VAGINAL
HYSTERECTOMY FOR
BIG UTERI
Dr. N. P. Pai-Dhungat
D.G.O., D.N.B., M.R.C.O.G.
Bombay Hospital Institute of Medical
Sciences, Mumbai
THANK YOU
Dr. P B Pai-Dhungat
Organisers
CAMPBELL 1946
The bulk of the uterus to be removed is
not a contraindication to the vaginal route.
60 years later no need to change the
dictum
Why Vaginal hysterectomy
EVALUATE study
Multicentre randomised controlled study
Where possible vaginal route should be
preferred
Cochrane reviews confirms the same
Evidence I B
Advantages of Vaginal
Hysterectomy
Shorter duration of hospital stay
Speedier return to routine activities
Fewer incidences of fever, infections
Morbidity significantly reduced.
Cost benefit analysis
Too much zeal for what is new and
contempt for what is old
Laparoscopic Hysterectomy
Benefits of vaginal hysterectomy
Longer duration of surgery
Costlier equipment
Higher incidence of ureteral injury
Greater surgical expertise
Need for training
Criteria for approach
Sheth’s
Clinical examination
Absence of contraindications
Detailed Ultrasound study
Laxity/ rigidity of tissues
Availability of uterus free space
Access to large fibroid
Experience
Criteria
Good assistance
Good anaesthesia
Good exposure—instruments, position
Instruments
Retractors- Jayle’s, Auvard’s, Soonawala,
Dever’s, Breisky- Navratil
Clamps
Myoma Screw
Tenaculum
Bull dog vulsellum
Size of Fibroids
Largest that we have removed is 1350
gms.
P C Mahapatra, A Magos, Paily, Sheth, V
Shah, A Virkud routinely report removal of
such large fibroids.
Technical Aspects
Good cervical traction.
Open the posterior pouch even if anterior
cannot be opened
Ligate and cut parametrium
Bladder Dissection
Bladder has to be well retracted at all
times especially if anterior peritoneum is
not opened.
Fibroid higher than internal os.
Fibroid at or lower than internal os
Technical Aspects
Once the uterines are ligated, no reason
why a fibroid of any size cannot be
removed.
Difficult in cases of large cervical fibroid.
Technical Aspect
After the uterines are ligated and cut,
suture and cut the broad ligament.
Either reverse the uterus
Start myomectomy or morcellation
Restart suturing and cutting the broad
ligament till the cornuals are reached.
Warning
However difficult and however big the
uterus never dissect lateral to the uterine
ligatures.
If you start dissecting lateral to the
uterines you are on the lateral pelvic wall
with risk of injury to the ureter or uterines
where it is difficult to ligate them
AIM : To remove large
fibroids but cause
minimal damage to pelvis
and vagina.
Removal in toto-myomectomy
Morcellation
Lash technique
Bisection of the uterus
Coring
Morcellation
Successive chunks of the fibroid are held
and cut out
Large wedges of tissue are removed.
Lash technique
Circumferential incisions given just below
the serosa and parallel to it.
Strong cervical traction
Enlarged fundus delivers as an elongated
mass.
Bisection
Cut in the midline from below upwards.
Try to reach upto the fundus by
successively applying clamps.
Offers more space to apply the clamps.
Often combined with morcellation or
myomectomy.
Anterior Fibroid
If low down and upto 7 cms, may reach it
from anterior aspect
Be careful of Bladder
Bissect the uterus to reach the fibroid
Cut through the posterior wall
Posterior Fibroid
Easier access
Myomectomy or morcellate
Technical aspects
Disconnect from one side upto cornuals
and then reverse or morcellate
Schukhardt’s incisions.
Adjuncts
Use of harmonic
Use of Biclamp
Laparoscopy pre vaginal or post vaginal
USG
MRI
Urography
Ureteric catherization
Drainage
Use of Foley’s drain.
Minimizes collection
Helps monitor the
patient.
Contraindications
Except malignancy with large uteri, there
should be no contraindication.
Endometriosis, suspected adhesions may
be tackled with Laparoscopy followed by
vaginal hysterectomy
Large subserous fibroid may need to be
confirmed with laparoscopy after
hysterectomy.
Previous scars relative contraindication
Contraindications
Citadel uterus
Very little space to work
Sudden bulging of the uterus at the angles
Our experience
2005 to 2008
500-1000 gms 42 cases
>1000 gms 5 cases
Our Series
3%
2%
2%
vaginal
hysterectomy
1%
1%
0%
Fever
Blood
Trans
Ureteric
injury
Bladder
injury
Prolonged
vaginal
Discharge
Duration
< 60 mins
1-2 hrs
> 2hrs
Hospital Stay
45
40
35
30
25
20
15
10
5
0
Column 1
48 hrs
72 hrs
>96 hrs
Complication
Neuropraxia of Femoral Nerve
Weakness at knee joint
Parasthesia over the knee joint
Avoid exaggerated lithotomy for prolonged
periods
Physiotherapy
Training
Start with easy cases
Build up confidence
Good assistance, anaesthesia
Use of adjuncts
Thank You