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Vaginal Hysterectomy
Shirish S Sheth
CHAPTER 1:
The History of Vaginal Hysterectomy
INTRODUCTION
THE EARLY HISTORY OF ABDOMINAL HYSTERECTOMY
History of Vaginal Hysterectomy
The First Elective Vaginal Hysterectomies
Conrad Langenbeck, Surgeon-General to the Hanoverian Army
Further Developments in Technique at the End of the 19th Century
THE INCIDENCE OF DIFFERENT TYPES OF HYSTERECTOMY
THE DEVELOPMENT OF GYNECOLOGICAL SURGERY IN THE 20TH CENTURY
Laparoscopic Hysterectomy
Laparoscopic-assisted Vaginal Hysterectomy
CHAPTER 2:
Vaginal Hysterectomy: Indications and Contraindications
INDICATIONS
Uterovaginal Prolapse
Abnormal Uterine Bleeding without Pelvic Pathology [Previously Called Dysfunctional Uterine Bleeding (DUB)]
Fibroids
Adenomyosis
Submucous Fibromyomas
Fibroid Polyps
Cervical Fibroid
Premalignant Conditions
Specific Oncological Conditions
ASSOCIATED CONDITIONS IN WHICH VAGINAL ROUTE OF HYSTERECTOMY HAS BEEN EVIDENCED TO BE SAFE AND BENEFICIAL TO PATIENT
Hysterectomy in Nulliparous Women
Previous Abdominal or Pelvic Surgery(ies)
Prophylactic Salpingo-oophorectomy (BSO)
Hysterectomy in Women with Obesity
RELATIVE CONTRAINDICATIONS
Uterus Size >12 Weeks
Benign Adnexal Pathology
Ovarian Endometrioma
Hysterectomy in a Case of Broad Ligament Fibroid
CONTRAINDICATIONS
CHAPTER 3:
Preoperative Assessment
BY A GYNECOLOGIST
Objectives of the Surgeon Preoperatively
Confirmation of Route of Hysterectomy
Role of Ultrasonography
Previous Abdominal and/or Pelvic Surgery
Examination under Anesthesia
Descent, Prolapse, and Mobility
Findings that Favor VH
Contraindications
Trial VH/ Trial Vaginal Route
Frozen Histopathology Study
BY AN ANESTHESIOLOGIST
Cardiovascular System
Hypertension
Ischemic Heart Disease
Valvular Heart Disease
Rhythm Disturbances
Coronary Stents
Respiratory System
Diseases of Endocrine System
Diseases of Renal System
Diseases of Hepatic System
Hematologic Disorders
Diseases of Central Nervous System
Musculoskeletal and Connective Tissue Diseases
Special Anesthetic Challenges
Blood Transfusion: Boon/Bane?
Antibiotic Timing and Prophylaxis for Infective Endocarditis
Preoperative Screening
Counseling and Declining Anesthesia—Role of the Anesthesiologist
CHAPTER 4:
Access to Vesicouterine and Rectouterine Pouches
INTRODUCTION
ACCESS TO VESICOUTERINE PERITONEUM/ANTERIOR POUCH
Infiltration of the Anterior Vaginal Mucosa
Technique
ACCESS TO VESICOUTERINE PERITONEUM VIA POUCH OF DOUGLAS
Inverted ‘T’ Incision
SPECIAL SITUATIONS
Surgical Technique in Women with History of One C Delivery (Section) in Past
Hysterectomy After One C Delivery (Section) in Past
Uterocervical-Broad Ligament Space
Anatomy of Uterocervical Broad Ligament Space
Surgical Technique
Surgical Technique in Women with History of Two or More C Deliveries (Sections) in Past12
Hysterectomy After Two or More C Deliveries (Sections) in Past
When to Take Abdominal Access
Anterior Myomas
Cervical Elongation
Atrophic Uterus
Masked Anterior Cervical Lip
Laparoscopic Assessment Prior to Accessing the Anterior Pouch Vaginally
Guidelines to Prevent Bladder Trauma
Place of Postoperative Routine Cystoscopy
ACCESS TO THE POSTERIOR CUL-DE-SAC/POUCH OF DOUGLAS
Technique
Variations in Technique
Transcervical Access to the Cul-de-Sac
SPECIAL SITUATIONS
Access to Pouch of Douglas Via Posterior Uterocervical Broad Ligament Space24
Obliterated Posterior Cul-de-Sac: Salpingo-Oopho-Rectomy at VH for Ovarian Endometriosis
Posterior Leiomyomas
Masked Posterior Cervical Lip
Cervix Flushed with Vaginal Walls
Compartmental Problems
Anterior Compartmental Problems
Posterior Compartmental Problems
Lateral Compartmental Problems
CONCLUSION
CHAPTER 5:
Vaginal Hysterectomy for Genital Prolapse
ANATOMY AND PHYSIOLOGY
CLASSIFICATION OF PROLAPSE
INDICATIONS OF PROLAPSE SURGERY WITH VAGINAL HYSTERECTOMY
How We Do It?
