HYSTERECTOMY PAST, PRESENT & FUTURE
Sandesh KamdiM.Pharm (Pharmacology)
HYSTERECTOMY FOR BENIGN GYNECOLOGY
Vaginal Abdominal Laparoscopic Robotic
HYSTERECTOMY: PAST AND PRESENT Vaginal hysterectomy (VH)
VH was performed by Themison of Athens in 50 BC by removing an inverted uterus that had become gangrenous.1
The first authenticated VH was performed by the Italian anatomist Berengario da Carpi of Bologna in 1507.
1. J Minim Invasive Gynecol 2010; 17(4):421-35. 2. Best Pract Res Clin Obstet Gynaecol 2005; 19:295-305.
HYSTERECTOMY: PAST AND PRESENT Self performed VH !!
In the early 17th century a 46-year-old peasant named Faith Haworth was carrying a heavy load when her uterus prolapsed completely.
Frustrated by this frequent occurrence, she grabbed her uterus, pulled as hard as possible, and cut the whole lot of it with a short knife.
The bleeding soon stopped and she lived on for many years, with a persistent vesico-vaginal fistula
Clin Obstet Gynaecol 1997; 11:1-22.
Noble Sproat Heaney - Chicago
One of the strongest proponents of vaginal
hysterectomy In 1934 he reported a series of 627 VH performed for benign pelvic disease, resulting in death in only three cases.
Best Pract Res Clin Obstet Gynaecol 2005;19:295-305.
In the first part of 20th century, Before the development of
gynaecology as separate speciality,many hysterectomies were done by general surgeons who, has not being
familiar with vaginal surgery, favoured the
abdominal route.
HYSTERECTOMY: PAST AND PRESENT
Abdominal Hysterectomy The pathway to abdominal
hysterectomy was laid down with the first laparotomy in the 19th century.
The human abdomen was deliberately surgically opened for the first time by Ephraim McDowell (Kentucky)
He successfully removed a 10.2 kg ovarian tumor without anaesthesia in 18095.
HYSTERECTOMY: PAST AND PRESENT
Ephraim McDowell (Kentucky)
Baillieres Clin Obstet Gynaecol 1997; 11:1-22.
Abdominal Hysterectomy He successfully removed a
10.2 kg ovarian tumor without anaesthesia in 18095.
McDowell operated on the kitchen table, performing an ovariotomy.
The operation lasted only 25 minutes, but was carefully planned.
After a rapid recovery, the patient lived for more than 30 years6.
HYSTERECTOMY: PAST AND PRESENT
Ephraim McDowell (Kentucky)
Baillieres Clin Obstet Gynaecol 1997; 11:1-22.
Radical HysterectomyRadical hysterectomy was
initially developed as a surgical treatment for cervical cancer due to the absence of other modalities of treatment.
John Clark performed the first radical hysterectomy at Johns Hopkins Hospital, in 1895.
HYSTERECTOMY: PAST AND PRESENT
Best Pract Res Clin Obstet Gynaecol 2005;19:387-401.
Laparoscopic HysterectomyThe first human laparoscopy was
performed by Hans Christian Jacobaeus of Stockholm in 1911, by using pneumoperitoneum and the Nitze cystoscope.
It was Raoul Palmer of France who popularised gynaecological laparoscopy in the 1940’s and who is considered to be the father of modern gynaecological laparoscopy
HYSTERECTOMY: PAST AND PRESENT
Hans Christian Jacobaeus
(Stockholm)
doctoral thesis. Helsinki: Medical Faculty University of Helsinki;1999.
Raoul Palmer (France)
Robotic Laparoscopic Hysterectomy
The first successful surgery using the da Vinci surgical system was performed in Belgium in 1997.
da Vinci S and da Vinci SI is equiped with double optic which gives the operator three-dimensional view of the operative field, and with adjustable magnification, enabling much improved vision of the pelvis.
HYSTERECTOMY: NOW
da Vinci surgical system
THE TRANSITION TO ROBOTICS
Fertility and Sterility 2005;84:1-11.
Robotic Laparoscopic Hysterectomy
Radical hysterectomy performed using robotic techniques was comparable with laparotomy, with equal lymph node harvest, shorter operating time, and reduced blood loss and the length of hospital stay.
HYSTERECTOMY: NOW
da Vinci surgical system
J Minim Invasive Gynecol 2010; 17(4):421-35.
