Book Page 1st To last

FOGSI FOCUSV a g i n a l S u r g e r i e s

Co-EditorDr. Krishna Kumari

Dr. Anil Sakhare

EditorDr. Kawita Bapat

Vice-Persident FOGSI2021 - 2022

Editor in ChiefProf. Dr. S. Shantha Kumari

Persident FOGSI2021 - 2022

Fogsi Focus Va g i n a l S u r g e r i e s

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Prof. Dr. S. Shantha KumariPersident


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FOGSI FOUCSVa g i n a l S u r g e r i e s

Editor - in - ChiefProf. Dr. S. Shantha Kumari

EditorDr. Kawita Bapat

Co-EditorDr. Krishna Kumari

Co-EditorDr. Anil Sakhare

ForewordDr. Shirish Seth

ForewordDr. Sudhir Shah


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CONTRIBUTING AUTHORSDr. Anjali Chitnis (M.D..D.G.O..D.F.P..F.I.C.O.G.)HOD Sahakar Rugnalay and Chitnis Nursing Home. Ex-Asso.Prof.V.M GOVT MEDICAL COLLEGESOLAPUR Maha.Trustee AMOGS. Ex-President AMOGS

Dr. Anil Sakhare (DNB, D.G.O., D.F.P., F.I.C.O.G.)Ex. Assistant Professor, Dr.S.C.Govt. Medical College, NandedConsultant OBGY, Rayat Hospital, Nanded, Maharashtra

Dr. Kawita Bapat ( MBBS, MS, FICOG )Vice President FOGSI Director of One Centre for Gynaecological Excellence,Bapat Hospital Bapat Chouraha Sukhliya Indore Madhya Pradesh

Dr. Manik Gurram (MD DICOG)Ankur, Gurram Nursing Home, 1895 New Paccha Peth SolapurMarkandeya Solapur Sahakari Rugnalaya

Dr. Mukesh Rathi (MBBS MD DNB DGO FCPS)Laxminarayan Memorial Hospital, Akola

Dr. S. S. Mehendale (MD(OBGY))Professor Emeritus, Bharti Vidyapeeth tobe Deemed University Medical College, Pune

Dr. S. P. Kakatkar (Consultant OBGY Pune)

Prof. Dr. Mrs. T. Srikala Prasad (M.D.(OBG), D.G.O., M.Ch.(Urology))Professor and Head of the Department of Urology, Chengalpattu medical College. Chengalpattu, Tamilnadu.Past Secretary OGSSI (Obstetrics and Gynecology Society of Southern India)Secretary, Tamilnadu Chapter of SOVSI (Society of Vaginal Surgeons of India)Nominated Indian Member of the Urogynecology Committee of AOFOG

Dr. Vyomesh Shah M.B.DG.O, F.I.C.A. F.I.C.M.C.H. Ph.D. (USA) F.M.R.S.H. (lon.), Dip in Endo (USA),Vaginal Surgeon & Endoscopist, Avani Hospital, Patan GUJARAT


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M e s s a g e

FOREWORD FROM THE PRESIDENT’S DESK

Dear FOGSIANS

Greetings from FOGSI 2021 -2022, I hope that your family and pa-tients are safe in these difficult pandemic times. Wish you the best of healthand please take care.

I have been very lucky to take over as President of our prestigiousorganization FOGSI with all your support. Vaginal surgery is an art thatremains ever interesting and loved by all obstetricians and gynecologists.It gives me great pleasure to write a few lines on a subject so very close tomy heart for the first FOGSI FOCUS released in my tenure as the 60thPresident of FOGSI.

India is famous for vaginal surgeons who have excelled in this art.I still remember my first years after joining as postgraduate and to date Iam in awe of the great legendary surgeons and I think most agree withme. But unfortunately the generation next who will be taking care of thehealth of future generations are not showing much interest in this surgi-cal sphere which needs only skill and perseverance and not elaborate ex-pensive instruments. This book is a homage to all our great vaginal sur-geons. We have made an honest effort to carry this legacy forward and Ihope that this FOGSI Focus of ours will revive the interest in youngObgyns.

Prof. Dr. S. Shantha KumariFOGSI President 2021-2022


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These “niche surgeries” often follow the correct approach sup-ported by evidences, and we should do more of them. Why don't we?Vaginal surgery procedures require tactile skill, muscle memory and pre-cise knowledge of anatomical landmarks. Learning correct techniques,practice and repetition are the only methods of perfecting this form ofsurgery.

I thank the authors for sharing their knowledge and experienceand congratulations for the whole team of editors for bringing it together.The chapters have been contributed by experts in their field and I hopethat this issue of FOGSI FOCUS on‘VAGINAL SURGERY’ will updategynaecologists and postgraduate students with the best techniques andlatest developments in vaginal surgery.

Prof. Dr. S. Shantha KumariMD DNB FICOG FRCPI (IRELAND) FRCOG (UK)

FOGSI President 2021Professor OBGYN

Chairperson ICOG 2018Consultant Yashoda Hospitals hyd

ICOG secretary (2015-2017)Member FIGO Working group on VAW

Vice President 2013IAGE Managing committee Member

National Corresponding Editor for JOGIChairperson FOGSI MNNRRC 2008

Mob: 9848031857


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M e s s a g e

FROM EDITOR DESK

Dear FOGSIANS

Vaginal hysterectomy in non-prolapsed uteruses is in real meansis : "no scar hysterectomy"The use of institutional guidelines for determining the hysterectomy routeand a standardised VH technique resulted in an increased number of per-formed VHs. This provided an essential opportunity for residents to ac-quire, improve and maintain the skills required to safely perform VH.Recent data suggest that outpatient vaginal hysterectomy can be a safeprocedure and is well-accepted by selected patients.

I usually do vaginal hysterectomy as a day care surgery at my hos-pital. As minimally advancing technology continues to be developed andrefined, surgeons must choose the safest and best cost-effective surgicalapproach for the patient; and this necessitates the need for resurgence ofNDVH.

I hope this fogsi focus will help the surgeons to know more aboutvaginal surgeries.I must thank all the contributors for their efforts.

Dr. Kawita BapatMS FICOG

DirectorOne Center for Gynecological Excellence

Bapat Hospital Indore, Madhaya Pradesh. India

Dr. Kawita BapatVice-Persident FOGSI

2021 - 2022


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FOGSI-FOCUS ON VAGINAL SURGERIES

The way to a woman’s uterus for Gynecologists has always beenthrough the vagina to examine her and/or do the surgery. However, formany Surgeons, Physicians, etc. it is abdomen and limits them with it.Gynecological, abdominal access for surgery is only when the vaginal routeis contraindicated or operator’s inefficiency. For hysterectomy, beyondshadow of doubt WHO mentions that vaginal route is the best for awoman/patient and ideal when compared with alternative via abdomi-nal route including laparoscopy. Vaginal is the least invasive with mini-mal access. Unfortunately, global statistics analysed by WHO are dissuad-ing to give very high rate of abdominal hysterectomies performed andlow use or access of vaginal route for hysterectomy. I write with humilityof having successfully performed scientifically more than 10,000 hyster-ectomies vaginally.

Numerous noted international colleagues have strongly propagatedhysterectomy via vaginal route. If hysterectomy vaginally was marketedas ‘scar less or no visible incision surgery’ it would have been the mostpopular procedure.

Every Gynecologist must remember that “Man learns as he livesand experience is the greatest teacher in the world” … Swami Vivekananda.

Dr. Shirish S. ShethPresident, FIGO (2000-2003)

Consultant Gynecologistat Breach Candy and Saifee Hospitals, Mumbai, India

F o r e w a r d


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To decide to publish the FOGSI FOCUS on Vaginal surgeries byour FOGSI President Dr.Shanthakumari Shekharan and Vice-PresidentDr.Kawita Bapat - is a dream come true decision not only ME ,but forthousands of Fogsians as since long they were demanding expert teach-ing by experienced and senior Vaginal Surgeons of our own country –INDIA. So,at the out set I would like to congratulate our entire FOGSITEAM to take this welcome decision for the members who wants to knowa lot for NDVH and Vaginal Surgeries.

India is country of Villages, Towns and Cities. Approximately 70percent of public stays at Villeges and Towns where 40 percentage of Gy-necologists are available to them. Gynecologists working at such remotearea may not have facilities of sophisticated instruments and infrastruc-tures , continuous Medical education and help of good team and Anes-thetists. This – quick – easy – cost effective and single handedly managedVAGINAL surgeries are more suitable to Gynecologists practicing at alllevels including Cities and Metros to Villages . Open Abdominal Surger-ies have played a long innings but with increase exposure, learning andwatching Vaginal route to remove the Uterus , Non Descent Vaginal Hys-terectomy has become more popular for the Gynecologists working at alllevels at India ,including cities and Metros. Gynecologists have started tobelieve that Every Uterus can be and should be removed VAGINALLYunless the route is contraindicated. Vaginal Hysterectomy is preferred toother routes as it is performed through a natural entrance, direct approachto cervix and uterus, indications are increasing and many contraindicationsof past years have now in the list of possible, More and More gynecologistare adopting this route as it is simple, quick, cost effective, needs less in-struments and staffs, can be performed under spinal anesthesia, recoveryis fast, least intra and post operative problems, least bleed loss and pa-

F o r e w a r d


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tients can be discharged after 24 hours. NDVH is easy if the selection ofpatient is proper, Surgeons having perfect knowledge of Pelvic anatomy,surgical steps, energy sources and have experienced assistants. The presentFOGSI FOCUS will enlighten the seniors, Juniors and Post Graduates tolearn a lot about NDVH and so will certainly increase the confidence toadopt this route for the removal of Non Descent Uterus of normal to largesizes, fibroids, adenomyosis or previous CS cases. All the authors hereare seniors and experienced in this surgeries.

Apart from NDVH –different kinds of other vaginal surgeries aredescribed here with full details to enrich the knowledge of all generationsGynecologist.

Remember we are Gynecologists and our route of entry for sur-gery is through Vaginal orifice. Surgeons removes the Tonsils throughoral cavities and not by cutting the skin over the Neck. Likewise we canremove the Uterus or do many Gynecologic surgeries through this route.This FOGSI FOCUS has the aim to create interest and enlighten the knowl-edge regarding Vaginal surgeries. This will shorten the learning curveand will make you a skillful surgeon.

Once again I congratulate President FOGSI – Dr.ShanthakumariShekharan , Vice-President Dr.Kawita Bapat and entire FOGSI TEAM tobring out this FOGSI FOCUS on a very important part of our subjects.

Dr.Sudhir R.ShahSenior Gynecilogist -

MANAN HOSPITAL, Rajkot


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1. "EVOLUTION OF NDVH ".... As I witnessed and experienced 11Dr. Anjali Chitnis

2. NDVH IN SPECIAL SITUATIONS... 13Dr. Anil Sakhare

3. TRAINING AND LEARNING CURVE IN VH… 21Dr. Kawita Bapat

4. HOW TO LEARN NDVH AT OWN HOSPITAL AND GET MASTERY 25Dr.Manik Gurram

5. VAGINAL HYSTERECTOMY IN CASES WITH PREVIOUS CESAREAN SECTIONS 28Dr .Mukesh Rathi

6. PELVIC ANATOMY IN THE CONTEXT OF VAGINAL SURGERIES ... 32Dr. S. S. Mehendale, Dr. S. P. Kakatkar

7. TIPS & TRICKS IN SAFELY OPENING ANTERIOR & POSTERIOR POUCHES... 41Prof. Dr. Mrs. T. Srikala Prasad,

8. NDVH FOR BIG UTERUS WITH PREVIOUS MULTIPLE C - SECTION 49Dr. Vyomesh Shah

C O N T E N T S


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"EVOLUTION OF NDVH "....As I witnessed and experienced

I devote this article to my esteem teacher andmentor Dr. B. N. Purandare from whom I learntthe Art, Science and Craft of performing theoriginal non descent vaginal hysterectomy inNawrosjee Wadia Hospital, Mumbai now calledas NDVH.

Since then I believe that the Gynecologistmust expand and master the procedure ofNDVH and then they willbe recognized in terms ofthe level of expertise.

The evolution in NDVHis a gradual process ofchange in developmentover period of time so as tocome to today's modernand made easy techniquesfor simple as well as diffi-cult cases.

