VAGINAL HYSTERECTOMY

1. VAGINAL
HYSTERECTOMY

2.  Hysterectomy is one of the most commonly performed
gynecological surgery
 The debate on whether the uterus should be removed
vaginally or abdominally was sparked when Langenbeck first
performed a vaginal hysterectomy in 1813
 The famous French surgeon doyen insisted in 1939 that no
one could call himself a gynecologist until he performed
vaginal hysterectomy in private.
INTRODUCTION

3. It is the removal of the uterus per
vaginum.
D C Dutta
VAGINAL
HYSTERECTOMY

4.  Uterovaginal prolapse in postmenopausal women.
 Genital prolapse in perimenopausal age group along
with diseased uterus like DUB, unhealthy cervix or
small submucous fibroid requiring hysterectomy.
 As an alternative to fothergill’s operation where
family is completed.
 As an alternative to abdominal hysterectomy in
undescended uterus either as a routine or in selected
case where abdominal approach is unsafe.
INDICATIONS

5. As an alternative to LAVH.
Relaxation of pelvic walls-
cystocele,rectocele,enterocele or a
combination of these.
Small symptomatic uterine fibroid causing
menorrhagia.
Cervical intraepithelial neoplasia

6.  Large uterine myoma with a size of more than 12
weeks of gestation
 Extreme narrowing of the vagina and narrow sub
pubic angle may also cause mechanical difficulties.
 Vaginal approach will be unsuitable if a significant
component of the patient’s symptom is pelvic pain of
unknown origin.
 Suspected pathology of adnexal organs ie,benign
malignant neoplasms,tubo-ovarian inflammation
mass;extensive endometriosis involving the ovaries.
CONTRAINDICATIONS

7. Advantages Disadvantages
Can be effectively done in obese
patients
Postoperative complications are less
Less morbidity and mortality
Less postoperative pain and less need of
analgesia
Less hospital stay
Early resumption of day-to-day activities
No abdominal incision and scar
More skill and experience are
needed on the part of the surgeon
Exploration of abdominal and
pelvic organs cannot be done
Tubo-ovarian pathology when
detected is difficult to tackle
Limitation in cases with:uterus
>12 weeks of size,presence of
pelvic adhesions or,previous
history of laparotomy with
adhesions.

8.  Pre-operative counseling and informed consent
Pre-operative discussion between a doctor and a
patient or guardian should be done. It should remove
patient’s anxiety and fear for operation. The following
should be explained to her :-
 Diagnosis of abnormality, nature of the operation and its
modifications depending on the findings during
operation.
 The likelihood of successful outcome.
 The potential risks and complications of surgery.
 Alternative treatments available.
 An informed consent must be in writing.
 Consent must be voluntary and must be signed by
patient and physician.
PROCEDURE

9.  Diet: Light diet in previous evening and nothing in
the morning of the day of operation. NPO at least 8
hours before is ideal.
 Preparation of bowel: A cleansing enema in the
evening on the previous day.
 Night sedation: To ensure good sleep at night prior to
the day of operation, either diazepam 5- 10 mg or
alprazolam 0.25- 0.5 mg is given at bed time.

10.  Local antiseptic care:Vaginal operations include
clipping of the pubic hair and up to the middle of
both the thighs. The perineum and the vulva are
cleaned with savlon using a sponge held in a sponge
forceps. The vagina is cleaned with povidone iodine
solution..
 Other medications: The patient is advised to take all
regular medicines on the morning of surgery with
sips of water,unless contraindicated.
 Prophylactic antibiotics: A broad spectrum antibiotic
is selected to cover the common gram positive, gram
negative and the anaerobic organisms. Generally, a
3rd generation cephalosporin is given slow IV).

11.  IV infusion - Ringer’s solution is started.
 Operation is done under general or epidural
anaesthesia.
 Patient is placed in a lithotomy position.
 Perineum is to be draped with sterile towel and legs
with leggings.
 Bladder is to be emptied by metal catheter
 Vaginal examination is done to assess the type and
degree of prolapse.
PRE OPERATIVE WORK UP IN OPERATION
TABLE

12.  Sims’ posterior vaginal speculum is introduced and
the anterior lip of the cervix is held by multiple
teethed vulsellum and firmly brought down by
assistant.
 A metal catheter is introduced to know the lower
limit of the bladder.
 An inverted ‘T’ incision is made on the anterior
vaginal wall.The horizontal incision is made below
the bladder and the vertical incision is made starting
from the midpoint of the transverse incision upto a
point about 1.5cm below the external meatus.
ACTUAL STEPS OF OPERATION

14.  The triangular vaginal flaps including the fascia on
either sides are separated from the endopelvic fascia
covering the bladder by knife and gauze dissection.
 The bladder with the covering endopelvic fascia is
now exposed as the edges of the vaginal wall are
retracted laterally.
.

15.  The vesicocervical ligament is held up with Allis
tissue or toothed dissecting forceps and divided.The
bladder is then pushed up by gauze covered finger
till the peritoneum of the uterovesical pouch is
visible.
 The uterovesical peritoneum is cut open. Landon’s
retractor is introduced and to held by an assistant.
 The posterior vaginal wall is incised along the
cervico-vaginal junction. The vaginal wall is dissected
down till the pouch of Douglas is reached. The
peritoneum is cut opened.

17.  First clamp is placed which includes uterosacral
ligament, Mackenrodt’s ligament and descending
cervical artery. The tissues are cut as close to the
cervix and replaced by vicryl no.i. similar procedures
are followed on the other side.
 Second clamp includes uterine artery and base of
the broad ligament, the structures are cut as close to
the uterus and replaced by ( vicrylno.1)ligature.same
on other side.

