Vaginal Hysterectomy: Modified Safe Technique

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Vaginal Hysterectomy Modified Safe Technique

• Professor Galal Lotfi, MD, MRCOG
• Obstetrics Gynecology
• Suez Canal University
• Egypt

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Suez Canal University Hospital
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Aim?

• This is not a comparison between vaginal and
  abdominal Hyst.
• This is not a comparison between vaginal and
  laparoscopic Hyst.

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Aim Of That Work

• Reviving, a Well Known Technique for
  Hysterectomy.
• Implementing a Technique, Safe Without the Tragic
  Vault prolapse.

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Material and Methods

• Women for hysterectomy.
• No prolapse.
• No contraindication for vaginal hyst.

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Indications

• Dub 188
• Fibroid uterus 79
• Adenomyosis 8
• CIN 3
• Contraception 1

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Requirements

• Mobility Especially downwards
• Uterus less than 12 weeks
• Cervix not atrophied
• Fornices adequate
• Healthy tissues
• Assessment under anesthesia, in lithotomy

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Broad Lines of the Technique

• To be safe secure pedicles at all times.
• To avoid a post operative vault prolapse secure
  pedicles to vagina.

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First Clamp
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First Clamp

• After pushing up the bladder and opening the
  pouch of Douglas (POD), 1st clamp is applied to
  uterosacral ligament as close to the uterus as
  possible Confirming that the inside blade is
  inside the peritoneal cavity to include the small
  vessels between the peritoneum and the base of
  the pelvis

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Ligatures.

• First ligatures is left with long threads, one
  with needle will be used to have a bite in the
  lateral vaginal angle so
• Support the vaginal vault by ligating it to the
  main supporting structures of the pelvis
• Shares in the homeostasis of that vascular area

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Stitching First Pedicle to Vaginal Angle

• Occlusion of the space in between
• Closure of small vessels
• Fixing uterosacral to vagina

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2nd Ligatures, Step ladder

• Almost always the 2nd bite will not reach the
  level of uterine vessels and we dont intend to
  do so.
• The long thread of the 1st bite is tied with one
  of the threads of the next ligature so the whole
  uterosacral was at the end taken to the vaginal
  angle.

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Uterine, Ovarian Ligatures
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So, At the End..

• The whole three pedicles are ligated together on
  one side with marked stitch. During
  peritonization, one thread from round ligament
  was tied to its counterpart on the other side and
  peritoneum was approximated

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At the end, The pedicles are sutured to the
vagina

• That vaginal angle was sutured to the uterosacral
  ligaments as a first step, giving a strong
  support to vaginal vault at the end of operation,
  preventing vault prolapse.

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Vaginal to Vaginal, Closing Vag
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Approximating Pedicles

• The marker stitch can help in pulling down any
  part of any pedicle when bleeding has to be
  secured.
• Ligaturing the pedicles together will occlude the
  small vessels in between making good hemostasis.
• These structures give good support to the vagina
  preventing posthysterectomy vaginal vault
  prolapse.

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Results.

• Median opertive time 60min.
• Post operative analgesics 33.
• Hospital stay 2.1 days.

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Complications

• Post op bleed 4
• One day fever 3
• Post op fever 2
• UTI 1
• Post op vault 0
• Stress Incont 1
• Det. Inst 1

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Cost.

• In 1998, the average charge for a
  laparoscopically-assisted vaginal hysterectomy in
  the united states was 14,500 An abdominal
  hysterectomy was 12,500 that for a vaginal
  hysterectomy was 10,380 And that for (stat bull
  Metrop Insur co 2000).
• Vaginal hysterectomy resulted in better
  quality-of-life outcomes and lower costs compared
  with laparoscopically assisted vaginal or
  abdominal hysterectomy (van den Eeden 1998).

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Conclusion..

• Vaginal hysterectomy should be considered
  whether there is associated prolapse or not.
• With proper selection, continued training, its
  rate will increase in front of abdominal or
  laparoscopic route.
• Good access and assessment of uterosacrals.
• Good support to the vagina.

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Step Ladder

• Easy access to all pedicles at any time.
• Good inspection of the pedicles at the conclusion
  of surgery.
• Minimizing oozing vessels in-between pedicles.

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Advantages of Technique

• Minimize well known postoperative vault prolapse,
  good support to vaginal vault.
• Minimize intraoperative bleeding.
• Minimize postoperative hematoma.
• Easy and versatile access to ligature.

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Advantages of Vaginal Approach

• Time of operation
• Exposure and Traumatization
• Good for high risk patients
• Post operative stay
• Cost

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Rules

• Opening the POD in proper plane
• Dont dissect the bladder from fascia
• In clamping uterosacral, inner blade includes the
  peritoneum
• Clamping the pedicle in two steps is better than
  a big sizeable pedicle
• First pedicle to be fixed to vaginal angle
• Keep your clamps adjacent to the uterus
• Step ladder procedure

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Epilog

• Abdominal route Surgery
• Laparoscopic Technological surgery
• Vaginal Art surgery

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Thank You