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Non-Descent Vaginal Hysterectomy Made Easy
© 2005, Sudhir R Shah, Beena N Trivedi, Dipal D Solanki
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the authors and the publisher.
First edition: 2005
Typeset at JPBMP typesetting unit
Printed at Paras Offset Pvt Ltd., C-176, N.I.A., Phase-1, New Delhi.
We dedicate this book to
Our patients who kept full faith in us and encouraged us indirectly to write.
Our family members without whose constant inspiration and cooperation this attempt would have been incompletedForeword
—But for the change nothing is permanent.
Average gynecologist is afraid to perform vaginal hysterectomy if there is no uterine descent. This is due to lack of proper training and exposure by the teachers during residency. Now with entry of laparoscope, more attention is paid to removal of the uterus with laparoscopic approach. There is enough data to show that vaginal approach for non-descent uterus has more advantage than abdominal approach. It is pleasing to note that attempts are made to revive vaginal hysterectomy for non-descent uterus. At least 60% hysterectomies are performed for Dysfunctional Uterine Bleeding (DUB) where the uterus is normal or slightly enlarged. I therefore, welcome effort by Dr Sudhir Shah and his associates to revive vaginal hysterectomy for non-descent uterus. The book is very well written giving details about various important steps including patient selection, preoperative care, surgical technique and finally postoperative follow up. Dr Sudhir shah is very innovative and resourceful. Dr Shah does not take anything for granted till he is satisfied. This inquiring state of mind is responsible for the spirit of dedication and resourcefulness. His modification of the slandard Butterfly needle for use as short straight needle simplifies the surgical technique when working space is minimal. This is his original idea. I have watched Dr Sudhir performing various gynecological surgeries. I was impressed by his zeal, meticulous care and neat surgical dissection. He wields the surgical knife with much ease and confidence. The procedure looks very easy when he is operating. I hope this short book kindles the desire among the gynecologists to vaginal approach for hysterectomy even when there is no uterine descent. The need for abdominal hysterectomy should be much less if the technique for vaginal approach is mastered. I hope efforts by Dr. Sudhir Shah, Dr, Beena Trivedi and Dr. Dipal Solanki will encourage use of vaginal approach more frequent than it is done at present.
Dr Rohit V Bhatt
Ex Prof and Head
Dept of Obstetric and Gynecology
Medical Collage, BarodaPreface
—Give us an inch and we will do the rest.
Gone are the days when vaginal hysterectomy was performed for prolapsed and descended uterus only. Recently, advances and innovation in surgery led to resurgence in learning vaginal hysterectomy irrespective of its undescentness, volume (fibroids, adenomyosis) and previous surgeries on it. One of the most dramatic changes in the route of removal of the uterus during last few years is switching over from abdominal to vaginal route.
Today gynec surgeons are becoming vaginal surgeons. They have started to believe that every uterus can be and should be removed vaginally unless the route is contraindicated.
Previously 80 percent of hysterectomies were done abdominally but with increased skill, experience and determination on the part of gynec surgeon have changed the scenario and almost more than 70 percent hysterectomies are performed vaginally.
Of course it differs from centre to centre.
In reality vaginal hysterectomy is the least invasive route because one is using the entrance designed by the nature. Without making any additional cuts it is kinder to the patients. It offers several benefits over abdominal route.
The benefits of a vaginal hysterectomy are:
- Direct approach to target organs, i.e. uterus and cervix. Increased safety.
- Least invasive.
- No visible stitch or scar on abdomen.
- Quick surgery.
- Best for obese patients.
- Less postoperative pain.
- Early ambulation.
- Faster recovery.
- Early discharge of the patient.
- Lower cost.
- Associated vaginal wall and perineal defect can be dealt with.
- Less chances of complications like incisional hernia, adhesions, stitch complications.
- Easy surgery after enough expertise.
The success of this surgery depends on:
- Intense desire and strong determination on the part of surgeon.
- Perfect knowledge of pelvic anatomy.
- Appropriate selection of the patient.
- Proper lithotomy position of the patient.
- Proper instrumentations.
- Trained and cooperative pair of assistants.
- Excellent anesthesia.
Here is a small attempt to describe important points including pelvic anatomy, selection of patients, steps of operative procedure with colour snaps, some special cases, pre- and postoperative details. Introduction of short straight SRS needle, anesthesia, urinary bladder problems and our experience in Non-Descent Vaginal Hysterectomy (NDVH) surgery.
The main purpose of publishing this small booklet is to stimulate more and more gynecologists to start doing vaginal hysterectomy in nondescent uterus. This is neither a textbook nor an operative manual but collections of some routine steps for the benefits of the beginners.
This small booklet is for those:
….who want to switch over to do NDVH and need some more confidence and moral support.
….who has strong desire to start NDVH in most of the cases.
….who are still thinking more about abdominal hysterectomy but are open enough to accept this route.
It will lead to do NDVH easily and confidently. Read this book and you deserve all Success.
We simply hope that our purpose will be served once you start doing NDVH in most of your such patients.
Sudhir R Shah
Beena N Trivedi
Dipal D SolankiAcknowledgments
We are thankful to
Dr Rohit V Bhatt Baroda, who has always taught us to be creative in professional life and to transfer our thoughts into action.
Dr Shirish Sheth whose book on Vaginal Hysterectomy encouraged us to take first step towards initiating of performing most of the hysterectomy through a new route.
Dr Vyomesh Shah whose operative steps in CD on NDVH brought tons of confidence in us.
Dr Aashish Jasani renowned uro-surgeon of Rajkot who contributed a very interesting chapter on urological injuries during NDVH.
Dr Hitesh Parekh renowned anesthesiologist of Rajkot who was constantly present during our all surgeries with his hilarious mood to keep our temperament cool and positive. He also contributed a Chapter on Anesthesia and NDVH.
Numbers of our friends and colleagues who helped us in many ways.
Trustees and Authorities of Dashasrimali Hospital, Kotharia Naka, Rajkot where we did all surgeries.
Our better halves Mrs Jyoti Shah, Dr Nimish Trivedi and Dr Dharmesh Solanki who helped us by constant inspiration in this difficult job.
Our Theatre staff to assist us by all means.
We would acknowledge M/s Jaypee Brothers Medical Publishers (P) Ltd., New Delhi for publishing this book.