Hysterectomy past present & future

HYSTERECTOMY PAST, PRESENT & FUTURE

Sandesh KamdiM.Pharm (Pharmacology)

HYSTERECTOMY FOR BENIGN GYNECOLOGY

Vaginal Abdominal Laparoscopic Robotic

HYSTERECTOMY: PAST AND PRESENT Vaginal hysterectomy (VH)

VH was performed by Themison of Athens in 50 BC by removing an inverted uterus that had become gangrenous.1

The first authenticated VH was performed by the Italian anatomist Berengario da Carpi of Bologna in 1507.

1. J Minim Invasive Gynecol 2010; 17(4):421-35. 2. Best Pract Res Clin Obstet Gynaecol 2005; 19:295-305.

HYSTERECTOMY: PAST AND PRESENT Self performed VH !!

In the early 17th century a 46-year-old peasant named Faith Haworth was carrying a heavy load when her uterus prolapsed completely.

Frustrated by this frequent occurrence, she grabbed her uterus, pulled as hard as possible, and cut the whole lot of it with a short knife.

The bleeding soon stopped and she lived on for many years, with a persistent vesico-vaginal fistula

Clin Obstet Gynaecol 1997; 11:1-22.

Noble Sproat Heaney - Chicago

One of the strongest proponents of vaginal

hysterectomy In 1934 he reported a series of 627 VH performed for benign pelvic disease, resulting in death in only three cases.

Best Pract Res Clin Obstet Gynaecol 2005;19:295-305.

In the first part of 20th century, Before the development of

gynaecology as separate speciality,many hysterectomies were done by general surgeons who, has not being

familiar with vaginal surgery, favoured the

abdominal route.

HYSTERECTOMY: PAST AND PRESENT

Abdominal Hysterectomy The pathway to abdominal

hysterectomy was laid down with the first laparotomy in the 19th century.

The human abdomen was deliberately surgically opened for the first time by Ephraim McDowell (Kentucky)

He successfully removed a 10.2 kg ovarian tumor without anaesthesia in 18095.

HYSTERECTOMY: PAST AND PRESENT

Ephraim McDowell (Kentucky)

Baillieres Clin Obstet Gynaecol 1997; 11:1-22.

Abdominal Hysterectomy He successfully removed a

10.2 kg ovarian tumor without anaesthesia in 18095.

McDowell operated on the kitchen table, performing an ovariotomy.

The operation lasted only 25 minutes, but was carefully planned.

After a rapid recovery, the patient lived for more than 30 years6.

HYSTERECTOMY: PAST AND PRESENT

Ephraim McDowell (Kentucky)

Baillieres Clin Obstet Gynaecol 1997; 11:1-22.

Radical HysterectomyRadical hysterectomy was

initially developed as a surgical treatment for cervical cancer due to the absence of other modalities of treatment.

John Clark performed the first radical hysterectomy at Johns Hopkins Hospital, in 1895.

HYSTERECTOMY: PAST AND PRESENT

Best Pract Res Clin Obstet Gynaecol 2005;19:387-401.

Laparoscopic HysterectomyThe first human laparoscopy was

performed by Hans Christian Jacobaeus of Stockholm in 1911, by using pneumoperitoneum and the Nitze cystoscope.

It was Raoul Palmer of France who popularised gynaecological laparoscopy in the 1940’s and who is considered to be the father of modern gynaecological laparoscopy

HYSTERECTOMY: PAST AND PRESENT

Hans Christian Jacobaeus

(Stockholm)

doctoral thesis. Helsinki: Medical Faculty University of Helsinki;1999.

Raoul Palmer (France)

Robotic Laparoscopic Hysterectomy

The first successful surgery using the da Vinci surgical system was performed in Belgium in 1997.

da Vinci S and da Vinci SI is equiped with double optic which gives the operator three-dimensional view of the operative field, and with adjustable magnification, enabling much improved vision of the pelvis.

HYSTERECTOMY: NOW

da Vinci surgical system

THE TRANSITION TO ROBOTICS

Fertility and Sterility 2005;84:1-11.

Robotic Laparoscopic Hysterectomy

Radical hysterectomy performed using robotic techniques was comparable with laparotomy, with equal lymph node harvest, shorter operating time, and reduced blood loss and the length of hospital stay.

HYSTERECTOMY: NOW

da Vinci surgical system

J Minim Invasive Gynecol 2010; 17(4):421-35.

