NON DESCENT VAGINAL HYSTERECTOMY

Speaker: Dr Rajni Singh

Moderater: H.O.D & Prof. Dr. S .Dasgupta BANKURA SAMMILANI MEDICAL COLLEGE

19/03/2014

Evolving passion of gynae surgeon among vaginal hysterectomy

Performed for causes other than prolapse

HISTORY

Langenbeck first performed vaginal hysterectomy in 1813 .

Nondescent Vaginal Hysterectomy pioneered by Haene’yin 1934

Why vaginal route?

Vaginal Hysterectomy is the safest and most cost-effective route.

Less complication,fast recovery with short hospital stay.

Without any visible scar.

INDICATION

Dysfunctinal uterine bleeding Fibroid uterus Adenomyosis Chronic pelvic pain Post menopausal bleeding Pyometra Cervical dysplasia Cervical polyp

CONTRAINDICATION

Uterus more than 20 wks size Adnexal pathology Limited vaginal space Restricted uterine mobility Cervix flushed with wall Previous history of fistula(VVF/RVF)

repair

Pre-operative Evaluation (should be done under anaesthesia)

Evaluation of Pelvic Support:

Uterine mobility

Evaluation of the Pelvis: Angle of the pubic arch:- 90 degrees/greater, Descent of cervix, Mobility of vaginal mucosa, Vaginal canal should be ample, Posterior vaginal fornix should be wide and deep.

BASIC STEPS OF NDVH

Anaesthesia: Combined spinal-epidural Position: Dorsal lithotomy Drapping and painting with betadine Labial sutures Metal catheterisation

CUL-DE-SAC

Posterior cul-de-sac should be open first. Anterior cul-de-sac:i. Bladder separated with sharp dissection ii. Mayo curved scissors tips are pointed

downward( 30° angle to the plane of the cervix)

iii. Lateral window may be used.

Vaginal pack with betadine Foley catheterisation

MODIFICATION IN CASES OF NDVH

SRS NEEDLE (short straight needle)

40 MM HALF CIRCLE SRS NEEDLE

Techniqualy difficult Incraesed chances of

injury Difficult to handle

needle

Movement easy Less injury to lateral

structure Easy to handle

needle

CLAMPLESS PROCEDURE FOR NDVH:-

1. direct suturing of ligaments and cutting.2. Suitable to work in less space.3. Broad ligament structures are tied in 3

parts4. Bloodless procedure

AQUA DISSECTION IN NDVH

1. Simplifies vaginal hysterectomy2. Make it bloodless3. Made bladder dissection easy

PRINCIPLE :-tissue beneath the mucosa is flooded with fluid,compresses the vascular plane(fluid tourniquet)

NS with/without adr is used for this

VESSEL SEALING SYSTEM IN NDVH

Newer hemostatic systems include1. Laser2. High frequency electrosurgery3. Utrasonic (limited for vessels upto 2mm)

LIGASURE vessel sealing system:- combination of pressure and bipolar

electrical energy Seal vessels upto 7mm

VOLUME REDUCTIVE SURGERIES

Bivalving/bisection Morcellation Myomectomy Intramyometrial coring

MORCELLATION

BISECTION

INTRAMYOMETRIAL CORING

POST OPERATIVE CARE

Routine prophylactic antibiotic, anti emetic (Ondansetron), Ranitidine

IV fluid 12 hours, Oral fluid after 3 hours, Catheter removal after 12 hours, Vaginal drain/betadine gauge removal after 6-8

hours, Solid diet after 12 hours, Analgesic for minimum 12 hours then if needed. Patient can go home after 24-36 hours of

operation

COMPLICATIONS

INTRAOPERATIVE COMPLICATIONS

Urinary tract injury

Bowel Injury

Hemorrhage

POSTOPERATIVE COMPLICATIONS

Vault hematoma Vaginal discharge Wound Infections Hemorrhage Urinary Tract Complications

1. Urinary Retention

2. Ureteral Injury- flank pain d/t ureteral obstruction

3. Vesicovaginal Fistula

THANK YOU