The Vaginal Hysterectomy
The Procedure
Site Specific Repair4 (Figs 1 to 4)
Posterior Repair
Mesh Plasties
COMPLICATIONS
Precautions that one should take in a Hysterectomy for Prolapse
CHAPTER 6:
Anterior, Posterior, and Apical Vaginal Reconstruction with and without Bolsters
INTRODUCTION
THE VAGINAL APEX—THE KEYSTONE
METHODS OF VAGINAL APEX REPAIR
ANTERIOR AND POSTERIOR VAGINAL WALL METHODS OF REPAIR
TIME AND PLACE FOR BOLSTERS
CONCLUSION
CHAPTER 7:
The Nulliparous Patient
INTRODUCTION
WHY PREFER LAPAROSCOPIC ASSISTANCE OR ABDOMINAL HYSTERECTOMY IN THE NULLIPARA?
Space
Descent and Mobility
Access
Indications
Severe Mental Handicap
CLASSIFICATION
Surgically Uncomplicated Nullipara
Surgically Complicated Nullipara
PREREQUISITES FOR VH
Examination under Anesthesia
TRIAL VH
PROPHYLACTIC OOPHORECTOMY
Place of Miniepisiotomy or Schuchardt's Incision
Place of Laparoscopy
Evaluation
Surgical Assistance
Place of TLH
Place of Abdominal Hysterectomy
Approach
Why the Vaginal Route?
CHAPTER 8:
Uterine Fibroids
INTRODUCTION
CONTRAINDICATIONS TO HYSTERECTOMY
INDICATIONS FOR HYSTERECTOMY
Criteria for Deciding the Approach
How to Start Doing Hysterectomy by Vaginal Route?
Uterine Size
Debulking
Accessible Fibroids
Inaccessible Fibroids
How to Assess Easy or Difficult Access
Technique
Anterior Wall Fibroid
Posterior Wall Fibroid
Fundal Fibroids
Multiple and Lateral Fibroids
Fibroid Uteri with Previous Scars
Degenerated Fibroid(s)
Fibroids and Prolapsed Uterus
Cervical Fibroids
Submucous Myoma (Myomatous Polyp)
Broad Ligament Fibroid
FIBROIDS WITH ADENOMYOSIS
MEDICAL DEBULKING
OTHER MODALITIES OF MANAGEMENT OF FIBROIDS
Transcervical Resection of Endometrium or its Alternatives: Balloon or Microwave Ablation
Uterine Artery Embolization (UAE)
Mri-Guided Focused Ultrasonographic Surgery70
Role of Ultrasonography
Role of MRI
UTERINE SARCOMA
Place of Frozen HP Study
Urography and Ureteric Catheterization
Endometrial Thickness
Hematological Studies
Trial VH
Indications for Abdominal Hysterectomy
Subtotal Hysterectomy
Options When the Uterus Is >12–14 Weeks
When to Shift to Only Myomectomy
Role of Laparoscopy
Available Techniques to Perform Hysterectomy for Uterine Fibroids
COMPLICATIONS
CONCLUSION
CHAPTER 9:
Uterine Debulking at Vaginal Hysterectomy
INTRODUCTION
HISTORICAL ASPECTS
INDICATIONS FOR MORCELLATION
Uterine Enlargement
Uterine Fixation
Cervical Obstruction
Limited Vaginal Exposure
CONTRAINDICATIONS TO MORCELLATION
Suspected Uterine Malignancy
Irreducible Limited Vaginal Exposure
Concomitant Uterine Enlargement and Immobility
Instrumentation
Retraction Instruments
Traction Instruments
Cutting Instruments
Clamping Instruments
PREOPERATIVE CONSIDERATIONS
Endometrial Assessment
Radiological Assessment
Techniques
Hemisection (Bivalving)
Intramyometrial Coring (Lash Procedure)
Wedge Morcellation
Systematic Anterior Morcellation (Pryor's Technique)
Posterior Fundal Morcellation
Core Enucleation (Doyen's Method)
Myomectomy at Morcellation
