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Presentation on theme: "VAGINAL HYSTERECTOMY FOR BIG UTERI"— Presentation transcript:

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 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

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



13 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.



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

17 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



20 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.

21 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.

22 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

23 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

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

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

26 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.

27 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



30 Posterior Fibroid Easier access Myomectomy or morcellate

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



34 Adjuncts Use of harmonic Use of Biclamp
Laparoscopy pre vaginal or post vaginal USG MRI Urography Ureteric catherization

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

36 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



39 Contraindications Citadel uterus Very little space to work
Sudden bulging of the uterus at the angles


41 Our experience 2005 to 2008 gms 42 cases >1000 gms 5 cases




45 Our Series

46 Duration

47 Hospital Stay

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

49 Training Start with easy cases Build up confidence
Good assistance, anaesthesia Use of adjuncts

50 Thank You


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