AD 120 Hippocrates bySoranus of Ephesus city in Greece amputateduterus vaginally, From 11th to 16th centuries iswas mainly for prolapse and inversion of theuterus performed by midwives, surgeons, pro-fessor of anatomy and patient herself.

In 18th Century, Langente performed firstever vaginal hysterectomy for Uterine Cancer.They progressed then by identifying and ligat-ing the broad ligament vessels and other liga-

ments. Vaginal hysterectomy was performed byCharles Clay in 1843. This was done well be-fore the procedure of abdominal hysterectomy.

Opening of the Cul-de-sac, pulling of the fun-dus, peritonisation, anchoring of the stumps tovaginal wall was performed by Schroeder in1880.Interesting fact is that Doderlein used ap-proach through anterior colpotomy. In 1894

technique of vertical and ob-lique morcellation of theuterus was used to reducethe size of the uterus.

In 19th century, thus Gy-necology was recognized asa separate specialty. In thisera, technique of Non De-scent Vaginal Hysterectomywas systematically studiedand developed by Professor.Sims, Wertheim, Schauta,

Kelley, Bonney, Mayo, Meige and thus we wit-nessed “ The Evolution of non descent vaginalhysterectomy ”.

Improvement in understanding the physiol-ogy, pathology of the female reproductive or-gans and its diseases lead to application of dif-ferent surgical techniques. Safeblood transfu-sions, effective antibiotics, modern anesthesiaadded to the improved outcome of operations.

Dr. Anjali Chitnis

Ex. Prof. DR. V. M.Govt. Medical College, SolapurHead of the Department O & G

Markandeya Rugnalaya, SolapurConsultant Obstetrician

and Gynecologist,Chitnis Nursing Home,Solapur


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Specifically designed and modified instrumentsadded to ease of operations. Indications andcontraindications to the vaginal route werefairly understood. Psychosocial Impact of vagi-nal operations was studied. It was researchedand concluded that certainly vaginal hysterec-tomy reduced mortality and morbidity of thepatients.

Indian contribution is noteworthy in thisfield of non descent vaginal hysterectomy. In-dia was not lagging behind in contribution tothe field of NDVH.Stalwarts like Dr. B.N.Purandare, Dr. V.N.Shirodkar, Dr. Mitra, Dr.Roy Chawdhari, Dr. V. N.Purandare contrib-uted enormously.

Dr. B. N. Purandare – student of ProfessorVictor Bonney, his vaginal hysterectomy wascalled a “Physiological “ operation,bloodless,no clamps, no tissue damage. Movements of hisfingers, feel of the tissue, knowledge ofanatomy and his confidence was unique andoutstanding.

Meticulous methodology of applyingclamps, infiltration with saline in the tissues,removal of adnexa, extended and radical vagi-nal procedures were added and made popularby Dr. V.N. Purandare, Dr V N Shirodkar , DR.Subodh Mitra and DR. Choudhari .

DR. Shirish Sheth from K.E.M. HospitalMumbai made it popular as “NDVH”. He usedthis technique for enlarged uterus i.e. for fibroiduterus and adenomyosis. He used vaginal routefor those with previous LSCS, with adnexal

pathology, and even in nulliparous patients.Further other operations like myomectomy,morecellation, intramyometrial coring, re-moval of adnexa were added by many youngand enthusiastic gynecologists.

Use of energy sources in vaginal surgery wasa novel concept to achieve haemostasis andavoid using clamps. This was another mile-stone. Use of electrodiathermy, bipolar energy,harmonic scalpels; replaced clamps and liga-tures. The Robotic Surgery was introduced in2005 which may not replace but can enhancethe performance of the surgeon.

Laparoscopic assisted vaginal hysterectomy,Laparoscopic hysterectomy, abdominal andvaginal hysterectomy were studied well andfinally NDVH was said the favorable, easy andleast morbid surgery.

In Summary, the success of NDVH dependson selecting the right operation for the patient,right patient for the operation. understandingthe anatomy and pathology, the clinical mani-festations of the disease as assessed by mod-ern diagnostic scans. The well learnt operativetechnique for NDVH and postoperative care isfundamental.

One must be familiar to all the techniquesand different routes. One cannot replace theother. NDVH is a relatively easy operation toperform. Movements of fingers, feel of the tis-sue, knowledge of anatomy and the surgeon'sconfidence – is the secret of success.Masteringthe art of NDVH is an art itself.


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NDVH IN SPECIAL SITUATIONS.

Hysterectomy is one of the most frequentlyperformed surgical procedure worldwide.1

Hysterectomy may be performed abdominally,vaginally, laparoscopically or with robotic as-sistance with the route depending uponphysician’s choice. Factors to be considered inchoosing the route of hysterectomy should in-clude safety, cost effectiveness and medical needof patient. Preferably surgi-cal approach of hysterec-tomy should be decided bythe woman in discussionwith surgeon and it ismoral responsibility of thesurgeon to provide evi-dence based unbiased opinion. 2.

Most of the literature support that vaginalhysterectomy when feasible is the safest andcost effective procedure for removal of uterusand should be the approach of choice wheneverfeasible. Evidences demonstrate that it is asso-ciated with better outcomes when comparedwith other approaches to hysterectomy.3, 4 & 5.

Younger trainees are seeing less vaginal pro-cedures being done and having less confidenceto carry out the procedure the surgeons aresteering away from vaginal approach becauselaparoscopic and robotic approaches are muchmore appealing and considered to be glamor-

ous.6, 7.There are very few contraindications for

vaginal hysterectomy. However there are somefactors that may influence the surgeon’s choiceof a route for hysterectomy like surgeons train-ing, accessibility of uterus, size and shape ofuterus, extent of extra uterine disease, need ofconcurrent procedure like oophorectomy and

salpingectomy and the caseswith previous caesarean sec-tion.

As a gynec surgeon I vi-sualize four situation forwhich each gynaecologistshould master the skills of

vaginal hysterectomy. Situation 1 is where be-cause of associated some type of pelvic organprolapse, vaginal approach is best suited. Thesituation 2, there are indications of hysterec-tomy where all three approaches are suitablebut ( Non-descent vaginal hysterectomy)NDVH is affordable to everybody. The situa-tion 3, it is scar less surgery in low socioeco-nomic settings. The situation 4, these are thecases where performing NDVH is difficult situ-ation. These are big uterus, irregular uterus,nulliparous uterus, pelvic adhesions, concomi-tant oophorectomy or salpingectomy, benignadnexal masses, obesity and cases with previ-

Dr.Anil Sakhare,

Consultant, OBS & Gyne,Nanded.


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ous caesarean section. Earlier few of these con-ditions were said to be relative contraindicationsfor NDVH. But with expertise and experience,these cases can be easily done by NDVH.

Fig 1

BISECTION, CORING, MORCELLATIONand ENUCLEATION are the debulkingtechniquesand proved to be gold standard. 200-

700 gm of uterus has been successfully removed(Fig 3 & 4, Source: Williams Gynecology Ed 3,Vaginal hysterectomy).

Fig 3 Fig 4

Peloci reported 2003 gm uterus removedvaginally. The golden rule of all debulking tech-nique is that they have to be performed after

Fig 3. Bisection., Fig 4. Coring.

ligation of uterine vessels.Intramyometrial coring was introduced by

Lash in 1941 and reintroduced in 1986 for re-

Cases of fibroids, adenomyosis, and irregu-lar uterus more than 12 weeks size can be easilydone vaginally by expertise (Fig 1& 2).

Fig 1 & 2. Irregular uterus more than 12 weeks size.


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moval of large uteri. In this technique myo-metrium can be circumferentially incised withscalpel placed parallel to uterine axis of uterusbeneath the serosal covering of uterus. This re-moves the core inside the uterus without vio-lating the integrity of endometrial cavity, to fa-cilitate the coring strong traction on uterus isnecessary. It reduces the width of uterus therebyincreasing the length; the effect of coring is- itconverts spherical structure into rod like struc-ture. When the uterine width is smaller, bisec-tion or morcellation is preferred over coring.

As the number of caesarean section are in-

creasing, in coming days there will be morenumber of patients undergoing hysterectomyto have caesarean section scar.NDVH can beperformed in cases with previous one or morecaesarean section. One study found that in 93%cases it was performed successfully without anycomplications. Only cases with previous caesar-ean scar having ventrofixed uterus adherent toanterior abdominal wall, are truecontraindications for NDVH.These cases caneasily diagnosed clinically by vaginally pullingdown the cervix and demonstrating the visibleabdominal wall retraction (Fig 5).

Fig 5. Post cesarean section ventro-fixed uterus.

A LSCS scar distorts the anatomy by reduc-ing vesicouterine space between the scar andthe urinary bladder. Controlled dissection ofcaesarean section scar is easier and more di-rectly visible in vagina than from abdomen.Bladder can be dissected and anterior pouch can

be approached by various methods. Onemethod suggested by Dr. Shirish Seth is lateralapproach which is going lateral to the LSCS scaron both the side through anterior fold of broadligament (Fig 6).


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Fig 6. Dr Shirish Seth’s lateral approach

Another method is going around the uterusafter opening of posterior pouch. But this

method is easy when uterus is of normal sizeand mobile (Fig- 7).

Fig 7.Pouch of Douglas first approach

The other method is dissection above thescar, performed by identifying the scar, the

bladder and the peritoneum as independentstructure (Fig- 8).


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Fig 8. Dissecting above the scar or through the scar.

On occasions it is possible to dissect underthe scar which keeps dissection further away

from the urinary bladder (Fig- 9).

Fig 9. Dissecting beneath the scar through perimetrium.

The evidence says that the risk of bladder injury during vaginal hysterectomy does not


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seem to be increased in women with previouscaesarean section.

Other special situation where NDVH is saidto be risky for fear of injury to large or smallbowel, is adhesions in pouch of Douglas. Ad-hesions in POD can be easily diagnosed clini-cally. Puckered or obliterated POD on per

speculum examination may give indication forpossible adhesions. To avoid injury to bowl pos-terior lip of cervix and vagina can be cut in ver-tical direction that exposes peritoneum at higherlevel at its junction with visceral peritoneum,so that it can be recognized and entered directly.This is cervicocolpotomy (Fig- 10).

Fig 10. Cervico-colpotomy.

Another special situation is where one hasto perform concomitant oophorectomy and /or salpingectomy along with hysterectomy. In-experienced or untrained gynec surgeon is re-luctant to perform NDVH in such a situation.Itappears that the surgeon thinks the vaginal hys-terectomy is more challenging and cumbersomewhen it needs to be completed with concomi-tant adnexectomy/salpingectomy. There ap-pears some reluctance to combine vaginal hys-terectomy with oophrectomy because vaginal

oophorectomy is thought to be risky and diffi-cult procedure.

Baden and walker described degrees of ova-rian descent 93%. Patient had ovarian mobilityup to grade2 that is up to midportion of vagina,in 4.6 percent ovaries can be pulled up tohymeneal ring. Only 2.5 % patients had littleovarian mobility and 0.1 percent had grade 0mobility (Fig- 11, Source: Telinde's Text Bookof Operative Gynecology Ed 10, Vaginal hys-terectomy).


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Fig 11.Baden and walker ‘s classification of degree of ovarian descent.

Oophorectomy by vaginal route can be eas-ily performed by a technique described byZimmerman. This technique mimics samemanoeuvres that are used to remove the adn-exa abdominally.Round ligament is clamped

and cut separately, and an extension of incisioninto the broad ligament is done to create the win-dow in the infra-tubal area. Clamp is then placedthrough the infra-tubal window to the ovario-pelvic ligament close to the ovary (Fig- 12).

Fig 12. Zimmerman technique of oophorectomy.


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Salpingectomy during hysterectomy are fre-quently performed for cancer prevention dur-ing TLH or AH. But these are not routinely re-moved during vaginal hysterectomy with theperception of increased morbidity or difficultyor inadequate training. Salpingectomy shouldbe routinely performed during VH becausetrade off with cancer prevention is highlyfavourable.

Benign mobile adnexal masses can be easilyremoved in 95% cases by vaginal route.Skillaugmentation for vaginal surgery can avoidneed of costly endoscopic surgeries. With in-creasing confidence and skills that comes fromexperience, there are very few patients with in-dications for hysterectomy in whom the proce-dure cannot be performed vaginally. Vaginalhysterectomy can be performed easily in casesof previous caesarean section and the caseswhich need oophorectomy and salpingectomy.Because of little more intraoperative compli-cation rate such special situations should beundertaken after good experience.