SURGICAL CONSIDERATIONS
General Strategy
Episiotomy
Cervical Amputation
Suprapubic Fundal Pressure
Control of the Upper Uterine Attachments
Control of Potential Adhesions
Use of Vasoconstrictors
Unsuspected Malignancy Diagnosed Postoperatively
Position
Placement of the Uterine Manipulator
Cruciate Suprapubic Incision
Placement of the Self-Retaining Abdominal Retractor
MINILAPAROTOMY TECHNIQUE FOR THE COMPLETION OF THE VAGINAL HYSTERECTOMY
Minilaparotomy Closure
REFERENCES
CHAPTER 10:
Hysterectomy after Previous Abdominopelvic Surgery
PREVIOUS ABDOMINOPELVIC SURGERY
CESAREAN DELIVERY (C-SECTION) IN PAST
EXAMINATION UNDER ANESTHESIA
TECHNICAL GUIDELINES TO OVERCOME PROBLEMS AT VH
USE OF LAPAROSCOPY IN ASSISTING VAGINAL SURGERY
TOTAL LAPAROSCOPIC HYSTERECTOMY: IS IT AN ADVANTAGE OR A “SHOW”?
CONCLUSION
CHAPTER 11:
Trial Vaginal Hysterectomy and Trial Vaginal Route
INTRODUCTION
TRIAL VAGINAL HYSTERECTOMY
Challenges
Peroperative Assessment
Large Uteri/Uterine Fibroids
Volume Reductive Surgery
Nulliparity
Obesity
Previous Cesarean
TRIAL VAGINAL ROUTE
Benign Adnexal Masses
Ovarian Endometrioma
Broad Ligament Fibroid
Ovarian Cyst Removal Via Pouch of Douglas
CHAPTER 12:
Contraindicated Abdominal Route
INTRODUCTION
CONTRAINDICATIONS TO THE ABDOMINAL ROUTE FOR HYSTERECTOMY
Absolute
Previous Ventral Scar Hernioplasty
Tuberculous Abdomen
Repeated Skin Keloids
Psychological
Failed Abdominal Hysterectomy
RELATIVE CONTRAINDICATIONS/PREFERRED AVOIDANCE OF THE ABDOMINAL ROUTE FOR HYSTERECTOMY
High Risk
Morbidly Obese Women
Severely Mentally Handicapped Women
Early Endometrial Cancer in a High-Risk Patient
Multiple Advantages of Sparing Abdominal Surgery
SPECIAL SITUATIONS
Previous Abdominal Tuberculosis
Morbidly Obese Women
Keloids
Endometrial Cancer
High Risk
CONCLUSION
CHAPTER 13:
Oophorectomy at the Time of Hysterectomy for Benign Indications
OVARIAN FUNCTION AFTER MENOPAUSE
POTENTIAL BENEFITS OF OOPHORECTOMY
Ovarian Cancer Prevention
Breast Cancer Prevention
Reoperation after Ovarian Conservation
RISKS OF PROPHYLACTIC OOPHORECTOMY IN LOW-RISK WOMEN HAVING HYSTEREC-TOMY FOR BENIGN INDICATIONS
Cardiovascular Events
Cognitive and Neurological Health
Psychological Well-Being and Sexual Function
Bone Health
Survival
CONCLUSION
CHAPTER 14:
Concomitant Salpingo-Oophorectomy at Vaginal Hysterectomy
INTRODUCTION
PROPHYLACTIC SALPINGO-OOPHORECTOMY
PROPHYLACTIC SALPINGO-OOPHORECTOMY AT HYSTERECTOMY
Indications
Contraindications
Guidelines for Prophylactic Salpingo-Oophorectomy
Ovarian Removal
Conservation of Ovaries
Low-Risk Factors Predisposing to Ovarian Cancer12
High-Risk Factors Predisposing to Ovarian Cancer12
OPERATIVE TECHNIQUE
Conventional Surgery
ALTERNATIVES
Vaginal
Endoscopic
Hospital Stay
DIFFICULT SITUATIONS
Preoperative
Nulliparae
Obesity
Obese with Narrow Subpubic Arch
Decreased Space
Descent
Difficult Access
Enlarged Uterus
INTRAOPERATIVE
Adhesions
Anesthesia
Laparoscopic Excision
Minilaparotomy
Ovaries Retained!
