Non descent vaginal hysterectomy

1. NON DESCENT VAGINAL HYSTERECTOMY Speaker: Dr R ajni S ingh Moderater : H.O.D & Prof. Dr. S . Dasgupta BANKURA SAMMILANI MEDICAL COLLEGE 19/03/2014

2. Evolving passion of gynae surgeon among vaginal hysterectomy Performed for causes other than prolapse

3. HISTORY Langenbeck first performed vaginal hysterectomy in 1813 . Nondescent Vaginal Hysterectomy pioneered by Haene’yin 1934

4. 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.

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

6. 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

7. 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.

8. BASIC STEPS OF NDVH

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

10. CUL-DE-SAC Posterior cul-de-sac should be open first. Anterior cul-de-sac: Bladder separated with sharp dissection Mayo curved scissors tips are pointed downward( 30° angle to the plane of the cervix) Lateral window may be used.

11. Vaginal pack with betadine Foley catheterisation

12. MODIFICATION IN CASES OF NDVH

13. SRS NEEDLE (short straight needle)

14. 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

15. CLAMPLESS PROCEDURE FOR NDVH:- direct suturing of ligaments and cutting. Suitable to work in less space. Broad ligament structures are tied in 3 parts Bloodless procedure

16. AQUA DISSECTION IN NDVH Simplifies vaginal hysterectomy Make it bloodless 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

17. VESSEL SEALING SYSTEM IN NDVH Newer hemostatic systems include Laser High frequency electrosurgery Utrasonic (limited for vessels upto 2mm) LIGASURE vessel sealing system:- combination of pressure and bipolar electrical energy Seal vessels upto 7mm

18. VOLUME REDUCTIVE SURGERIES Bivalving /bisection Morcellation Myomectomy Intramyometrial coring

19. MORCELLATION

20. BISECTION

21. INTRAMYOMETRIAL CORING

22. 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

23. COMPLICATIONS

24. INTRAOPERATIVE COMPLICATIONS Urinary tract injury Bowel Injury Hemorrhage

25. POSTOPERATIVE COMPLICATIONS Vault hematoma Vaginal discharge Wound Infections Hemorrhage Urinary Tract Complications Urinary Retention Ureteral Injury- flank pain d/t ureteral obstruction Vesicovaginal Fistula