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
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. 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
Adjuncts Use of harmonic Use of Biclamp Laparoscopy pre vaginal or post vaginal USGMRIUrography 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