Should the Tubes be Removed?
Learning Points
Oophorectomy without Hysterectomy
CONCLUSION
CHAPTER 15:
Adnexal Pathology at Vaginal Hysterectomy
POSSIBLE ADNEXAL SURGERY AT VH
Role of Imaging Techniques
PREREQUISITES FOR VH WITH ADNEXECTOMY VIA VAGINAL ROUTE
CONTRAINDICATIONS TO CONCOMITANT ADNEXECTOMY AT VH
PREOPERATIVE ASSESSMENT
Technique
Hydrosalpinx
Endometrial Cyst of Ovary
Contralateral Normal Adnexa
DISADVANTAGES OF LAPAROSCOPIC ADNEXECTOMY OR CYSTECTOMY
WHY THE VAGINAL APPROACH
DIFFICULTY IN CONCOMITANT VAGINAL ADNEXECTOMY
ROLE OF FROZEN SECTION
WHEN TO ABANDON THE VAGINAL ROUTE
WHEN TO SWITCH OVER TO LAPAROSCOPIC ASSISTANCE
WHEN TO PERFORM LAPAROTOMY
COMPLICATIONS
DISCUSSION
CHAPTER 16:
Subtotal Vaginal Hysterectomy
INTRODUCTION
TOTAL VERSUS SUBTOTAL HYSTERECTOMY
Cervical Cancer
Urinary Tract
Sexual Function
Bowel Function
Other Parameters
RATIONALE FOR THE VAGINAL APPROACH
BASIS FOR SUBTOTAL VAGINAL HYSTERECTOMY
TECHNIQUE OF VAGINAL SUBTOTAL HYSTERECTOMY
RESULTS OF SURGERY
CONCLUSION
CHAPTER 17:
The Difficult Vaginal Hysterectomy
HOW TO DETERMINE THAT PREOPERATIVE ASSESSMENT OF EXTRAUTERINE DISEASE EXTENDS BEYOND THE CONFINES OF THE UTERUS MATCHES THE POSTOPERATIVE FINDINGS
USE OF GUIDELINES TO DETERMINE THE ROUTE OF HYSTERECTOMY (FLOW CHART 1)
CHAPTER 18:
Hybrid Approach for Difficult Vaginal Hysterectomy
INTRODUCTION
THE HYBRID APPROACH
LAPAROSCOPIC HYBRID APPROACH FOR DIFFICULT VAGINAL HYSTERECTOMY
Large Myomatous Uterus
Severe Endometriosis
Severe Pelvic Adhesions
MINILAPAROTOMY HYBRID APPROACH FOR DIFFICULT VAGINAL HYSTERECTOMY
HYBRID APPROACH WITH A COMBINATION OF BOTH LAPAROSCOPY AND MINILAPAROTOMY IN DIFFICULT VAGINAL HYSTERECTOMY
DISCUSSION
CHAPTER 19:
Hysterectomy on High-Risk Women
PREOPERATIVE EVALUATION
MEDICAL, DRUG, AND PREVIOUS ANESTHETIC HISTORY
PHYSICAL EXAMINATION
INVESTIGATIONS
Hematology
Electrolytes
Chest Radiography
Electrocardiography
COEXISTING MEDICAL CONDITIONS
Cardiovascular
Left Ventricular Failure
Ischemic Heart Disease
Hypertension
Cardiac Pacemakers
Respiratory
Chronic Obstructive Airways Disease
Chronic Restrictive Airways Disease (Pulmonary Fibrosis)
Asthma
NEUROLOGICAL
Epilepsy
Parkinson's Disease
Other Neurological Conditions
Endocrine and Metabolic Systems
Obesity
Positive Airway Pressure Therapy
Diabetes Mellitus
Other Endocrine Disorders
Liver
Renal
Is Two Better Than One?