DaVinci System1999: Introduced for surgical

use2000: Approved by FDA for

performance of procedures in the abdomen and pelvis

2003, 2004: Approved by FDA for cardiac surgery, specifically MVR, Coronary Artery Bypass

2005: Approval by FDA for Robotic Hysterectomy

HYSTERECTOMY: NOW

da Vinci surgical system

Benefits of robotics 3-Dimensional viewingTremor filtration Intuitive movements7 degree instrument movement90 degree articulationComfortable seated position for the

surgeonMinimizes the number of needed

assistantsTelesurgery/telementoring

HYSTERECTOMY: NOW

Surgical dexterity and the robot8-12% surgeons report

pain or numbness after performing LSC

The robot allows for 7 degrees of motion versus the limited 4 degrees of motion in laparoscopy

Tremor is removed

HYSTERECTOMY: NOW

Trocar Placement

Laparoscopic Robotic

NON DESCENT VAGINAL HYSTERECTOMY (NDVH)

ACOG 2009:

Vaginal hysterectomy is associated with better outcomes and fewer complications than laparoscopic or abdominal hysterectomy1.

A Cochrane Review of 34 RCTs: vaginal hysterectomy has the best outcomes over laparoscopic and abdominal hysterectomy2

1. Obstet Gynecol 2009;114:1156–1158. 2. Cochrane Database Syst Rev 2009; 3. CD003677.

COCHRANE 2009

LAPAROSCOPIC VAGINAL HYSTERECTOMY

Limitation:

Laparoscopic vaginal hysterectomy is usually associated with higher cost and longer duration of operation and involves large number of specially trained personnel.

60% of the patients without descent underwent successful removal of uterus.

Up to 16 weeks pregnancy size uterus were removed.

There were minimal surgical complications, blood loss, operative time or hospital stay.

METHOD 100 cases were taken for NDVH &

100 for AH.

Cases of Dysfunctional DUB, Uterine fibroid of less than 12wks, adenomyosis and cervical polyp, Previous LSCS with mobile uterus were included in the study

Free communication (oral) presentations / International Journal of Gynecology & Obstetrics 119S3 (2012) S261–S530

RESULTS

NDVH AH0

10

20

30

40

50

60

70

38

61

Duration of surgery

Tim

e (

min

ute

s)

Free communication (oral) presentations / International Journal of Gynecology & Obstetrics 119S3 (2012) S261–S530

RESULTS

NDVH AH0

20

40

60

80

100

21%

100%

Post operative cathetarization

%

Free communication (oral) presentations / International Journal of Gynecology & Obstetrics 119S3 (2012) S261–S530

NDVH AH

Early ambulation 6-14 hours 24-48 hours

Regular diet Earlier Late

Post Operative stay 2-3 days 5-7 days

Complications rate Lower Higher

RESULTS

Free communication (oral) presentations / International Journal of Gynecology & Obstetrics 119S3 (2012) S261–S530

CONCLUSION

NDVH is least invasive route with least morbidity, least expensive technique & with most rapid postoperative recovery.

The absence of an abdominal incision leads to lower morbidity, less hospital stay, more rapid convalescence and patient compliance.

Free communication (oral) presentations / International Journal of Gynecology & Obstetrics 119S3 (2012) S261–S530

100 patients with uterine size 8-10 weeks gestation

Age: 35.2±5.2 years Mean parity: 4.17±1.5

METHOD

Free communication (oral) presentations / International Journal of Gynecology &

Obstetrics 107S2 (2009) S93–S396

NDVH

Duration of surgery 35.5 mins

Mean hosp stay 3.5 days

Blood loss 100-300 ml

RESULTS

Free communication (oral) presentations / International Journal of Gynecology &

Obstetrics 107S2 (2009) S93–S396

CONCLUSION

The new technique of aqua dissection in NDVH is easy, fast, safe and relatively less bleeding in modern gynecology

Free communication (oral) presentations / International Journal of Gynecology &

Obstetrics 107S2 (2009) S93–S396

74 patients with uterine size 8-10 weeks gestation

Age: 35-55 years Volume of uterus: 80-500 cm3

METHOD

NDVH

Duration of surgery 46 mins

Mean hosp stay 48 hours

Avg Blood loss 50 ml

RESULTS

ADVANTAGES

• No abdominal wound

• No significant destruction of intestine

• Less post operative discomfort

• Easier mobilization

• Earlier discharge from hospital

THANK YOU