References:

1. Choosing the route of hysterectomy forbenign disease. Committee Opinion No.701. American College of Obstetriciansand Gynecologists. Obstet Gynecol

2017:129:e155–9.2. Ray A, Pant L, Magon N. Deciding the

Route for Hysterectomy: Indian TriageSystem. J Obstet Gynaecol India. 2015;65(1):39–44.

3. Tohic AL, Dhainaut C, Yazbeck C,Hallais C, Levin I, Madelenat P. Hyster-ectomy for benign uterine pathologyamong women without previous vagi-nal delivery. Obstet Gynecol2008;111:829–37.

4. Doucette RC, Sharp HT, Alder SC. Chal-lenging generally acceptedcontraindications to vaginal hysterec-tomy. Am J Obstet Gynecol2001;184:1386–9; discussion 1390–1.

5. Kovac SR, Barhan S, Lister M, Tucker L,Bishop M, Das A. Guidelines for the se-lection of the route of hysterectomy: ap-plication in a resident clinic population.Am J Obstet Gynecol 2002;187:1521–7.

6. Moen, M.D., Richter, H.E. Vaginal hys-terectomy: past, present, and future. IntUrogynecol J 25, 1161–1165 (2014).https://doi.org/10.1007/s00192-014-2459-x.

7. Melendez, J. Vaginal hysterectomy andtraining. Int Urogynecol J 26, 621 (2015).https://doi.org/10.1007/s00192-014-2611-7.


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TRAINING ANDLEARNING CURVE IN VH...

In the last two decades, surgery carried outin outpatient settings has grown much morestrongly than inpatient operations. Day surgeryis generally defined as a non emergency proce-dure undertaken during the period of a normalworking day (not exceeding 24 hours) in hospi-tals or other facilities set up for this purpose.

The concept does not account for minor sur-gery under local anesthesiausually conducted in phy-sicians' offices. The increaseof day surgery was drivenby innovations in surgicaland anesthetic techniques,together with financial in-centives and patient expec-tations. For many proce-dures, day surgery appearsas an effective and efficient approach, offeringseveral advantages to patients as well as sur-geons and hospital managers. While cost sav-ings have been the primary incentive to daysurgery development, the benefits in term ofenhanced social and emotional recovery areimportant. Less nosocomial infections, quickerreturn to mobility, and high satisfaction in cen-ters where the outpatient procedure has becomestandard practice. Minimal invasive vaginalhysterectomy is latest and innovative proce-

dure.It is basically non descent vaginal hysterec-

tomy with minimal invasion.Vaginal hysterectomy for total vaginal pro-

lapse used to be done so it is surgery of pastbut becoming surgery of future. Technologicalchange is like an axe in the hands of pathologi-cal criminal (Albert Einstein). Thus all the newer

changes in procedures arealways welcome for the ben-efit of patients.

Hysterectomy is the sur-gery which is significantlycosting the health care sys-tem. More than half millionhysterectomies occur in ayear. By the age of 61, out often, three women undergo.

Hysterectomy and majority for benign indica-tions like fibroids, bleeding, endometriosis andpelvic pain.

Hysterectomy as a surgery, revolutionizedin last 50 years. At first when started total ab-dominal hysterectomy used to be performed.Then the era of vaginal hysterectomy came.Vaginal hysterectomy was done only for pro-lapse of uterus. Than with advents of laparo-scope era of laparoscopic surgery had come. Thefirst was laparoscopic assisted vaginal hyster-

Dr. Kawita Bapat

Vice President FOGSI 2021-2022Director of One Centre for

Gynaecological Excellence,Bapat Hospital Bapat Chouraha

Sukhliya Indore Madhya Pradesh


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ectomy. Laparoscopically Assisted VaginalHysterectomy (LAVH) is a procedure usinglaparoscopic surgical techniques and instru-ments to remove the uterus and/or tubes andovaries through the vagina (birth canal).

Its greatest benefit is the potential to convertwhat would have been an abdominal hysterec-tomy into a vaginal hysterectomy. An abdomi-nal hysterectomy requires both a vaginal inci-sion and a four to six inch long incision in theabdomen, which is associated with greater post-operative discomfort and a longer recovery pe-riod than for a vaginal procedure.

Another advantage of the LAVH may be theremoval of the tubes and ovaries which on oc-casion may not be easily removed with a vagi-nal hysterectomy.

This does not mean that all hysterectomiescould or should be done by LAVH. There arecertain conditions that will necessitate abdomi-nal or vaginal hysterectomy. In fact a vaginalhysterectomy by itself, if indicated, is less timeconsuming, less expensive, and can be less dan-gerous. When LAVH is performed, severalsmall abdominal incisions are made. A cameraattached to the laparoscope provides a continu-ous image that is magnified and projected ontoa television screen. It provides the view bywhich the surgeon operates.

The uterus is detached from the ligamentsthat attach it to other pelvic structures usinglaparoscopic tools, electro-coagulation or a la-ser. Adhesions may have to be freed and, if thetubes and ovaries are to be removed, they aredetached from their ligaments and blood sup-ply. They then can be removed with the uterusthrough an incision made in the vagina. Sincethe incisions are small, the scarring and painfrom LAVH is often less than that associatedwith abdominal hysterectomy.

LAVH advances in laparoscopic supracervi-cal hysterectomy, than most modern but diffi-

cult one total laparoscopic hysterectomy & nowminimal invasive vaginal hysterectomy.

Whatever the root of hysterectomy in fewquestions to be answered :

Q.1 What should be new selection criteria?Q.2 What are the challenges?Q.3 What is the technique?Q.4 What are the new instrumentation?Q.5 What is the fun?CHALLENGES :

Challenges in doing hysterectomy are exposure-1) The important challenge is vaginal out-

let is small but it is a challenge to deliveruterus out.

2) To maintain homeostasis.3) Entry into culde-sac. How to enter into

it and large uterus is also a great chal-lenge, as there are chances of internalinjury.

CRITERIA IN DETERMINING ROUTE FORHYSTERECTOMY :

Level of suspicion for malignancy. Presence of adnexal mass Vaginal access Assessment of the mobility of the uterus What the size of the uterus Previous cesarean section.

MINIMAL INVASIVE VAGINAL HYS-TERECTOMY (MIVH)

As vaginal surgeons trained in vaginal sur-gery. With the advance of evolution in electrosurgical units. Vaginal surgeon then becomeeasier and popular. Previously there used to bemonopolar instrumentation, conventionallynow bipolar instrumentation. There is verymuch improvement in bipolar instrumentation.It has vessels sealing capacity, bipolar cuttingability and tissue impedence feedback on com-puterized cauteries. In term, there is a improvedoutcome.


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The general principles of doing MIVH areclassical steps of

conventional surgery + three new principles.1. Only two other instruments2. Application of clamps close to uterus3. No tractionSequence of operation-1. Vaginal circumferential cut around the cervix .2. Heameostasis around cervix.3. Heameostasis and additional amputation of uterine vessels.4. Amputation of uterus at adnexa5. Adnexectomy with clamp6. Occulsion of vaginal vault.7. Technical challenges to the vaginal approach.EXPOSUREHaemostasisEntry into the cul-de-sac.Large uterus.Ureteral injuryHigh adnexaTECHNIQUE

• Entry into the cul-de-sac• Stay within the uterus• Do not abort (if u cannot enter anteriorly

or even posteriorly) at some point,uterus will come down and present it-self. SO delay entry until u you havegood dissensus and visualization.

• IN case of large uterus -• Bifurcation of uterus• Amputation of cervix• Make uterus pear shape to apple shape• Apply morcellation technique.• To avoid ureteral injury,mobilized blad-

der pillars superiorly and laterally.• Perform cystoscopy

• Present inadvertent• Occult kinking of the ureter and blad-

der injury.THERMAL HEAMOSTASIS-Need three steps1. Positioning of clamp2. Removal of clamp3. Cutting with scissorsPREVENTION OF ACCIDENTS1. Burns of skin and mucosa (prevention

through2- Positioning of clamp3- Suctioning of surgical smoke4- Thermal necrosis at the ureter5- Thermal wounds of digestive tract6- Bleeding –immediate and secondaryLIGATURE VESSEL SEALING SYSTEM1- Low voltage2- High current3- Impedance feedback4- Optimal pressureVessel sealing technology ensures reliable,

consistent, isolate vessel, thermal spread, pre-dictable, less energy delivery, the pedicles aresmaller and therefore the steam effects are muchless lateral to the instrument.

No sticking, charring, reliable seals. Bipolarvessel sealing systems decreased blood loss byan average of 48 ml and operative duration byan average of 17 min compared with suturing.

Sealing system causesOCCULSION OF VESSLESMechanical –FlatteningCompressionThermal –Dehydration of tissuesDestruction of proteinsHardening of the collagen


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BENEFITS OF TISSUE FUSION SYSTEM1. Consistent control of energy delivers2. Zones are more flexible and stronger3. Greater reduction of thermal spread4. Less charring and sticking.5. Reduction of pain.6. Good psychological preparation.7. Multimodal anesthesia.8. Non aggressive operative technique.9. No forcible pulling of pedicle & ligaments.10. Ensuring haemostasis through thermo

fusion.IMPACT ON PAINThermal haemostasias reduces inflammatory

and painful events.

Absence of necrotic tissue & foreign bodies.MIVH PROCEDURE IS – Fast, Latest, Reli-

able, Painless, Suture less, Convenient, Needsno CO2, bloodless, less OT time. It is cost effec-tive, early recovery; it needs less duration of an-esthesia, Less duration of stay. It is Expertisetechnique which has Worldwide acceptance andinternationally acclaimed in MIVH we Need notto go through seven layers of abdomen.

CONCLUSION: MIVH is Good procedure,we should develop new criteria for selectingpatients, New technology and instrumentationshould be used cautiously and after training andas vaginal surgeons MIVH is only future.


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Abdominal hysterectomy is a surgery.Laparoscopic hysterectomy is a technologi-

cal surgery.But vaginal hysterectomy is an art surgery.Vaginal hysterectomies were already being

performed since the 19th century. The first onewas done by Langenbeck. Since then manymodifications and variations have been re-ported. Most methods inuse today like the Porges,Falk, von Theobald,Heaney, Joel-Cohen andthe Chicago methods arecarried out with definedsequences. These sequencesresult from personal interpretations of the pel-vic anatomy and the individual experience ofthe authors. When hysterectomy is indicated,because of the quick recovery, the lack of ab-dominal scar and the short hospital stay vagi-nal route should always be considered.

In order to find out whether vaginal hyster-ectomies can still be optimized and simplifiedre-evaluation of the six mentioned methods wasdone by Michael Stark Sandro Gerli Gian Carlo,Di Renzoy. Steps common to all these methodswere defined and analysed. Then the steps werere-assessed and excluded if considered unnec-essary. Thereafter, the ways of performing the

essential steps were critically compared. As aresult, only the re-evaluated and absolutely ir-replaceable steps remained, some times withmodifications. Finally, their logical sequencewas defined and described.

The result is the so-called ‘Ten-Step VaginalHysterectomy’. This method is logical, easy tolearn, to perform and to teach. These are -

1. INCISION OFTHE VAGINAL WALL

2. DETACHINGBLADDER FROM THEUTERUS

3. OPENING POS-TERIOR PERITONEUM

4. DISSECTION OF THE LOWER PARTOF THE UTERUS

5. CUTTING AND LIGATING THEUTERINE ARTERIES

6. OPENING THE ANTERIOR PERITO-NEUM

7. DISSECTION OF THE UPPER PARTOF THE UTERUS

8. THE ‘NON-STAGE’ – LEAVING THEPERITONEUM OPEN

9. RECONSTRUCTION OF THE PELVICFLOOR IF REQUIRED

10. CLOSING THE VAGINAL WALL

Dr. Manik Gurram

Consultant, OBGY Solapur

HOW TO LEARN NDVH ATOWN HOSPITAL AND GET MASTERY


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There are various ways to perform vaginalhysterectomy.

