Vaginal Hysterectomy

OBG

1. Vaginal Hysterectomy
DrRK Saxena
Professor (O&G)
MVJ MC & RH

2. Introduction of VH
Vaginal hysterectomy is a procedure in which the
uterus is surgically removed through the vagina.
Ovaries and fallopian tubes may be removed
during the procedure as well; bilateral salpingo-
oophorectomy (BSO)
A vaginal approach may be used if the uterus is
not greatly enlarged, and if the reason for the
surgery is not related to cancer. (NDVH: non
descent vaginal hysterectomy)

3. Indications
•Pelvic organ prolapse
•Abnormal uterine bleeding
•Fibroids
•Cervical abnormalities
•Endometrial hyperplasia
•Chronic pelvic pain

4. Advantages of VH over TAH
•Early resumption of day to day activity
•Post operative complications are less
•Less post operative pain and less need of
analgesia
•Less morbidity and mortality
•Can be done effectively in obese patients

5. Disadvantages of VH
Skilled surgeon needed
Exploration of abdominal and pelvic organs
cannot be done
Difficult with restricted mobility (Adhesions)
Difficult with uterus size >12 wks
Tubal and ovarian pathology difficult to
tackle

6. Patient Preparation
•Pre-operative testing-EKG, chest x-ray, and
blood testing, Reserve 1 unit blood.
•Consent, Overnight fasting (after 10 pm), Tab
Diazepam 10mg HS, Clipping of pubic hair,
Enema (optional)
–For patients at risk, thromboembolism
prophylaxis is begun preoperatively
–Prophylactic antibiotic agent should be given as
a single dose 30 minutes prior to surgery

7. Steps of Surgery
•Anaesthesia–Spinal / Epidural / CSE / GA
•Position –Lithotomy (buttocks at edge of
table), Trendelenburg (Head low position)
•Assessment under anesthesia –downward
mobility of uterus, size of uterus, adenexa

8. Steps of VH
•Under aseptic precaution parts painted &draped
•Catherisationto empty bladder & note the lower
edge of bladder.
•Cervix grasped and saline (with or without
epinephrine for hemostasis) injected below
vaginal mucosa (hydro-dissection)
•Incision made below the lower edge of bladder -
dissection of vaginal mucosa
•Posterior Colpotomy-Entry into POD

9. Steps of VH
•Hydro-dissection
–To minimize blood loss during dissection, 10
to 15 mL of a dilute saline solution containing
vasopressin (20 U diluted in 30–100 mL of
saline) or 0.5-percent lidocaine and
epinephrine (1:200,000 dilution) may be
injected circumferentially along the incision
path.
–This fluid also to separate the fascial planes
and makes dissection easier

10. Steps of Surgery
•After pushing up the bladder and opening
the pouch of Douglas (POD), 1stclamp is
applied to uterosacral ligament as close to
the uterus as possible, Confirming that the
posterior blade is inside the peritoneal
cavity
•The uterosacral pedicle threads are kept
long for later identification

11. Steps of Surgery
•Anteriorly Utero-vescicalfold of peritoneum is
opened & bladder is pushed up

12. Uterine vessels
clamped
Clamp utero-ovarian
ligament & fallopian tube
(Fundal inversion to permit
cornualstructure clamping)

13. Repair

14. Repair Continued…
•McCall Culdoplasty
•Peritoneal closure above the pedicles
•Vaginal mucosa closure
•Bladder Drained
•Foleys put.

15. McCall Culdoplasty
The firstexternal suture is placed through the fullthickness of the
posterior vaginal wall andincorporates the posterior peritoneum
andUSL. Progressive left-to-rightbites are then taken serially
through the rectalserosa to reach the opposite USL. Finally, the
sutureenters the opposite USL,passed through the posterior
peritoneum,and exits through the full vaginal wall thicknessto
reenter the vagina.

16. Repair
•Culdoplasty:
–For supporting the vault with uterosacral
ligaments & prevent vault prolapse in future.
•Closing the Peritoneum (Enterocelerepair):
–Purse-string suture bites taken on peritoneum
above the level of stitches on the pedicles so
that all pedicles are exteriorized.
•Tying the 2 uterosacral ligaments together
–Provides support to base of bladder

17. Repair
•Anterior Colporraphy(Cystocele repair):
–Repair of tears in pubo-cervical septum.
–Repair Pubo-Vescicalfasia
–Remove redundant (extra) vaginal tissue
–Close vagina with delayed absorbable
continuous suture (Vicryl 1-0)
•External Culdoplastsutures are now tied to
lift up the vault of vagina.

18. Cystocele repair: Anterior Colporraphy
Thinning of the pubocervicalfascia (PCF) causes
prolapse of the bladder base. Repair PCF

19. Repair
•Posterior Colpo-periniorraphy(Rectocele &
perineal body repair):
–Separate rectum from vaginal mucosa
–Identify LevatorAni M on both sides & tie
them together –this repairs the torn
perineal body.
–Repair of tears in Recto-Vaginal fasia
–Remove redundant (extra) vaginal tissue
–Close vagina & perineal skin

20. Rectocele repair: Posterior Colpoperiniorraphy

21. Rectocele repair: Posterior Colpoperiniorraphy
Defect in the Rectovaginal fascia (RVF) causes
Rectocele. Repair RVF

22. Post operative Care
•Vaginal Pack (Optional)
–Usually given if associated colpo-
perriniorraphydone
•Indwelling transurethral catheter-(24-48h)
–Occasional transient insult to the bladder
and transient postoperative voiding
problems
•Nil orally (12-24h) / IV Fluids
•Antibiotics / Pain relief

23. Perioperative Complications
•Hemorrhage
•Infection
•Constipation
•Urinary retention
•Blood clots
•Damage to adjacent organs
•Early menopause
•Prolapse of the vaginal vault
•Granulation tissue at the vaginal vault-

24. Thank You