Local Infiltration Analgesia
CONCLUSION
CHAPTER 20:
Simplified Technique of Vaginal Hysterectomy
RATIONALE
SURGICAL TECHNIQUE
Phase 1: The Hemostatic Liquid Tourniquet
Phase 2: Peritoneal Entry
Phase 3: Bladder Mobilization
Phase 4: Cervical Mobilization
Phase 5: Arterial and Upper Parametrial Division
Phase 6: Management of the Vaginal Cuff
Technical Considerations
CHAPTER 21:
Is Vaginal Hysterectomy a Day Care Procedure?
INTRODUCTION
CAN VAGINAL HYSTERECTOMY BE ADOPTED AS AN OUTPATIENT PROCEDURE?
CONCLUSION
CHAPTER 22:
Malignancy Related to Vaginal Hysterectomy and Laparoscopically Assisted Vaginal Hysterectomy
MALIGNANT HISTOLOGY FOUND AFTER TREATMENT
SQUAMOUS OR ADENOCARCINOMA OF THE CERVIX
Action
Microcarcinoma
Investigations
TRUE INVASIVE CANCER
Action
ATYPICAL HYPERPLASIAS OF THE ENDOMETRIUM
Action
Adenocarcinoma, Adenosquamous Carcinoma, and Squamous Carcinoma of the Endometrium
Adenocarcinoma of the Endometrium
Action
STAGE I GRADE I DISEASE
Action
STAGE I GRADE III DISEASE
Chemotherapy
Progestogens
Cancer of the Ovary
Action
There is no Perfect Answer!
Port Site Implantation
Fallopian Tube Carcinoma
Action
Sarcoma of the Corpus, Usually Arising in Fibroids
TISSUE TYPES
Action
CHORIOCARCINOMA
Action
MEDICOLEGAL IMPLICATIONS
CONCLUSION
CHAPTER 23:
Vaginal Hysterectomy for Carcinoma of the Endometrium
INTRODUCTION
VAGINAL HYSTERECTOMY FOR THE TREATMENT OF ENDOMETRIAL CANCER
CONCLUSION
SUMMARY
CHAPTER 24:
Newer Perspectives
INTRODUCTION
CLINICAL AND SONOGRAPHIC SIGNS FOR THE DENSE UTEROCERVICAL ADHESIONS WITH LOWER ABDOMINAL WALL
Clinical Sign
Sonographic Sign
SUPER FLEXION POSITION
GENITAL MALIGNANCY
Endometrial Cancer
SURGICAL TECHNIQUE TO ACCESS VESICOUTERINE PERITONEUM (VUP) IN WOMEN WITH HISTORY OF TWO OR MORE C DELIVERIES (SECTIONS) IN PAST13
POSTERIOR UTEROCERVICAL BROAD LIGAMENT SPACE—A SURGICAL SPACE TO ACCESS OBLITERATED POSTERIOR CUL-DE-SAC AT VH AND PERFORM CONCOMITANT SALPINGO-OOPHORECTOMY FOR OVARIAN ENDOMETRIOSIS14
OOPHORECTOMY OR SALPINGO-OOPHORECTOMY?
