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VAGINAL HYSTERECTOMY FOR BIG UTERI

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.

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VAGINAL HYSTERECTOMY FOR BIG UTERI

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  1. 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

  2. THANK YOU Dr. P B Pai-Dhungat Organisers

  3. 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

  4. Why Vaginal hysterectomy • EVALUATE study • Multicentre randomised controlled study • Where possible vaginal route should be preferred • Cochrane reviews confirms the same • Evidence I B

  5. 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

  6. Too much zeal for what is new and contempt for what is old

  7. Laparoscopic Hysterectomy • Benefits of vaginal hysterectomy • Longer duration of surgery • Costlier equipment • Higher incidence of ureteral injury • Greater surgical expertise • Need for training

  8. Criteria for approachSheth’s • Clinical examination • Absence of contraindications • Detailed Ultrasound study • Laxity/ rigidity of tissues • Availability of uterus free space • Access to large fibroid • Experience

  9. Criteria • Good assistance • Good anaesthesia • Good exposure—instruments, position

  10. Instruments • Retractors- Jayle’s, Auvard’s, Soonawala, Dever’s, Breisky- Navratil • Clamps • Myoma Screw • Tenaculum • Bull dog vulsellum

  11. 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.

  12. Technical Aspects • Good cervical traction. • Open the posterior pouch even if anterior cannot be opened • Ligate and cut parametrium

  13. 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

  14. 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.

  15. 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.

  16. 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

  17. 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

  18. Morcellation • Successive chunks of the fibroid are held and cut out • Large wedges of tissue are removed.

  19. Lash technique • Circumferential incisions given just below the serosa and parallel to it. • Strong cervical traction • Enlarged fundus delivers as an elongated mass.

  20. 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.

  21. 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

  22. Posterior Fibroid • Easier access • Myomectomy or morcellate

  23. Technical aspects • Disconnect from one side upto cornuals and then reverse or morcellate • Schukhardt’s incisions.

  24. Adjuncts • Use of harmonic • Use of Biclamp • Laparoscopy pre vaginal or post vaginal • USG • MRI • Urography • Ureteric catherization

  25. Drainage • Use of Foley’s drain. • Minimizes collection • Helps monitor the patient.

  26. 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

  27. Contraindications • Citadel uterus • Very little space to work • Sudden bulging of the uterus at the angles

  28. Our experience • 2005 to 2008 • 500-1000 gms 42 cases • >1000 gms 5 cases

  29. Our Series

  30. Duration

  31. Hospital Stay

  32. Complication • Neuropraxia of Femoral Nerve • Weakness at knee joint • Parasthesia over the knee joint • Avoid exaggerated lithotomy for prolonged periods • Physiotherapy

  33. Training • Start with easy cases • Build up confidence • Good assistance, anaesthesia • Use of adjuncts

  34. Thank You

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