1. Vaginal hysterectomy with use of clamps& ligation of pedicles.

2. Clampless vaginal hysterectomy with li-gation of pedicles.

3. Vaginal hysterectomy with use of energysources.

Advantages of use of energy sources :Bipolar coagulation is a simplest, easily avail-

able and afford-able source of en-ergy.

Bipolar electrocautery was con-firmed to be safeand useful evenfor open surgeryby reducing theoperating time andblood loss withoutincreasing postop-erative morbidity.

Thus its usewould lower thecost of surgery.

This beneficialeffect was found to be more pronounced in dif-ficult NDVH procedures.

Simple bipolar energy source is available atany small nursing home.

Bipolar & Step Ladder Technique NDVHeasy for any one and can be done anywhere ataffordable cost to patients. These are our day today used cautery machines. Not very high endmachines. Time required for bipolar electrocau-terization is less as compared to ligationmethod. More number of ligatures are requiredfor the routine method.

Postoperative pain is very less in bipolar cau-terization. Blood loss is less with bipolar methodas compared to ligation method.

Tying the pedicles with ligatures makes is-chemic pedicles with nerve endings are open.Suture material produces foreign body reaction.

Prolonged compression over bladder & rec-tum is avoided as less time required for bipolarhysterectomy.

If we combine ten steps vaginal hysterectomywith bipolar coagulation, NDVH is very easy.Even difficult NDVH cases can be approachedby step ladder type hysterectomy. Pedicles areeasily accessible. If required oozing can be con-trolled by bipolar immediately.

ADVANTAGES OF BIPOLARCOAGULATION IN VAGINALHYSTERECTOMY AREGood visibility because retrograde bleeding

from the uterus is avoided, shorter operatingtime, rapid convalescence and early mobiliza-tion for the patient, avoids ligatures, no subse-quent tissue necrosis, therefore less pain.

Highly economical, Bi Clamp is reusable, theprocedure saves time and suture material.

Combination of TEN STEP HYSTEREC-TOMY AND BIPOAR COAGULATION hasbeneficial effect and it was found to be morepronounced in difficult procedures and it low-ers the cost of surgery for doctors and patients.

There are many Gynaecologists performingNDVH ny bipolar coagulation. If you want totry just follow few steps.

Begin with NORMAL SIZE UTERUS forVaginal hysterectomy.

All steps are same for any other vaginal pro-cedures.

Keep cautery ready, hold cervix.With bipolar cautery coagulate cervical lip

so that you can judge cauterysetting (most oftimes keep it between 40 to 45 watt).

Our aim should be make that area white notblack.

Open Douglas pouch, and push bladder up-

Bipolar Scissors

Bipolar Shearer


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ward.Instead of clamp or ligatures hold the pedicle

with bi-clamp and cauterize till it become whiteand bubbles stop coming out.

Always stay near to uterus.Start cauterization and cut the pedicle with

scissors.See for haemostasis if any ooze recauterize.Step by step move upward by cauterizing

and cutting pedicles.Even uterine pedicles can be cauterized be-

fore opening peritoneal spaces.At the last pedicle of ovarian and cornual

structures don’t give extra traction.Remove uterus .Inspect for haemostasis. If any ooze, use bi-

clamp to stop it.Vagina suturing as usual.BUT NOW ONE QUESTION REMAINS.

WHY THIS BIPOLAR NDVH NOT POPU-LAR?

Most of the gynaecologist are notacoustomed with electrocautery even duringpost graduate days. Using cautery for vaginalprocedures is difficult for many of us. Many of

us use bipolar for laparoscopic surgery but notfor vaginal surgery. Most important thing iseconomics of NDVH.

A bipolar clamp is reusable, energy sourceand Bi-clamp are the only two instrument re-quired for bipolar NDVH.

We all know how many instruments are re-quired for TLH or LAVH.I am sure if you askany company, it prefers TLH or LAVH overNDVH. Its because of only economics.

But if look in to this “bipolar NDVH” frompatient and doctor point of view anaesthesiarequirements, cost to patient, running cost ofsurgery for doctors, no requirement of suture,time of surgery, man power in operation the-atre, skilled assistance in surgery, post opera-tive pain and recovery, complications rateNDVH by bipolar scores far better than TLHand LAVH.

Even at remote places, in small operationtheatre, under spinal anaesthesia with help ofnon skilled assistants ,with routine bipolar en-ergy source (of 150000 Rs) and a reusable clampof Rs 10,000 one can complete NDVH and cango for bigger size uterus with step ladder tech-nique after gaining experience.


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The vaginal route for hysterectomy in thepresent times is being pushed to backgroundamidst the glitz and glamour of laparoscopicroute, consequently the new generation of gy-necologists find their experience limited be-cause of the inadequate training. Over andabove that , the vaginal route for hysterectomyin cases with previous scars on the uterus islooked upon with appre-hension of not being able tofind the correct planes , ac-cidental bladder injury orbleeding .But with a betterdetermination and a littlecareful approach, the gynecological surgeoncan offer the patient all the advantages of thenatural orifice surgery.

Advantages of the vaginal route in cases ofpreviously scarred uterus :

Scarring and adhesion formation are the con-sequences of practically all the surgeries . Incases of previous LSCS, the adhesions betweenthe bladder and uterine surface, uterus and theparietal surface of anterior abdominal wall andat times the uterus and the bowel or omentumare the ones which are found most commonly .These can be dense, covering the entire uterus ,altering the entire pelvic anatomy , but are the

well settled and asymptomatic adhesions mostof the times. By the vaginal route, one doesn’thave to disturb these adhesions , and uterus isremoved from underneath these curtains ofadhesions, thus eliminating the risk of injury tothe viscera while separating these adhesionsbefore reaching the uterus , by the abdominalor laparoscopic route. One just has to dissect

the bladder away from theuterine surface or excise thefibrous band from the uterusto the parietal wall. Offcourse one has to take thehelp of a laparoscope in a few

cases where the approach is difficult by the vagi-nal route.

Preoperative evaluation before planningthe surgery.

A) History : Detailed history of why, howand where the cesarean sections were done andcomplications if any.

B ) Clinical examination :Per Abdomen : Nature of the scar , whether

uterus is palpable or notPer speculum :1) A stretched up posterior wall of the va-

gina, the cervix that is difficult to visualize andgrasp with the vulsellum and the puckering of

Vaginal Hysterectomy In CasesWith Previous Cesarean Sections

Dr. Mukesh Rathi

Consultant, OBS & Gyne, Akola


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the anterior abdominal wall on pulling downthe cervix (Sheth’ssign ) , strongly suggest pa-rietal adhesions or a band .

2) Have to mobility of the uterus.Per vaginal : Size , mobility and how high

the uterus is, along with the evaluation of adn-exal pathology if any .

Investigations.A good sonography for the size , number

and localization. A dynamic sonography tolook for the signs of suspected adhesions like apulled up and elongated cervix, not being ableto see the full bladder between the fundus ofthe uterus and anterior abdominal wall andmarkedly upwardly displaced uterus is ofgreat help.

Contraindications to the Vaginal route :1) Absence of uterine mobility , difficult to

visualize and grasp the cervix2) Positive cervico-fundal Sheth’s sign3) Associated big fibroids, adnexal masses,

malignancy4) Previous complex surgeries of the uterus

like rupture5) Big size uterus (depends upon indi-

vidual surgeons experience )6) Narrow subpubic angle or a narrow fi-

brosis vaginaIn such cases one can take the help of lap-

aroscope or adopt a laparoscopic or abdominalroute , though with experience one can dealwith some of these cases by the vaginal route .

Examination Under Anaesthesia (EUA)The decision on the final route of surgery

should always be taken after EUA as under re-laxation, the descent and mobility tend tochange. Secondly a detailed confirmation of theclinical findings, helps in making a judgement.

Surgical approach : Key steps and precau-tions.

1) Approaching the lateral window: Aftertaking the semilunar incision on the cervix, the

two lateral corners of the anterior vaginal wallare heldup, a closed scissor or a finger opensup a space medial to the uterocervical borderof the incision . Bladder is dissected up to clearthe cervical surface and take the uterosacral liga-ment. (image 1)

Image 12 ) Entering the lateral window :Adhesions of the bladder and the uterus are

mainly in the central 3/5 area of the uterocer-vical surface. Remaining area on the either side,is devoid of any adhesions . This surgical win-dow (Sheth’sspace) just lateral to the uterocer-vical border and underneath the lateral mostborder of the overlying bladder, between thetwo leaves of the broad ligament is a safe spaceto begin the dissection from. (image2a). Theperitoneal fold just over the uterine arteries isheld up, incised, and the space widened byopening up the scissor or by finger dissectionover the cervicouterine surface to dissect thebladder away. This will lead to the space be-tween the bladder and the uterovesical fold ofperitoneum. Similar procedure is carried out onthe other side . So now the bladder is adherentonly in the centre. A right angle retractor se-cures the bladder underneath it on the lateralside . . Under the guidance of the finger, thecentral part of the bladder is dissected away,close and flush to the uterus. (Image 2b)


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Image 2 a Image 2b

3) Uterine artery –cardinal ligament complexis secured , the uterovesical fold of peritoneumidentified and opened, to open up the anteriorpouch (Image 3)

If the UV fold cannot be opened this way thensome alternative methods like retrograde open-ing of the pouch after delivering out the fun-dus through the posterior pouch or bisectingthe cervix causing the thin cervical layer of thefascia to separate from the overlying bladder ,thus providing the space to dissect the bladderaway and open the anterior pouch .

Image 34) From here on the routine steps of the vagi-

nal hysterectomy are taken and the uterus de-

livered out. Flimsy omental or paraovarian ad-hesions can be snipped off.

5) If the thick fibrous band of adhesion is en-countered, then if feasible they can be clampedand cut ( very often they are avascular) or co-agulated and cut .In case the band of adhesioncannot be tackled from below, then one needsto take the help of laparoscope in certain rarecircumstances.

6) After securing the pedicles and hemosta-sis, one must always rule out the accidental in-jury to the bladder. The reddish tinge or a hem-orrhagic urine along with the field of surgerygetting filled with watery fluid, should invari-ably lead to ruling out accidental cystotomy.Identifying the rent in the bladder is the nextstep. Filling up the bladder with 100-150 ml ofnormal saline with methylene blue or giving20 mg frusemide would help in identifying thelocation of the rent. The anterior and the pos-terior margins of the rent along with the anglesare identified, and depending upon the loca-tion , one must ascertain that the ureteric ori-fice is not close to the suture line. Bladder isthen closed in 2 layers with 3-0 delayed absorb-able sutures. Omental graft can be placed overthe suture line if feasible or the rent is big . .Sub-


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sequently the vault is sutured and the bladdercatheter (no 16 or 18) kept 5-20 days dependingupon the extent of injury .

Non feasibility of the vaginal route for thescarred uterus is a thought barrier. With aproper knowledge of the anatomy and the sur-gical principles superseded by the zest to do it,the majority of such uteri can be removed bythe vaginal route .

“ It is really difficult to say what is impos-sible for us “

REFERENCES1 ) American College of Obstetricians

and Gynaecologists (ACOG ) . Vaginal hyster-ectomy often a better option than abdominal.ACOG Today.Washington DC, USA, AmericanCollege of Obstetricians and Gynaecologists.2009, Nov/

2) Surgical approach to hysterectomy forbenign gynecological diseases. Cochrane Data-base Syst Rev. 2015 Aug 12;(8):CD003677. doi:10.1002/14651858.CD003677.pub5.

3) Sheth SS.: Vaginal hysterectomy or ab-dominal hysterectomy. In: Sheth SS, Sutton C,eds Menorrhagia. Oxford: Isis Medical Media,1999: pp. 21330

4) Sheth SS, Hajari AR, Lulla CP, KshirsagarD.: Sonographic evaluation of uterine volumeand its clinical importance. J of Obstet &Gynecol Research. 2017; 43: 185-189.

5) Sheth SS.: An approach to Vesicouter-ine Peritoneum through a New Surgical Space.J Gynecol Surg. 1996; 12: 135-140.

