VAGINAL%20HYSTERECTOMY%20FOR%20BIG%20UTERI

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VAGINAL HYSTERECTOMY FOR BIG UTERI

• Dr. N. P. Pai-Dhungat
• D.G.O., D.N.B., M.R.C.O.G.
• Bombay Hospital Institute of Medical Sciences,
  Mumbai

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THANK YOU

• Dr. P B Pai-Dhungat
• Organisers

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• CAMPBELL 1946
• The bulk of the uterus to be removed is not a
  contraindication to the vaginal route.
• 60 years later no need to change the dictum

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Why Vaginal hysterectomy

• EVALUATE study
• Multicentre randomised controlled study
• Where possible vaginal route should be preferred
• Cochrane reviews confirms the same
• Evidence I B

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Advantages of Vaginal Hysterectomy

• Shorter duration of hospital stay
• Speedier return to routine activities
• Fewer incidences of fever, infections
• Morbidity significantly reduced.
• Cost benefit analysis

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

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Laparoscopic Hysterectomy

• Benefits of vaginal hysterectomy
• Longer duration of surgery
• Costlier equipment
• Higher incidence of ureteral injury
• Greater surgical expertise
• Need for training

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Criteria for approachSheths

• Clinical examination
• Absence of contraindications
• Detailed Ultrasound study
• Laxity/ rigidity of tissues
• Availability of uterus free space
• Access to large fibroid
• Experience

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Criteria

• Good assistance
• Good anaesthesia
• Good exposureinstruments, position

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Instruments

• Retractors- Jayles, Auvards, Soonawala,
  Devers, Breisky- Navratil
• Clamps
• Myoma Screw
• Tenaculum
• Bull dog vulsellum

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Size of Fibroids

• Largest that we have removed is 1350 gms.
• P C Mahapatra, A Magos, Paily, Sheth, V Shah, A
  Virkud routinely report removal of such large
  fibroids.

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Technical Aspects

• Good cervical traction.
• Open the posterior pouch even if anterior cannot
  be opened
• Ligate and cut parametrium

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Bladder Dissection

• Bladder has to be well retracted at all times
  especially if anterior peritoneum is not opened.
• Fibroid higher than internal os.
• Fibroid at or lower than internal os

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Technical Aspects

• Once the uterines are ligated, no reason why a
  fibroid of any size cannot be removed.
• Difficult in cases of large cervical fibroid.

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Technical Aspect

• After the uterines are ligated and cut, suture
  and cut the broad ligament.
• Either reverse the uterus
• Start myomectomy or morcellation
• Restart suturing and cutting the broad ligament
  till the cornuals are reached.

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Warning

• However difficult and however big the uterus
  never dissect lateral to the uterine ligatures.
• If you start dissecting lateral to the uterines
  you are on the lateral pelvic wall with risk of
  injury to the ureter or uterines where it is
  difficult to ligate them

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• AIM To remove large fibroids but cause minimal
  damage to pelvis and vagina.
• Removal in toto-- myomectomy
• Morcellation
• Lash technique
• Bisection of the uterus
• Coring

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Morcellation

• Successive chunks of the fibroid are held and cut
  out
• Large wedges of tissue are removed.

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Lash technique

• Circumferential incisions given just below the
  serosa and parallel to it.
• Strong cervical traction
• Enlarged fundus delivers as an elongated mass.

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Bisection

• Cut in the midline from below upwards.
• Try to reach upto the fundus by successively
  applying clamps.
• Offers more space to apply the clamps.
• Often combined with morcellation or myomectomy.

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Anterior Fibroid

• If low down and upto 7 cms, may reach it from
  anterior aspect
• Be careful of Bladder
• Bissect the uterus to reach the fibroid
• Cut through the posterior wall

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Posterior Fibroid

• Easier access
• Myomectomy or morcellate

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Technical aspects

• Disconnect from one side upto cornuals and then
  reverse or morcellate
• Schukhardts incisions.

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Adjuncts

• Use of harmonic
• Use of Biclamp
• Laparoscopy pre vaginal or post vaginal
• USG
• MRI
• Urography
• Ureteric catherization

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Drainage

• Use of Foleys drain.
• Minimizes collection
• Helps monitor the patient.

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Contraindications

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

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Contraindications

• Citadel uterus
• Very little space to work
• Sudden bulging of the uterus at the angles

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Our experience

• 2005 to 2008
• 500-1000 gms 42 cases
• gt1000 gms 5 cases

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Our Series
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Duration
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Hospital Stay
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Complication

• Neuropraxia of Femoral Nerve
• Weakness at knee joint
• Parasthesia over the knee joint
• Avoid exaggerated lithotomy for prolonged periods
• Physiotherapy

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Training

• Start with easy cases
• Build up confidence
• Good assistance, anaesthesia
• Use of adjuncts

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Thank You