Non descent vaginal hysterectomy
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Transcript of Non descent vaginal hysterectomy
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NON DESCENT VAGINAL HYSTERECTOMY
Speaker: Dr Rajni Singh
Moderater: H.O.D & Prof. Dr. S .Dasgupta BANKURA SAMMILANI MEDICAL COLLEGE
19/03/2014
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Evolving passion of gynae surgeon among vaginal hysterectomy
Performed for causes other than prolapse
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HISTORY
Langenbeck first performed vaginal hysterectomy in 1813 .
Nondescent Vaginal Hysterectomy pioneered by Haene’yin 1934
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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.
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INDICATION
Dysfunctinal uterine bleeding Fibroid uterus Adenomyosis Chronic pelvic pain Post menopausal bleeding Pyometra Cervical dysplasia Cervical polyp
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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
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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.
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BASIC STEPS OF NDVH
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Anaesthesia: Combined spinal-epidural Position: Dorsal lithotomy Drapping and painting with betadine Labial sutures Metal catheterisation
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CUL-DE-SAC
Posterior cul-de-sac should be open first. Anterior cul-de-sac:i. Bladder separated with sharp dissection ii. Mayo curved scissors tips are pointed
downward( 30° angle to the plane of the cervix)
iii. Lateral window may be used.
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Vaginal pack with betadine Foley catheterisation
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MODIFICATION IN CASES OF NDVH
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SRS NEEDLE (short straight needle)
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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
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CLAMPLESS PROCEDURE FOR NDVH:-
1. direct suturing of ligaments and cutting.2. Suitable to work in less space.3. Broad ligament structures are tied in 3
parts4. Bloodless procedure
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AQUA DISSECTION IN NDVH
1. Simplifies vaginal hysterectomy2. Make it bloodless3. 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
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VESSEL SEALING SYSTEM IN NDVH
Newer hemostatic systems include1. Laser2. High frequency electrosurgery3. Utrasonic (limited for vessels upto 2mm)
LIGASURE vessel sealing system:- combination of pressure and bipolar
electrical energy Seal vessels upto 7mm
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VOLUME REDUCTIVE SURGERIES
Bivalving/bisection Morcellation Myomectomy Intramyometrial coring
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MORCELLATION
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BISECTION
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INTRAMYOMETRIAL CORING
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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
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COMPLICATIONS
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INTRAOPERATIVE COMPLICATIONS
Urinary tract injury
Bowel Injury
Hemorrhage
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POSTOPERATIVE COMPLICATIONS
Vault hematoma Vaginal discharge Wound Infections Hemorrhage Urinary Tract Complications
1. Urinary Retention
2. Ureteral Injury- flank pain d/t ureteral obstruction
3. Vesicovaginal Fistula
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THANK YOU