19.  The fundus is now brought out through the anterior
pouch by a pair of Allis tissue forceps.
 The third clamp includes – round ligament, fallopian
tube, mesosalpinx and ligament of the ovary. The
structures are cut and replaced by transfixing suture.
Same procedures are carried out on the other side.
The uterus is removed.

21. Peritoneum is closed by a purse string suture.
The sutures of the uppermost pedicles on the
either side are tied.
Redudent portions of the vaginal flaps are
excised and the margins approximated by
interrupted sutures (catgut No.0).

22. Perineorrhaphy is done.
Vaginal packing is done.
Self retaining catheter is introduced.

23. The pre-requisites prior to shifting are :-
 Vital signs such as pulse, respiration and blood
pressure become steady.
 Patient recovers from anesthesia and fully
conscious.
 Anesthetist’s consent should be available.
 Fluid balance and any bleeding from surgical site is
checked.
POST OPERATIVE WORK UP

24.  Placement in the bed : The patient is gently placed
on her side in the bed. If spinal anesthesia is given,
the foot end is raised for about 12 hours.
 Observation : The observation of the vital signs such
as pulse, respiration and BP is made half hourly in
the initial period. Attention should be paid for any
bleeding from the operated site.

25.  Fluid replacement : Following operation, fluid is replaced
intravenously. Blood transfusion if needed is given during the
operation and soon after. Blood transfusion should not be
given unnecessarily. Urine output of atleast 30ml/hr indicates
adequate fluid replacement. An additional amount of 2.25
litres of fluid are to be infused.
 Pain control : Liberal analgesics should be given to relieve
pain and to ensure sleep. Pethidine hydrochloride 100mg or
morphine sulphate 10mg IM can be given. Non-steroidal anti-
inflammatory drugs are also effective analgesics.

26.  Nausea and vomiting : Can be prevented by
simultaneous administration of metaclopramide 10
mg or ondansteron 4mg IM/IU.
 Antibiotics : Routine post operative antibiotics are
prescribed. This should be administered parenterally
for 48 hours followed by oral route for another 3
days.

27.  Bladder care : The patient is encouraged to pass
urine atleast 6-8 hours after operation. If she fails,
catheterization should be done.
 Diet : Till 24 hours after surgery intravenous fluids
should be administered. On second day oral feeding
in the form of plain or electrolyte water is given in
small quantity at frequent intervals. On the third day
light solid diet and on the fourth day, the diet can be
brought to her normal.

28.  Care of perineum : The perineal wound should be
dressed atleast twice daily with spirit and antibiotic
powder or ointment. Local pain and edema may be
relieved by hot compress.

29.  Patient may be discharged by 5 -7 days following
hysterectomy.
Examination prior to discharge
 Perineal wound is checked to assess the state of
healing
 Vaginal exploration with a finger is useful to detect
accidently a retained and forgotten gauze piece.
DISCHARGE

30. Seek medical care if:
 Fever more than 101 F by mouth
 Shaking chills
 Trouble breathing
 Upset stomach or vomiting
 Loose stools or diarrhea
 Pain or foul odor when passing urine
 Foul odor from vaginal drainage
 Suture line warmth, drainage, or hardness
ADVICES GIVEN ON DISCHARGE

31. Rest :light household work can be resumed
after 3 weeks and outside or office works to
be resumed after 6 weeks.
Activities:
Driving - Do not drive a car for at least 2 weeks.
If you ride in the car, plan to stop and stretch at
least every 2 hours
Lifting - Do not lift heavy objects which would
make you strain. Lift no more than 10 pounds
(such as a 10-pound bag of sugar). Lift slowly
and use good body posture to prevent strain.

32. Exercise - Gentle stretching and walking as
tolerated are encouraged and are acceptable.
Coitus: There is no fixed time bar.as soon as
she is physically and psychologically fit,
intercourse is permissible. However, it should
not be resumed prior to the postoperative
check up (ie 6 weeks) specially following
vaginal plastic operation and hysterectomy.

33.  Diet :Eat a well-balanced diet, including protein fruits
and vegetables, which will help with healing after
surgery. Drink about 8-10 glasses of fluids a day to
keep well hydrated. Increase fibre rich diet to
prevent constipation.
 Personal hygiene:
Take bath twicely and keep the incision site clean and
dry.
Keep the perineal care clean and dry until the vaginal
discharge and bleeding stops.

34.  Vaginal discharge: report if you experience heavy
vaginal bleeding,start passing blood clots or have an
offensive-smelling discharge.
 Wound care and dressing: Clean the incision site
gently with soap and water and keep it dry.Check the
incision site daily for any increased
redness,draining,swelling,pus or separation of
skin.Support the incision site while coughing or
sneezing.
 Follow up is usually after 6 weeks or earlier if some
complications occur.

35. Immediate
 Primary hemorrhage
 Ureteral injury
 Bladder injury
 Rectal and bowel injury
Late
 Reactionary and secondary hemorrhage
 Vault cellulitis
 Wound infection
 Wound dehiscence
COMPLICATIONS OF VAGINAL
HYSTERECTOMY

36.  Pelvic infection
 Hematoma and abscess formation
 Vesicovaginal, ureterovaginal and rectovaginal fistula
 Septicemia
 DVT and pulmonary embolism
 Dyspareunia
Remote
 Vault prolapse

37.  Pre-operative
Fear and anxiety related to forecoming surgery
 Post-operative
Acute pain related to surgical incision.
Deficit fluid volume related to blood loss during
surgery
Risk for infection related to impaired skin integrity
secondary to surgical intervention.
NURSING MANAGEMENT

38. Thank you