6) G. D. Maiti1*, Ashok Pillai2 : Non-de-scent vaginal hysterectomy in women with pre-vious caesarean section scar: our experience :International Journal of Reproduction, Contra-ception, Obstetrics and Gynecology 2018Jun;7(6):2404-2409

7) ShethSS .: Vaginal hysterectomy inwomen with a history of 2 or more cesareandeliveries ; Int. journ of Gynaecology and Ob-stetrics , 122(2013) 70-74

8) Ozdemir E, Ozturk U, Celen S, Sucak A,Gunel M, Guney G, et al. Urinary complicationsof gynecologic surgery: iatrogenic urinary tractsystem injuries in obstetrics and gynecologyoperations. Clin Exp Obstet Gynecol.2011;38:217-20

9) Mamik M.M. Antosh D. Risk factors forlower urinary tract injury at the time of hyster-ectomy for benign reasons. IntUrogynecol J Pel-vic Floor Dysfunct. 2014; 25: 1031-1036


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PELVIC ANATOMY in the context ofVAGINAL SURGERIES

Introduction :Vaginal surgery requires comprehensive

knowledge of pelvic floor.For safely attain access.Maximum exposure.Ensure hemostasis.Avoid injury to bladder blood vessels & bowel.What is Pelvic Floor?Dome shaped muscular

sheet which provides pri-mary dynamic support topelvic viscera along withconnective tissue and liga-ments that keep the viscerain position.

It consists of pelvic dia-phragm, superior perinealmembrane, deep perinealpouch and perineal body.

Maintains the continence of urine, faesces.

Allow voiding of urine, defecation, sexualactivity and child birth.

It consists of pelvic diaphragm formed bylevator ani and endo pelvic fascia.

Which in turned is formed by1. Pubo coccygeus which is comprised of two

parts pubo vaginalis and pubo rectalis.Pubo coccygeus muscle is

inserted into coccyx. Medialmost fibers of right and leftbelly meets in the center andforms a thick plate called asano coccygeal Raphae orlevator plate.

2. Illio coccygeus Arisesfrom arcus tendenus belowthe arcuate line, goes downwards and backwards andget inserted into coccyx and

last piece of sacrum and give support to pubococcygeus.

3. Coccygeus muscle. It arises from last partof arcus tendenus at ischial spine and insertedinto coccyx.

Arcus tendenus is formed by thickened fas-cia covering obturator internus muscle alsocalled as white line. White line extends fromposterior surface of pubic symphysis to 0.5 cmbelow illeopectineal line & ends at ischial spine.

Authors

Dr. S. S. Mehendale

Prof. Emeritus, Bharati Vidyapith,Pune

Dr. S. P. Kakatkar

Consultant Gynecologist,Pune


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Basic tone of levator ani is due to 70% slowtwitch fibers and 30% fast twitch fibers whichare situated at peri urethral site and anorectaljunction.

Function:With increase intra abdominal pressure the

fast twitch fibers are activated so that both thehiatus get compressed prevents saggingleavator ani and prevents incontinence too.

There are two openings in levator ani, Ante-rior is hiatus urogenitalis which is surroundedby pubo vaginalis.

Pubo Vaginalis & Pubo Rectalis Sling Pubo Vaginalis Sling

Pubo vaginalis forms sling at junction ofmiddle and lower one third of vagina when in-tra abdominal pressure is raised the junction ispulled anteriorly and compresses vagina. Asresult upper two third becomes horizontal. Soit prevents prolapse.

Posterior opening is hiatus rectalis which issurrounded by pubo rectalis. Pubo rectalisforms sling at ano rectal junction. When intraabdominal pressure is raised anorectal junctionis compressed and pulled anteriorly and anorec-tal angle becomes acute.

In turn prevents incontinence.Pubo vaginalis forms sling at junction of

middle and lower one third of vagina when in-tra abdominal pressure is raised the junction ispulled anteriorly and compresses vagina. Asresult upper two third becomes horizontal. Soit prevents prolapse.

Posterior opening is hiatus rectalis which is

surrounded by pubo rectalis. Pubo rectalisforms sling at ano rectal junction. When intraabdominal pressure is raised anorectal junctionis compressed and pulled anteriorly and anorec-tal angle becomes acute.

In turn prevents incontinence.

Pubo Rectalis

Fibers of pubo rectalis forms the externalanal sphincter .


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Endopelvic Fascia and LigamentsIt is mesh like group of collagen fibers inter-

laced. with elastine smooth cells and fibroblasts.It is parietal and visceral. Parietal fascia is denseand thick. It covers levator ani muscle on supe-rior and inferior aspect, is attached laterally toarcus tendenious.

Visceral fascia covers bladder, uterus cervixand vagina and anterior wall of rectum poste-riorly. Endopelvic fascia covering the bladderand anterior vaginal wall is thin as compared

to recto vaginal septum. Endopelvic fascia cov-ering upper two third posterior vaginal walland anterior surface of rectum forms a thickplate called as rectovaginal fascia or DenonVilliers fascia.

At hiatus urogenitialis and rectalis parietalfascia merges with visceral fascia and formsthick ring at hiatus and prevents prolapse aswell as incontinence.

Visceral fascia covers bladder, uterus, cervix,vagina and anterior and lateral wall of rectum.

LigamentsThis is thickened endopelvic fascia with

smooth muscle. It forms a ring around supravaginal part of cervix.


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These are pubo cervical, transverse cardinalor Mackenrodt ligament, uterosacral ligaments.

Important avascular spaces are present be-tween ligaments are para vesicle, vesico cervi-cal, recto vaginal, recto sacral and para rectalspaces.

Blood vessels pass through the ligamentsand not through the space.

Ureteric tunnel is situated inMackenrodt ligament. In the tunnel,ureter lies 1.5 cm lateral to the cervixat internal os. At this point there iscrossing of uterine artery and ureter.Uterine artery is on the roof of tunneland then ascends close to uterus. At thecrossing point it gives descending cer-vical and circular artery.

Vagina is supplied by differentbranches of internal illiac. They formazygous vessels.

Relation of Ureter with LigamentsMean distance of ureter in ureteric

tunnel from the cervix is 1.5 cm.Mean distance from uterosacral liga-

ments closed to cervix at insertion 0.9 +/- 0.4 cmMiddle part is 2.3 +/- 0.9 cmAt sacral region it 4.1+/- 0.6 cmIt is approximately 1.2 cm from the lateral

fornix.Perineal PouchesMean distance of ureter in ureteric tunnel


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from the cervix is 1.5 cm.Mean distance from uterosacral ligaments

closed to cervix at insertion 0.9 +/- 0.4 cmMiddle part is 2.3 +/- 0.9 cmAt sacral region it 4.1+/- 0.6 cmIt is approximately 1.2 cm from the lateral

fornix.Perineal PouchesAfter leaving hiatus urogeniatalis, urethra

and vagina enters deep perineal pouch.Deep perineal pouch is formed by superior

and inferior perineal membrane.

Perineal membrane is fibromuscular at-tached to lower border of pubic symphysis, de-scending rami of pubis, ischial tuberosity andto the base of perineal body.

After opening the inferior perineal mem-branes deep perineal pouch is visible in whichdeep transverse perineal muscle and striated

urogenital sphincter complex comprisingsphincter urethra, compressor urethrae andurethra vaginal sphincter and then urethra andvagina open at the vestibule.

Underneath the bulbospongiosus muscle,inferior perineal membrane is seen. On whichvestibular bulb and bartholin gland is seen lat-


( 37)

eral to vagina. Superficial perineal pouch is be-tween the inferior perineal membrane aboveand Colle's fascia below.

Pelvic outlet is divided in two triangles an-terior is urogenital and posterior is anal triangle.

Inferior perineal membrane covers the uro-genital triangle of pelvic outlet.

Posterior triangle is not covered by perinealmembrane. It is comprised of levator animuscles when perineal body contracts perinealmembrane compresses the vaginal and urethralopening preventing incontinence of urine.

Perineal BodyThree layers of the muscles of pelvic floor

are represented in perineal body.Formed by

1. Bulbospongiosus2. Superficial transverse perineal muscle3. External anal sphincterMiddle pieceDeep transverse perineal muscleSphincter urethraeCompressor urethraeUrethro vaginal sphincterApexFormed by pubo rectalis, it is attached to

recto vaginal septum of endopelvic fascia.Relation of uterus with bladder and rectumDome of bladder is close to supra vaginal

part of cervix.Posterior wall of bladder is in relation with

upper two third of anterior vaginal wall. Ure-thra is resting on lower one third of anteriorvaginal wall.

Upper one third of posterior vaginal wall isseparated from rectum by pouch of Douglas.Middle one third of posterior vaginal wall isclosed to rectum but separated by rectovaginalfascia.

Lower one third of posterior vaginal wall isrelated to perineal body.

Sulci on anterior vaginal wall1. Sub meatal sulcus2. Transverse sulcus denotes urethro vesicle

junction.

3. Vesical sulcus denotes upper limit of blad-der.

Applied AnatomyRelated to Perineal Surgery1. In complete perineal tear posterior vagi-

nal wall is to be separated from the rectum. Thisdissection should be in the rectovaginal space.


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2. While suturing deep episiotomy and colpoperineorrphy, complete perineal tear, approxi-mation of the perineal muscles is necessary tobuild the perineal body.

3. Identification of internal and external analsphincter is essential for its approximation dur-ing repair of complete perineal tear.

4. In lower rectovaginal fistula repair is doneby creating complete perineal tear.

Related to Vaginal HysterectomyDuring vaginal hysterectomy, incision on

anterior vaginal wall should be taken above thevesical sulcus where the rugosity starts. Belowthe vesical sulcus vagina is adherent to cervicaltissue, incision taken on this smooth epitheliumleads to disruption of cervical tissue leading tobleeding. This will cause difficulty in separa-tion of bladder. If incision is above the vesicalsulcus, inadvertent entry into the bladder maytake place.

During prolapse surgery vertical incision onanterior vaginal wall should be upto transversesulcus. Above the transverse sulcus urethra isadherent to vagina it may get damaged.

During vaginal hysterectomy separation ofthe bladder must be in the vesico cervical spaceto avoid bleeding.

After separation when the bladder is re-tracted, bladder pillars stand out which can beeasily separated.

While opening the pouch of Douglas the in-cision should be at level of the rugosity.

Opening of the pouch is done by two ways1. Direct opening along with vagina.

2. Separation of vagina is done, visualize theperitoneum and open it.

If the incision is more posterior to rugosityfat is visible.

Presence of fat denotes proximity to rectum,in turn, can lead to injury to rectum.


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Uterosacral clamping and cutting should notbe very close to cervix as ureters are only 0.9cmfrom the uterosacral.

Cardinal ligament clamping should be veryclose to cervix to avoid injury to ureter and uter-ine artery at ureteric tunnel.

In NDVH for adenomyosis or uterine fibroid,cardinal ligament may get displaced due to ir-regularity and enlargement of uterus.

In cervical fibroid before clamping ligamentsenucleation is necessary as anatomy is distorted.

In prolapse uterus with supra vaginal elon-gation, there is fanning of cardinal ligament atits attachment to the lateral wall of supra vagi-nal part of cervix. May need multiple clampingand cutting for ligating the Mackenrodt liga-ment. If not, uterine artery may get damaged.

Uterine artery should be clamped and cutclose to internal os to avoid injury to ureter.

In case of NDVH for broad ligament fibroid,extra care is necessary. Psudo broad ligamentfibroid arises from the lateral wall of uterus andenters into the broad ligament. Ureter and uter-ine artery are displaced laterally. In true broad

ligament fibroid, ureter and uterine are posteriomedial to fibroid.

After uterine artery ligation, the clampshould be applied on cornue, which includesround ligament, ovarian ligament and tube.After removal of uterus, if enterocele is present,Macold’s culdoplasty is done. Anchoring ofutero sacral and Macendrot ligament is done tovaginal angle for prevention of vault prolapse.


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During cystocele and rectocele repair if theplane is not proper, there will be bleeding asvagina is vascular.

During cystocele repair pubo vesico cervi-cal fascia is approximated.

During rectocele repair it is essential to ap-proximate the para rectal fascia and recto vagi-nal fascia.

It is attached to the apex of perineal body. Itsupports rectum and posterior vaginal wall pre-venting rectocele.

Perineorrphy is done to reduce the vestibule.During conservative surgical procedure for

prolapsedA. Fothergill operation Mackenrodt is

stitched anteriorly to support bladder base.B. In Shirodkar's modification, utero sacral

ligaments are brought anteriorly and stitchedover the anterior wall of cervix making theuterus anteverted. Advancement of Pouch ofDouglas is also done.