DaVinci System1999: Introduced for surgical
use2000: Approved by FDA for
performance of procedures in the abdomen and pelvis
2003, 2004: Approved by FDA for cardiac surgery, specifically MVR, Coronary Artery Bypass
2005: Approval by FDA for Robotic Hysterectomy
HYSTERECTOMY: NOW
da Vinci surgical system
Benefits of robotics 3-Dimensional viewingTremor filtration Intuitive movements7 degree instrument movement90 degree articulationComfortable seated position for the
surgeonMinimizes the number of needed
assistantsTelesurgery/telementoring
HYSTERECTOMY: NOW
Surgical dexterity and the robot8-12% surgeons report
pain or numbness after performing LSC
The robot allows for 7 degrees of motion versus the limited 4 degrees of motion in laparoscopy
Tremor is removed
HYSTERECTOMY: NOW
Trocar Placement
Laparoscopic Robotic
NON DESCENT VAGINAL HYSTERECTOMY (NDVH)
ACOG 2009:
Vaginal hysterectomy is associated with better outcomes and fewer complications than laparoscopic or abdominal hysterectomy1.
A Cochrane Review of 34 RCTs: vaginal hysterectomy has the best outcomes over laparoscopic and abdominal hysterectomy2
1. Obstet Gynecol 2009;114:1156–1158. 2. Cochrane Database Syst Rev 2009; 3. CD003677.
COCHRANE 2009
LAPAROSCOPIC VAGINAL HYSTERECTOMY
Limitation:
Laparoscopic vaginal hysterectomy is usually associated with higher cost and longer duration of operation and involves large number of specially trained personnel.
60% of the patients without descent underwent successful removal of uterus.
Up to 16 weeks pregnancy size uterus were removed.
There were minimal surgical complications, blood loss, operative time or hospital stay.
METHOD 100 cases were taken for NDVH &
100 for AH.
Cases of Dysfunctional DUB, Uterine fibroid of less than 12wks, adenomyosis and cervical polyp, Previous LSCS with mobile uterus were included in the study
Free communication (oral) presentations / International Journal of Gynecology & Obstetrics 119S3 (2012) S261–S530
RESULTS
NDVH AH0
10
20
30
40
50
60
70
38
61
Duration of surgery
Tim
e (
min
ute
s)
Free communication (oral) presentations / International Journal of Gynecology & Obstetrics 119S3 (2012) S261–S530
RESULTS
NDVH AH0
20
40
60
80
100
21%
100%
Post operative cathetarization
%
Free communication (oral) presentations / International Journal of Gynecology & Obstetrics 119S3 (2012) S261–S530
NDVH AH
Early ambulation 6-14 hours 24-48 hours
Regular diet Earlier Late
Post Operative stay 2-3 days 5-7 days
Complications rate Lower Higher
RESULTS
Free communication (oral) presentations / International Journal of Gynecology & Obstetrics 119S3 (2012) S261–S530
CONCLUSION
NDVH is least invasive route with least morbidity, least expensive technique & with most rapid postoperative recovery.
The absence of an abdominal incision leads to lower morbidity, less hospital stay, more rapid convalescence and patient compliance.
Free communication (oral) presentations / International Journal of Gynecology & Obstetrics 119S3 (2012) S261–S530
100 patients with uterine size 8-10 weeks gestation
Age: 35.2±5.2 years Mean parity: 4.17±1.5
METHOD
Free communication (oral) presentations / International Journal of Gynecology &
Obstetrics 107S2 (2009) S93–S396
NDVH
Duration of surgery 35.5 mins
Mean hosp stay 3.5 days
Blood loss 100-300 ml
RESULTS
Free communication (oral) presentations / International Journal of Gynecology &
Obstetrics 107S2 (2009) S93–S396
CONCLUSION
The new technique of aqua dissection in NDVH is easy, fast, safe and relatively less bleeding in modern gynecology
Free communication (oral) presentations / International Journal of Gynecology &
Obstetrics 107S2 (2009) S93–S396
74 patients with uterine size 8-10 weeks gestation
Age: 35-55 years Volume of uterus: 80-500 cm3
METHOD
NDVH
Duration of surgery 46 mins
Mean hosp stay 48 hours
Avg Blood loss 50 ml
RESULTS
ADVANTAGES
• No abdominal wound
• No significant destruction of intestine
• Less post operative discomfort
• Easier mobilization
• Earlier discharge from hospital
THANK YOU