CONCOMITANT ADNEXECTOMY FOR BENIGN PATHOLOGY AT VH
BROAD LIGAMENT FIBROID
FOLLOWING THOUGH “OLD PERSPECTIVES” CAN PROVE NEW AND HELPFUL TO NEW GYNECOLOGICAL SURGEONS
Examination under Anesthesia
Reliable Ultrasonography
Laparoscopic Evaluation
Laparoscopic Assisted Vaginal Hysterectomy
Total Laparoscopic Hysterectomy
Indications and Contraindications
VAGINAL ASSISTED LAPAROSCOPIC HYSTERECTOMY (VALH)
ROBOTIC
MESH
FOR VAGINAL SURGEONS
CHAPTER 25:
Associated Urethral Sphincter Incompetence
INTRODUCTION
PHYSIOLOGY
PATHOPHYSIOLOGY
DIAGNOSTIC EVALUATION
CONSERVATIVE MANAGEMENT OF SUI
SURGICAL MANAGEMENT
BURCH COLPOSUSPENSION
LAPAROSCOPIC COLPOSUSPENSION
MARSHALL-MARCHETTI-KRANTZ (RETROPUBIC URETHROPEXY) (MMK) PROCEDURE
NEEDLE SUSPENSION PROCEDURES
ANTERIOR REPAIR WITH KELLY PLICATION
BULKING AGENTS
SLING PROCEDURES
PUBOVAGINAL SLINGS
MID-URETHRAL SLINGS
SINGLE INCISION MINI-SLINGS
ARTIFICIAL URINARY SPHINCTER
SUI AND HYSTERECTOMY FOR NONPROLAPSE INDICATIONS
CONCOMITANT SUI AND POP
CONCLUSION
CHAPTER 26:
Associated Nongynecological Surgery
INTRODUCTION
ANESTHESIA
ADVANTAGES OF COMBINED PROCEDURES
ISSUES OF SAFETY
SURGICAL PROCEDURES THAT CAN BE COMBINED WITH VH
Laparoscopic Cholecystectomy
Abdominal Wall Hernia
Paraumbilical Hernia
Incisional Hernias
Laparoscopic Appendectomy
Diagnostic Laparoscopy, Adhesiolysis, Lymph Node Biopsy
Benign Extra-Abdominal Pathology
POSTOPERATIVE MANAGEMENT
CHAPTER 27:
Place of Sacrospinous Colpopexy at Vaginal Hysterectomy
INTRODUCTION
HISTORY
ANATOMICAL CONSIDERATIONS
ANATOMY OF THE PELVIC FLOOR
Level 1 (Suspension)
Level 2 (Attachment)
Level 3 (Fusion)
VAGINAL AXIS
Sacrospinous Ligament
Indication for Sacrospinous Colpopexy at Vaginal Hysterectomy
PATIENT EVALUATION
VAGINAL SACROSPINOUS COLPOPEXY
Surgical Technique
COMPLICATIONS AND THEIR MANAGEMENT
Bleeding
Nerve Injuries
Injury to Bowel, Rectum, and Soft Tissue
Surgical Failure
Damage to the Vaginal Wall
LEARNING THE TECHNIQUE OF SACROSPINOUS FIXATION
RESULTS AND OUTCOME OF SACROSPINOUS COLPOPEXY
ONE OF THE AUTHOR'S STUDIES
Materials and Methods
RESULTS
CONCLUSION
CHAPTER 28:
Hysterectomy and Sexuality
INTRODUCTION
EVIDENCE-BASED REVIEW OF EFFECTS OF HYSTERECTOMY ON SEXUAL RESPONSE
Simple Hysterectomy [Total Abdominal (TAH), Subtotal Abdominal (STAH), and Vaginal Hysterectomy (VH)]
Radical Hysterectomy (RH)
Laparoscopic Hysterectomy
MANAGEMENT OF PATIENT WITH SEXUAL DYSFUNCTION AFTER HYSTERECTOMY
History, Examination, and Investigations
Treatment
CONCLUSION
CHAPTER 29:
Vaginal Hysterectomy versus Transcervical Resection of the Endometrium
INTRODUCTION
EVOLUTION OF TRANSCERVICAL RESECTION OF THE ENDOMETRIUM
HISTORICAL DEVELOPMENTS
RANDOMIZED CONTROLLED TRIALS
SECOND-GENERATION ABLATION TECHNIQUES
PSYCHIATRIC AND SEXUAL SEQUELAE
COST
COMPLICATION RATES
CONCLUSION
CHAPTER 30:
Vaginal or Abdominal Hysterectomy?
INTRODUCTION
CONTRAINDICATIONS
INDICATIONS
ABNORMAL UTERINE BLEEDING WITHOUT PELVIC PATHOLOGY
ADENOMYOSIS
FIBROIDS
Criteria for Deciding the Approach (see Chapter 8)
INDICATIONS FOR ABDOMINAL HYSTERECTOMY
SUBMUCOUS MYOMATOUS POLYP
ENDOMETRIOSIS
ADNEXAL MASS
CARCINOMA IN SITU OF CERVIX
POSTMENOPAUSAL BLEEDING
ENDOMETRIAL CANCER
ASSOCIATED CONDITIONS AND SITUATIONS
Previous Abdominal Surgery
PREVIOUS CESAREAN SECTION OR MYOMECTOMY REQUIRING HYSTERECTOMY
UTEROCERVICAL DISPLACEMENT FOLLOWING ADHESIONS AFTER CESAREAN SECTION (CERVICOFUNDAL SIGN)46
PREVIOUS VAGINAL SURGERY
NULLIPARITY
OBESITY
High-Risk Group
ROLE OF ULTRASONOGRAPHY
Trial VH or Trial Vaginal Route
DEBULKING: WHEN?