In stress incontinence secondary to posteriorurethro vesicle angle disturbance, Kelly stitchis taken which should be at the level of trans-verse sulcus for restoration of angle.

Le Forte operation is essential to approxi-mate fascia covering anterior and posteriorvaginal wall which forms thick septum betweentunnels of vagina.

Vault Prolapse RepairDuring sacrospinous fixation of vault, care

should be taken to anchor the stitch by passingthe needle 1 to 1.5 cm medial to ischial spine toprevent injury to pudendal vessel.

ConclusionFor uneventful vaginal surgery precise

knowledge of pelvic floor, proper training indifferent surgical procedures and perfect selec-tion of the cases is essential.

References1. Gastroenterol Clin North Am. 2008 Septem-

ber; 37(3) 493-VII2. Hawkins & Bourne; Shaws Textbook of Gy-

necology’; Chapter 1, Page 13 (14th Edition)3. D C Datta’s Textbook of Gynecology, Chap-

ter 1, Page 13, (7th Edition)4. Schorge Schaffer Halvorson, Hoffman

Bradshaw Cunningham Williams Gynecol-ogy, Chapter 38, Page 779

5. State of the Art Vaginal Surgery by NeerjaGoel, et all, Chapter 2, Page 8, 2nd Edition.

6. Pelvic Anatomy Revisited, Clinical Appli-cation, Dr. Nirmala Vaze, Chapter 2, Page19, (1st Edition 2018)

7. American Journal of Obstetrics & Gynecol-ogy, Vol. 222, Issue 3, Page 204-218, Mar 1,2020 .


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Tips & tricks in safelyopening anterior & posterior pouches.

Vaginal hysterectomy is a common proce-dure performed routinely by gynaecologists ef-ficiently. “Well begun ishalf done” is a famous En-glish proverb. Opening theanterior and posteriorpouches is the initial taskinvolved in performingvaginal hysterectomy andit is also easily done mostly.It can however be openedwith difficulties. This chapter gives a few tricksand tips to ensure successful and safe access andmakes us sail through the whole procedure

smoothly.Opening the anterior pouch.

Where to put the circularincision in the anterior vagi-nal wall? This is an importantdeciding factor for successfulanterior colpotomy. Empty-ing the bladder prior to anypelvic surgery is an impor-tant step which will emptythe bladder and minimise the

chances of inadvertent bladder injury. The samemetal catheter can be used to know the extentof the bladder.

Prof. Dr.Mrs. T. Srikala Prasad

Professor & Head of theDepartment of Urology,

Chengalpattu Medical College,Tamilnadu.


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The bladder sulcus is identified on the ante-rior vaginal wall. This can be seen as the placewhere the bulging bladder margin comes andgets inserted on to the cervix. We will be ableto see a crease at the junction between the blad-der and the cervix. This crease will get accentu-ated if we give to and fro movement of theuterus with a vulsellum forceps held on to theanterior lip of the cervix in the midline.

With the anterior lip of the cervix being heldwith a vulsellum forceps and downward trac-tion applied, we can use our nondominanthand to catch the anterior vaginal wall (includ-ing the cystocele) and give countertraction.This will clearly identify the place where thebladder and we can place our circular or trans-verse incision on the anterior vaginal wall from9 o’ clock to 3 o’ clock.


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Strong traction on the cervix and counter-traction with Allis forceps applied on the ante-rior vaginal wall is a key to successful colpo-tomy. This helps us to identify the bladder pil-lars which are the cervico vesical strands ex-tending from the bladder to the cervix. Withcontinued traction and countertraction, acurved scissors with curvature facing down-

wards is used to cut these strands and mobilisethe bladder staying horizontal to the anterioraspect of the cervix and uterus. Havingmobilised the bladder we now proceed to open-ing the thin uterovesical (UV) fold of perito-neum. A bladder retractor now can be placedto safeguard the bladder.

Alternate approachIn case of difficulty in opening the UV fold

of peritoneum in patients with Pelvic OrganProlapse (POP) or in women with atrophicuterus, the Pouch of Douglas (POD) is openedand the fundus of the uterus is hooked and the

bladder is dissected from the uterus. We willnow be able to see the thin UV fold of perito-neum, which is opened and the fundus of theuterus is delivered.

Opening the UV fold of peritoneumthrough the POD


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Difficult situationsPrevious LSCSDifficulty can be encountered when we

handle a patient with history of previous LSCS.The bladder may be densely adherent to thelower uterine segment. The key to successfulentry is using sharp dissection. The bladder maybe lifted up using our left hand which helps ingiving continued traction and by sharp dissec-tion the bladder is safely mobilised. It is impera-tive to avoid pushing with gauze when the blad-der is densely adherent, as it may result inbladderinjury with the anterior wall of the blad-der being pushed and the posterior wall adher-ent to the lower uterine segment. It is prefer-able to have few fibres of the uterus or the cer-vix on the bladder rather than have few fibresof the bladder on the uterus or the cervix.

Sheth’s space(Uterocervical Broad LigamentSpace). -Anatomically it is the middle three fifthof the bladder which is in close relation to thecervix and the lower uterine segment. TheSheth’s space or the Uterocervical Broad Liga-

ment Space is the space in relation to the lateralone fifth of the bladder on either side which liesfree and is not in close proximity. That is thereason we encounter dense bladder adhesionsin the central three fifth in patients with previ-ous history of single or multiple LSCS. Access-ing this Sheth’s space in women with previoushistory of LSCS would help us to prevent blad-der injuries.

Masked anterior cervical lipAnterior vaginal wall in some patients is seen

stretching to reach the anterior lip of the cer-vix. This may make the access to the anteriorpouch difficult. Allis forceps can be used insteadof the vulsellum forceps to hold the cervix andthey may be held in the 3 and 9’o clock positioninstead of the 12 ‘o clock position. The anteriorvaginal wall with the underlying cystocele maybe held with the nondominant hand and usedas traction while countertraction is given by theAllis holding the cervix. This will clearly demar-cate where we have to put the incision and therest of the procedure is the same.

Masked Anterior Cervical Lip


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Cervical elongation In patients who have supravaginal elonga-

tion of cervix, the elongation of the cervix isabove the bladder sulcus. The bladder sulcus isat the same level as in patients with a normaluterocervical length. The circular incision on theanterior vaginal wall is made in the usual wayand further dissection is proceeded to reach theUV fold of peritoneum.

On the contrary,in patients with infra vagi-nal elongation, the cervical elongation is belowthe bladder sulcus. Depending on the length ofthe cervical elongation, the bladder sulcus maybe far away from the external os and may becloser to the bladder neck (transverse vaginalsulcus). We need to exert care in identifying theplace where the bladder gets attached and placethe circular incision in the anterior vaginal wallcorrectly so that we enter the correct plane.

Infra vaginal elongation of cervix with a fibroid polyp

Anterior fibroidsAnterior cervical fibroid poses problems in

dissection between the bladder and the cervix.It is better to proceed with opening the POD,tackling the USL-cardinal ligament complexand getting some more descent.

Infiltrating vasopressin into the planned areaof the incision will help in reducing the bleed-ing. A midline vertical incision is made over the

anterior cervical wall with diathermy till we areable to see the compressed pseudo capsule overthe myoma. Enucleation attempted in this planewill help removal of the myoma in a relativelybloodless way. We need to be aware of the pos-sibility of severe bleeding in view of the fact thatthe uterines have not yet been tackled.

Managing bladder injuryDetecting bladder injury is relatively easy


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compared to detecting intraoperative uretericinjury. Metal catheter inserted will revealbloodstained urine and will help identify thesite of injury. Instilling methylene blue throughthe Foley catheter will help in identification ofthe injured site, in cases of a small rent.

The bladder rent can be closed in 2 layers inmost patients vaginally itself. However in somepatients, especially when NDVH has been donein patients who have undergone multiple LSCSwe may face difficulty in repairing from below.The bladder will be at a higher level and theremay be difficulty in safely accessing it for ameticulous repair. Even though we can try toimprove access by giving an episiotomy orSchuchardt’s , it is better to ensure safety andwe need not hesitate to open. Bladder is a for-giving organ and heals beautifully when re-paired well. The first repair is the best repair.Allefforts to ensure a successful repair are taken.

We need to ensure that all the edges of thebladder are well mobilised and amenable to su-turing. Sometimes the posterior wall of the blad-der may be densely adherent to the lower uter-ine segment and needs to be mobilised. Thissituation can be managed with help from Urolo-gist. We need to visualise both the ureteric ori-fices and confirm the ureteric jets.It is better toprotect both the ureteric orifices from inadvert-ent inclusion during rent repair by DJ stentingor placing Infant feeding tubes which can be re-moved at theend of the pro-cedure Thereis no need tostent if thebladder rent isfar away fromthe orifices.The uretericorifices insome patientsmay be dan-

gerously close requiring reimplantation. It isbetter to take the help of a urologist in such dif-ficult situations. The bladder injury can be tack-led after completion of hysterectomy. The blad-der rent is closed in two layers with a suprapubic cvatheter inserted by Lowsley’s tech-nique. Excellent postoperative care ensuring ad-equate continuous drainage by catheter, anti-biotics, analgesics and anticholinergics (to re-duce bladder spasms) are given.

Simple bladder injuries can be tackled by thegynecologists. The services of a Urologist canbe taken when difficulties are encountered orwhen the treating gynecologist does not haveenough expertise in dealing with bladder injury.

Opening the posterior pouch We need to know where to put the incision

in the posterior vaginal wall. The posterior lip of cervix is held with a

volsellum and drawn anteriorly.The junction ofthe cervix and the posterior vaginal wall is iden-tified by pushing the cervix slightly inside andlooking for the transverse crease which is the firstrugosity. The posterior vaginal wall and perito-neum is grasped 1-2 cm below the loose fold anda bold cut is made & the posterior vaginal wall& peritoneum are opened in one stroke itself.There will not be any bleeding as both the layersare together. Small amount of straw colouredperitoneal fluid may come out. We will be ableto see the peritoneal cavity and its contents.


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In case the peritoneum is not opened and werealise that only the transverse incision on theposterior vaginal wall has been made, weshould proceed to safely opening theperitoneum.Two Allis forceps are used to holdthe upper posterior edge and tent it. This ex-

poses the cervico vaginal fascia from which anyadherent structures are cleared by pushing themaway. We can catch the thin peritoneum with 2hemostats and open it. We can see a smallamount of peritoneal fluid coming out.

The opening may be extended with fingersand a Sims speculum is placed there. Catchingthe posterior vaginal wall and the peritoneumtogether with Allis forceps will ensure good he-mostasis. The peritoneum is inspected for ad-hesions, mass lesions or other abnormalities thatrequire care and caution. Vaginal hysterectomycan be safely proceeded now.

Difficult situations can arise which can bemanaged by vaginal surgeons having more sur-gical expertise in handling these challengingsituations. The POD may be found obliteratedbecause of endometriosis or pelvic inflamma-tory disorders or Genital Tuberculosis. Therecan be difficulty when the cervix is flushed with

the vaginal walls. Accessing either or both theanterior and posterior pouches will be a techni-cally challenging one. It is better to begin at-tempting to access the posterior pouchfirst.Difficulty may also be encountered whenthe cervical lip is masked by overhanging of theposterior vaginal wall. In both these situations,the posterior vaginal wall is held in the midlinefrom the posterior lip of cervix and reflected bya midline vertical incision preferably afterhydrodissection. The fold of peritoneum is nowheld with hemostats and carefully opened.

The presence of posterior cervical fibroidmakes access difficult. Experienced vaginal sur-geons will manage with hydrodissection, vaso-


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pressin infiltration, enucleation with assistancefrom myoma screw etc.

Rectal injuryInadvertent injury to the rectum is less com-

mon compared to the bladder being opened. Wemust be ready to tackle this problem. Cleans-ing of the rectum is done with adequate salineirrigation. The rectum is closed in 2 layers ofintermittent suturing with a 2-0 delayed absorb-able Polyglactin. Further protection is given byimbricating the pararectal fascia over the sutureline as a third layer. It can easily be repaired bythe gynecologist from below itself and does notneed any diversion. In case, the site of injuryappears high or the operating gynecologist feelsinsecure and does not have the needed surgicalexpertise, the services of a general surgeon or a

specialist gastro intestinal surgeon can be ob-tained. The need of an interpositional graft likeMartius graft is not needed except in the rareinstances where the vitality of the tissues are ofpoor quality and feared to give way.

