

Use of adjunctsUse of adjuncts

Thank YouThank You