EXAMINATION UNDER ANESTHESIA
Descent, Prolapse, and Mobility
FINDINGS UNDER ANESTHESIA THAT FAVOR THE VAGINAL ROUTE (SEE CHAPTER 3)
Failed Vaginal Hysterectomy. Why?
Indications for Laparoscopic Assistance or TLH
Indications for Abdominal Hysterectomy
USE OF LIGASURE
SALPINGO-OOPHORECTOMY AT HYSTERECTOMY
SUBTOTAL HYSTERECTOMY
ROLE OF LAPAROSCOPIC EVALUATION
URETERAL, BLADDER, AND OTHER INJURIES
MORBIDITY AND MORTALITY
MORTALITY
WHY THE VAGINAL AND NOT ABDOMINAL ROUTE?
CHAPTER 31:
Vaginal Hysterectomy versus Laparoscopic Hysterectomy
WHICH ROUTE FOR HYSTERECTOMY
POSITION OF PATIENT
SURGEON'S COMFORT
STEPS TO INCREASE VISIBILITY DEEP INSIDE VAGINA
MODIFICATION OF INSTRUMENTS
CHANGE IN TECHNIQUE
OOPHORECTOMY
REMOVING FIBROIDS OR LARGE SIZE UTERUS
SPECIAL SITUATIONS
Endometriosis
Previous Cesarean Section
SALIENT POINTS IN THE TECHNIQUE OF NONDESCENT VH
WHEN IS LAPAROSCOPIC ASSISTANCE NEEDED?
NULLIPARITY
HISTORY OF PELVIC SURGERY IN PAST
UTERINE FIBROIDS
BENIGN ADNEXAL PATHOLOGY
Prophylactic Salpingo-oophorectomy and Benign Adnexal Pathology
WHEN TO HAVE LAPAROSCOPIC ASSISTANCE OR LAPAROSCOPIC HYSTERECTOMY
INDICATIONS FOR ABDOMINAL HYSTERECTOMY
ROLE OF LAPAROSCOPIC EVALUATION
CONCLUSION
CHAPTER 32:
Complications, Morbidity, and Mortality of Vaginal Hysterectomy
INFECTION
HEMORRHAGE
BLADDER AND URETER INJURIES
BOWEL INJURY
NERVE INJURIES
FIMBRIAL PROLAPSE AND GRANULATION TISSUE
Vault Prolapse
Vaginal Vault Dehiscence
Vaginal Vault Evisceration
Takotsubo Cardiomyopathy
LATE SEQUELAE
MORBIDITY
MORTALITY RISK
CONCLUSION
CHAPTER 33:
Cosmetogynecology
INTRODUCTION
HISTORY
TERMINOLOGY
COSMETIC RATIONALE AND UNIQUE CONSIDERATIONS
NONSURGICAL COSMETOGYNECOLOGY
Mons Pubis and Vulvar Depilation
ABLATION OF VULVAR VARICOSITIES
THERMAL RESURFACING OF VAGINAL EPITHELIUM
SURGICAL COSMETOGYNECOLOGY
MONS PUBIS
Mons Pubis Liposuction
Mons Pubis Lift
Mons Pubis Resection and Lift
LABIA MAJORA
Labia Majora Excisional Reduction
Labia Majora Liposuction Reduction
Labia Majora Laser Lipolysis
Labia Majora Augmentation with Autologous Fat
LABIA MINORA
Linear Labia Minoraplasty
Wedge Labia Minoraplasty
Partial-Thickness Labia Minoraplasty
Clitoral Hood
HYMENOPLASTY
VAGINOPLASTY
THIGHPLASTY
VULVOVAGINAL RECONSTRUCTION POST-THIGHPLASTY
SUMMARY
CHAPTER 34:
Choosing the Correct Hysterectomy Technique
INDICATIONS FOR THE HYSTERECTOMY
OUTCOMES, COMPLICATIONS, AND TECHNICAL FACTORS
SURGEON FACTORS
PATIENT FACTORS
FINANCIAL CONSIDERATIONS
SUMMARY
INDEX
TOC
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