We are sure to win if we follow the standardguidelines and safety measures and complete avaginal hysterectomy successfully and safely.In case of difficulty one can request for a seniorperson’s help or the help of a urologist or GIsurgeon. It is not a shame to request for help orconvert to open procedure or get laparoscopicassistance. The ultimate aim is ‘patient safety’and our peace of mind. We need to go up thesurgical ladder with adequate mentoring andcontinuing to do more demanding cases as wegain more expertise.


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NDVH for Big Uterus withPrevious Multiple C - Section

Index1) Abstract2) Introduction3) Aims & Objectives4) Material & Methods5) Surgical steps6) Results7) Discussion8) Conclusion9) References Abstract : A unique study was undertaken in a entre-

preneur set up in a town with Institutional background of more than 33021 cases of Vaginalhysterectomy in cases without prolapse.thestudy included cases of multiple/ single largefibroids, previous 1-2 or 3 caesarean section,bulky uterus without descent till 20 weeks size,high risk cases with medical problems or badabdominal hernia repaired by mesh, nullipa-rous patients with bulky uterus, case of badabdominalkochs needing hysterectomy etc.

A new method of aqua dissection was donein all cases with simple significant modificationof dissecting & not cutting the vessels in tradi-tional fashion. The purpose of the study was todevelop a simple method to do vaginal hyster-ectomy in difficult cases which can be easily

followed by all gynecologists the amateur & theexperienced who wants to master the traditional

this Indian traditional heri-tage to it's fullest potentialsafely.

Out of 33021 vaginal hys-terectomy there were onlysmall complications in 0.3%cases with no mortality Theindications varied from mul-tiple large fibroids, adnexal

masses, previous caesarean sections/abdomi-nal surgery, high risk medically & surgicallywith abdominal mesh repair of hernia, manypatients of more then 120 kg. to even 160 kg. inweight etc.

The major importance of this aquadissectiontechnique is that this can be quickly learnt byany gynecologists & could be implemented inclinical practice.

“In today's era advanced costly technologiesbecomes inevitable in medical research, how-ever finding "n avenues in already establishedsurgery is more challenging to a skilled gyne-cologist. Such research solutions enhances skill,ease & excellence to do surgery for all gynecolo-gist a novice or an expert."

Dr. Vyomesh Shah

Consult Gyne. Patan (Gujarat)


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Introduction In today's scenario, conscious attempts are

being made to reduce the number of abdomi-nal hysterectomies and replace them preferablywith vaginal hysterectomy or with laparoscopicassistance as the next choice.

The vaginal approach has always been an artrestricted to the gynaecologists only. Vaginalsurgery differentiates the gynaecologist fromthe others. However, there are gynaecologistswho do think of vaginal route only when thereis uterine prolapse or with some uterine laxity.Is this justifiable? Is this scientific? Is doing vagi-nal hysterectomy in difficult situation a mentalblock or true skill limitation ?

Davies et al' reviewed 500 cases of Hyster-ectomies. 19.2 % of those were vaginal hyster-ectomies and 76 % done by the abdominal routein the absence of an absolute contraindicationto Vaginal Hysterectomy. Common reasonsgiven for not taking vaginal route were absenceof prolapse in 76 %, presence of fibroid in 45 %and need for Oophorectomy in 43% dysfunc-tional uterine bleeding, suspected Adenomyo-sis and polyps can be clubbed together as theideal set up for vaginal hysterectomy.

Nulliparity per se should it always contrain-dicate vaginal hysterectomy ?

Past history of abdominal or pelvic surgerydoes in itself constitute a contraindication tovaginal hysterectomy ? The commonest pelvicsurgery is caesarean section and according toChapron, currently 20 % or more of deliveriesare by caesarean section in most countries.

Cervical Dysplasia; for severe dysplasia,when the decision is to resort to hysterectomy,in the absence of contraindication, vaginal hys-terectomy could be the suitable procedure ?This makes gynecologists stand apart from oth-ers.

Oophorectomy at vaginal hysterectomy:Oophorectomy is technically possible and can

it be safely performed while doing vaginal hys-terectomy without increasing the morbidity?

Medically High Risk cases : The vaginaltechnique becomes a clear option when the ab-dominal route and Laparoscopic route may bedifficult and/or risky. Previous ventral scarhernia repaired with prolene mesh, repeatedskin keloids, pulmonary fibrosis, tuberculousabdomen and hypertensive with diabetes aresome of the examples inviting to resort to vagi-nal route for hysterectomy.

AIMS AND OBJECTIVESWe evaluated that with the help of our Aqua

Dissection Technique the feasibility of doing forUterus without descent with various pathology,Vaginal Hysterectomy could be made veryeasy, fast, nearly blood less, economical withgood quality of post operative life. Any Gyne-cologist with moderate surgical experience canconfidently do Vaginal Hysterectomy for NonDescent Uterus without complications follow-ing standard teaching & meticulously imple-menting the suggestions given in this researchstudy.

In our study we performed vaginal hyster-ectomy in uteri without any descent. All pa-tients requiring hysterectomy with benign gy-necological disorders of the uterus without de-scent were taken up for the study, provided theuterus was mobile, its size did not exceed 20weeks gestational size and there was adequatevaginal access. Morcellation techniques like bi-section, debulking by myoma removal aftersecuring uterine arteries, wedge debulking orcoring or combinations of these were employedin bigger size uteri.

Hysterectomy is one of the most commangynecological surgery perform all over world-wide. The Vaginal technique has been intro-duced and performed centuries back, but it hasbeen successfully not done due to lack ofconfidence,experience among the gynecologist


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due to misconception that abdomen Hysterec-tomy is safer and easier

By our ?echnique at the present study it wasconcleded that NDVH is associated with lessblood loss , faster ,easier with best operative lifecompare to TAH ,LAVH „AH with minimalstay in the hospital and faster convalescence.

NDVH for big uterus with previous LSCSAs name suggest NDVH means normally

difficult vaginal hysterectomy or non descentvaginal hysterectomy. Big uterus means size ofthe uterus is more than 14 to 16 weeks size onwhich one or multiple scar of LSCS is present.

Usually big uterus is due to1) Severe Adenomyotic huge uterus2) Multiple fibroids3) Single huge fibroid may be intramural ,

sub serous or sub mucous and broad ligamentfibroid.

In cash of normal uterus without any LSCSscar very easy to operate as bladder doesn'tcome in the way

Technique• My technique is AQUA DISSECTION -

where I am injecting normal saline ap-proximate 200cc all around cervix onuterine wall which creats avascular tour-niquet and compresses small vessels sobleeding will be less at the time of inci-sion. Not only that due to AQUA DIS-SECTION technique we gate beautifulplan for dissection which makes the sur-gery easy, fast and bloodless

• Here we are injecting extra 30cc of nor-mal saline at the juncture of bladder onuterine wall which gives us place to cutand push the bladder away from the in-cision line and prevents bladder injury

• We use vessel sealer that is ligasure forcutting and cauterize that makes surgeryvery fast and bloodless

• As uterus is big due to severe Ad-enomyosis , we core out uterus by cut-ting or chopping it so gradually uterusshrinks and coming down .we go on cor-ing till we remove uterus by myomascrew. we always remove fallopian tubesas per international study to preventovarian cancer, we don't use any specialinstrument for last pedicle that is tuboovarian pedicle we cut and cauterize thatpedicle or tube by our ligasure small jaw.

• By usage of cautery we minimize bleed-ing , bloodless and surgery becomes veryvery easy

• If uterus is having multiple fibroids wego on removing one by one and demassthe uterus and facilates descent of theuterus. Here we use same technique ofaqua dissection and ligasure

• If uterus is big due to single fibroid andpatient is multipara we remove the bigfibroid by using myoma screw and aquadissection. If patient is having no nor-mal delivery we just go on coring the fi-broid to make it smaller and smaller sowe can have good descent of remainingpart of the uterus.

• In case of previous Iscs as we already toldwe use extra aqua dissection techniqueat bladder anchoring on uterine wall anddissect and seperate bladder away fromarea of surgery

• Our study of 33021 vaginal hysterectomyduring 2001 to2019 are as below.

Material and MethodsAll patients requiring hysterectomy for be-

nign gynecological disorders without prolapsewere studied from march 2001 to july 2019.

Prerequisites for vaginal route were : uter-ine size not exceeding 20 weeks of gravid uterus, adequate vaginal access and uterine mobility.


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Patients with severely restricted mobility,complex adnexal mass and suspicion of malig-nancy were excluded, Informed consents weretaken

Table 1: Indications and associated condi-tions for vaginal hysterectomy in patients-33021 cases

Indications Associated relevant detailsMenorrhagia(a) Dysfunctional uterine bleeding & Nullipara(588) Adenomyosis (14694)(b) Uterine fibroids (13047) Previous abdominal surgery (1950)(c) Cervical polyp/fibroid Previous vaginal surgery (1044)Bulky Uterus High risk (381)Benign Adnexal pathology(936) -Carcinoma in situ of the cervix( 114)

Endometrial cancer (288)

Contraindications:• Uterus> 20 weeks' size• Uterine volume > 400 cm³• Restricted uterine mobility• Diminished vaginal space• Inaccessible cervix• Vesicovaginal fistula repair• Invasive cancer of the cervix• Although the first four are vital and most

commonly sought, the last two are un-common in day- to-day practice.

Preoperative investigations tests :• Blood for complete count• Blood group and Rh factor• Creatinine• Urea• Sugar - fasting and 2 h after 75g glucose• HbsAg - Australia antigen• Hepatitis C antigen• Human immunodeficiency virus• Bleeding, clotting and prothrombin time

and platelet count• Urine routine examination

• Chest radiograph• Ultrasonography• Endometrial thickness• CT/MRI in selected cases• ECG• Few Thalassaemia particularly in Medi-

terranean belt• Rarely G6PD in certain geographical ar-

eas and communities• CA-125 and allied tumour markers if

Adnexal mass present• Two dimensional echocardiography and

stress test if necessary• Pulmonary function tests in few• Intraoperatively: frozen section histopa-

thologyOur surgical step with new modifications :

AQUA DISSECTION IN VAGINAL HYS-TERECTOMY

1. Material used :(a) Fluid-normal saline 150 to 250 ml(b) Suture-Polyglactin no. 1 suture material


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(c) For injection of normal saline – 10 cc syringe with 18 gauze needle

(d) Adrenaline - dose 0.6 ml in 1 liter saline2. Place where saline is injected :Beneath vaginal mucosa all around cervix1

cm away from external os,injected in 2 cm areacircumferentially till blanching occurs approxi-mately ½ cm deep to mucosa.

3. What is the advantage of this step?Tissue beneath mucosa is flooded with fluid.

It compresses vascular structures artery & veinscreating vascular tourniquet in injected area.

a) It creates vascular tourniquet in lowerpart of uterus - compress small vesselsprevents bleeding at the time of surgery-bloodless surgical planes.

b) Tissue planes are full with fluid whichgives proper plane for dissection whichbecomes very clean, fast, bloodless, easy,artistic.

How Vaginal Hysterectomy is simplified?Vascular tamponade, easy tissue planes &

safe to bladder.Technique in detailsStep no. 1 : Aqua dissection as above.Step no. 2 : Opening of peritoneal cavity

- We do not chase & open anterior pouch- Give a stretch to pull posterior vaginal wall.- Sharp cut with scissors will open posterior

pouch and peritioneal cavity is opened.- Small incision is made on anterior surface

of cervix.- Join anterior and posterior incision by cut-

ting lateral vaginal wall making circumfer-ential incision.

Step no. 3: Bladder mobilization- Sharp dissection on anterior vaginal wall

is made with scissors to cut utero vesicalfascia and blunt blade of "vim's speculum"

will draw away the bladder from surgicalfield.

Step no. 4: Managing uterosacral ligament- properly dissected uterosacral ligament is

caught with single simple kocher's clamp-cut and ligated with polyglactin no. 1 su-ture and suspended on posterior vaginalwall at 5 O'clock and 7 O'clock position toprevent future vault prolapse.

Step no. 5: Managing uterine arteryafter securing utero sacral ligament on bothside, proper skeletonisation of uterine com-plex is so artistic that single simple kocher'sclamp is sufficient to secure uterine com-plex confidently

- both side uterine complex secured in samefashion.

- An important modification is routinelydone by us wherein the uterine vessels arenot cut after clamping, but going closureto the uterus it's shaved off with minimaluterine tissue. Thus even if we release theclamp the uterine arteries will not bleedsince vessels are not cut. PN figures in op-erating technique.

Step no. 6: Managing ascending branch ofuterine artery

- Once again sharp dissection with scissorswill give proper exposure of the pedicle.

- This part also contain some collagen tissueso after separation, support of uterus is de-creased which facilitates further easy de-scent of uterus.

Step no. 7: Management of last pedicle whichcontainsRound ligament, Tube, Uteroovarian liga-ment & vessels.Again simple singlekocher's clamp take care of this pedicle, we


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usually secure this pedicle twice as it con-tains ovarian vessel which is direct branchof aorta which can slip giving rise to pro-fuse bleeding.

Step no. 8: Managing vaginal vaultOne stitch is made at lateral angle of vaultfrom anterior to posterior vaginal wall andtied with utero sacral ligament to give ex-tra support to vault.Continuous pursestring suture form pos-

terior vaginal wall to anterior vaginal wallis made - at the end middle half of vault isopen which allows drainage of blood orfluid from peritoneal cavity.Step no. 9: Bladder catheter is kept for 12hours till patient walks to toilet on herself.Please read: VH = Vaginal Hysterectomy,Cx = Cervix, NS = Normal Saline, u/s =Utero Sacral Ligament Almost all caseswere done under regional anesthesia, eitherspinal or epidural

INSTRUMENTS

Injection of Normal Saline Anteriorly Injection of Normal Saline


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Injection of Normal Saline on laterally Knife incision ~anterior vagina

Post .vagina made prominent Vagina stretched Posterioly

Opening of Pouch of Douglas Opened of Pouch of Douglas


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Securing left Utero sacral Ligament Suspension of U/S lig.on post .vaginal wall

Securing left Ut. Vessels with kocher’s clamp Securing Right Uterine vessels with Kocher’s clamp

Opening of Anterior Pouch Securing of ascending branch of left Ut.Artery


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Securing of ascending branch of right Ut.Artery Securing left round lig ,ovarian vessels & tube

Securing other last pedicle Dissection of last pedicle with cautery

Showing last pedicles on both side Vault closure by inverting margine of the vault


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Middle 2/4 of the vault kept open for drain-age of collected fluids

PN : This is actual surgery with hardly anyblood lossVARIOUS TYPE OF FIBROIDS REMOVEDVAGINALY WITH LARGE UTERUS BY"AQUA DISSECTION"


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ResultTable I.Age and parityAge (Years) No. of Patients Parity No. of Patients35 - 40 (12%) 1 (4%)41-45 (54%) 2 (24%)46 - 50 (20%) 3 (46%)Above 50 (14%) 4 and above (24%)

Table IIIndications for Vaginal Hysterectomy in 33021 patients :

IndicationsDysfunctional uterine bleeding/adenomyosis 14694Uterine fibroids 13047Nulliparity severe mental disability (included) 588Previous abdominal Surgery 1950Previous vaginal Surgery 360Cervical polyp/ fibroid 1044Carcinoma in situ of cervix 114Endometrial cancer 288Benign adnexal pathology 936Total 33021

Table II. Surgical results Parameters Mean operating time 20 minutes (range 15-35 minutes)Mean blood loss 20 ml (range 10-30 ml)Average hospital stay 1 dayTable III: Vaginal Hysterectomies: ComplicationsBladder injury 09 Rectum 01Small bowel injury 01Ureterinjury Nil


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Reactionary haemorrhage 06Vaginal bleeding 10Failures 06Mortality Nil

Table IV:Out come of the Study Non Descent Vaginal Hysterectomy with Aqua Dissection Method

Criterias evaluated OutcomePatient's comfort ExcellentPatient's recovery Smooth & FastOperating time Very LessSurgeons Comfort Most ComfortableAnaesthetist Comfort Very good & less Anaesthesia TimePost Operative Analgesia MinimalIntra Operative Bleeding Average <20 mlOperative Complication 0.3 %Cost of the Setup Very EconomicalCost for Hysterectomy Rs.10000 - 15000Conversion to Abdominal Route 6 cases

Comparison of Vaginal Hysterectomy with AquaDissection & Laparoscopic Hysterectomy

Particulars VH with Aqua Dissection Laparoscopic HysterectomyOperative Time < 30 Min. >2 hourBlood Loss 20 - 30 ml > 300 mlHospital Stay 1 day 2-3 daysRecovery Period Fast painless & Uneventful Comparitively slow with PainRecovery Time Resume duty in 3-7 days May require > 10-15 daysSurgeons Comfort Less operative time, very Much more operating

lessbleeding timemore bleedingAnesthetist Comfort Short anesthesia 20-60 minutes Long-strainful >2 hour


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Discussion Though India probably has the best vaginal

surgeon on the earth who were our teachers &pioneers of the art of vaginal hysterectomy ineven most difficult cases.Surprisingly it is awell-known fact that in many centres 60% to70% of hysterectomies are performed by ab-dominal route and vaginal approach is usuallyused only in uterovaginal prolapse. The unfa-vorable factors for vaginal hysterectomy iden-tified by many, are absence of significantuterovaginal descent, presence of significantuterine enlargement, previous caesarean sectionand the need for oopherectomy

With adequate vaginal access, technical skill,and good uterine mobility, vaginal hysterec-tomy can easily be achieved. The main supportsof the uterus, the uterosacral and cardinal liga-ments, situated in close proximity to the vagi-nal vault can be easily divided to produce de-scent. Multiparity, lax tissues due to poor invo-lution following multiple deliveries and lessertissue tensile strength gives a lot of comfort tovaginal surgeon even in the presence of signifi-cant uterine enlargement.

The second most important reason for thelower proportion of hysterectomies performedvaginally is the presence of uterine enlargementwith leiomyomas', one of the most common in-dications. However, now big and bulky uterican be dealt with by techniques like bisection,debulking myoma or morcellation. In our study,we could remove uteri of up to 20 weeks preg-nancy size vaginally without any increase insurgical complications, blood loss, operativetime or hospital stay. Similar findingsarereported, operated upon uteri weighing 200to 1700 gm, without any increase in complica-tions as compared to Laparoscopic or abdomi-nal hysterectomies. Complications in our studywere minor and few. We consider vaginal hys-terectomy safe upto 20 weeks size. Das and

Seth¹°,¹¹ use ultrasonographic calculation ofuterine volume for assessing the feasibility ofvaginal hysterectomy. They needed debulkingfor uteri with a volume of more than 300cm.

Vaginal hysterectomy in women with non-descent and moderately enlarged uteri issafe¹²,¹³. A combination of morcellation tech-niques is often needed and the surgeon needsto be familiar with them. With experience, op-erative time, blood loss and complications canbe reduced. This technique should be practicedmore frequently and there should be an activeeffort in residency training programmes toteachthis.

With increasing concern over the contain-ment of health care costs¹4, there is a need forexpanding the indications for performing hys-terectomies via the vaginal route rather thanlaparoscopic method, instead of confining it touterine descent. Usual limitation of vaginal hys-terectomy in non-descent uterus is its size butnow with larger sizes, hysterectomy can be fa-cilitated by bisection, myomectomy, wedgedebulking and intramyometrial coring (morcel-lation)

Keeping in view that this approach couldsubstantially decrease cost, duration of hospi-tal stay and morbidity we decided to study vagi-nal hysterectomies in women with benign gy-necological disorders, other than prolapse. Ouraim was to find characteristics / indicationsother than prolapse, which make women suit-able for vaginal hysterectomy and to exploredifferent surgical techniques that make vaginalhysterectomy simpler and easier to perform.

ConclusionMost of the gynecologists are keen to do re-

moval of uterus vaginally & a significant num-ber are glamorized by Laparoscopic route",which has not convincingly reduced operatingtime, cost & most important patient's safety.


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We chose the path which was lonely but nowthe whole world is joining, a difficult study wasundertaken of more than 11000 removal ofuterus without any descent with various pa-thologies over a decade. The conclusions wererewarding, useful to all gynecologists & mostimportant affordable to all patients in towns,villages & even metros. With the help of aquadissection & other innovative modification ofspecially securing uterine vessels Vaginal Hys-terectomy for non descent uterus with variouspathology is very simple,nearly bloodless, veryfast with excellent quality of post operative life.With this technique an average gynecologistwith average surgical skill can do vaginal hys-terectomy for more than 95 % of the cases.Most important take home message of thestudy

1. By injecting normal saline in good quan-tity (150-250 cc), tissue is adequatelyinfilterated which provides bloodlessfield for dissection and works as a vas-cular tourniquet making surgery easy

2. Uterine vessels is not cut but it is dis-sected out close to uterus so least bleed-ing occurs even though opposite uterineartery intact.

3. Don't chase to open anterior pouch it willcome on it's own.

4. Clamps remain flush to uterus & goodretraction so no chances of damagingureter.

5. In case of previous caesarean section, weinject 10 cc normal saline at anchoringarea of bladder and by sharp dissectionwe push the bladder without any dam-age, this is usually a band of adhesion.

6. We are not closing vault completely butkeeping middle portion open for drain-age of blood, fluid etc to prevent postoperative infection & pyrexia.

7. Both uterosacrals ligaments are sus-pended on posterior vaginal wall to pre-vent future vault prolapse.

8. We are not suspending ovary any whereon the vault so there is no dragging painor dysparunia post operatively.

It is truly said that anatomical knowledgecomes from cutting tissues apart but surgicalwisdom comes from putting together. Don't letyour mental inhibition prevent you to under-take apparently difficult vaginal surgery whichyou are actually capable of doing easily.

References :1) Davies A, Wizza E, Bournas N et al. How

to increase the proportion of hysterecto-mies performed vaginally. Am J ObstetGynecol 1998;179:1008-12.

2) Chapron C, Dubuisson J B Total hyster-ectomy by laparoscopy Advantage forthe patient or only a surgical gimmick?

3) Kumar S, Antony ZK. Vaginal hyster-ectomy for benign nonprolapsed uterus- initial experience. J Obstet Gynecol Ind2004;54:60-3.

4) Mazdisnian F, Kurzel RB, Coe S et al.Vaginal hysterectomy by uterine morcel-lation : efficient, nonmorbid procedure.Obstet Gynecol 1995;86:60-4.

5) Lash AF A method for reducing the sizeof uterus in vaginal hysterectomy Am JObstet Gynecol 1941, 42 452-96.

6) Sheth S S, Malpani A Routine prophy-lactic oophorectomy at the time of vagi-nal hysterectomy in postmenopausalwomen Arch Gynecol Obstet 1992;251:87-91.

7) Sheth SS The place of oophorectomy atvaginal hysterectomy Br J OhstetGynecol 1991.98 662-666

8) Davies A. O'Connor H, Magos AL A pro-spective study to evaluate oophorec-tomy at the time of vaginal hysterectomy


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Br J Obstet Gvnecol 1996, 103 915-9209) Sheth SS Uterine fibroids. In Sheth SS.

Studd JWW. eds Vaginal HysterectomyLondon Martin Dumt: Ltd. 2002, pp 79-84 Gynecologic surgery 1996, 1275-88

10) Das S, Sheth S. Uterine volume: an aidto determine the route and technique ofhysterectomy. J Obstet Gynecol Ind2004;54:68-72.

11) Sheth SS Preoperative sonographic esti-mation of uterine volume an aid to de-termine the route of hysterectomy JGynecol Surgery 2002, 18 13-22 4.

12) Sheth SS Vaginal or abdominal hyster-ectomy? In Sheth SS. Sutton C, eds Men-orrhagia Oxford Isis Medical Medici,1999.213-37

13) Navratil E The place of vaginal hyster-ectomy J Ohstet Gynaecol BrCommonwith 1965, 72 841- 846

14) Van Den Eeden, Glasser M, Mathais SDet al Quality of life health care utiliza-tion and costs among women undergo-ing hysterectomy in a managed care set-ting Am J Obstet Gynecol 1998, 17891-110

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