Our Fears• Access, mobility.• Dissecting off the bladder.• Opening POD.• Pedicles.• Slippage of a ligature, in so restricted field.• Postoperative vault problems.
Requirementsfor safe technique. Lesson 1of safety= SELECTION• Mobility; Especially downwards• Uterus less than 12 weeks• Cervix not atrophied• Fornices adequate• Healthy tissues• Assessment under anesthesia, in lithotomy
What we need duringHysterectomy?• Safe: secure pedicles at all times.• Avoid post operative vault prolapse: secure pedicles to vagina.
Technique• Circumferential, don’t dissect vagina off bladder, push them up together.• Open POD, choose the dimple behind the cervix. The earlier you are in, the better off you are. Probe around with your finger.
First Clamp Lesson 2 Safety• 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
If you are very close to uterus• Will have a good pedicle, we need long pedicle here as the main difficulties to encounter is the lack of mobility of the uterus in the early steps of the operation thast make the field tight; with good pedicle gives safeguard if the clamp- have slipped.• Will avoid damage surrounding structures like base of the bladder that is usually caught here.
Ligatures. Lesson 3 Sefety• 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
Lesson 4: Vaginal support: Stitching First Pedicle to Vaginal Angle• Occlusion of the space in between• Closure of small vessels• Fixing uterosacral to vagina
2 Ligature, Step ladder ndLesson 5: Securiy•Almost always the 2nd bite will not reach the level ofuterine vessels and we don’t intend to do so.• I think that if one bite is taken to the wholeuterosacral ligament, it would be a big prediclethat necessities more than one suture ligature tocontrol the pedicle. Too many sutures in that areaare more hazardous. Usually 2 bites are neededto finish the whole uterosacral ligament.
2nd Ligatrue……•The short thread of the 1st bite is tiedwith one of the threads of the nextligature so the whole uterosacral was atthe end taken to the vaginal angle.
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
At the end, The pedicles aresutured 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.
Why Approximating Pedicles: Lesson 6• 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.
Results.• Median opertive time 60min.• Post operative analgesics 33%.• Hospital stay 2.1 days.
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%
Cost.• In 1998, the average charge for a laparoscopically- assisted vaginal hysterectomy in USA was $14,500; An abdominal hysterectomy was $12,500: that for a vaginal hysterectomy was $10,380.• In Egypt Hospital cost is the least for vaginal hysterectomy.• Vaginal hysterectomy resulted in better quality-of- life outcomes and lower costs compared with laparoscopically assisted vaginal or abdominal hysterectomy (van den Eeden 1998).
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.
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.
Advantages of Vaginal Approach • Time of operation • Exposure and Traumatization • Good for high risk patients • Post operative stay • Cost
Vaginal Approach…• 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.• These ligaments afford the main support of the uterus and upper vagina ( Howkins & Bourne 1976). For that reason the proposed modifications entails suturing of the cardinal ligament and lateral vaginal wall together to create adhesive forces that help holding the vagina.
Story of vault prolapse• It should be noticed that the vagina lies parallel to the levator ani in a horizontal position. With increased intrabdominal pressure, the levator ani and cardinal ligament hold the cervix and upper vagina in their proper position. Distortion of vaginal axis due to weak support places the vaginal apex in an unsupported position over the uterovaginal hiatus i.e. the vagina cannot rest upon the levator plate resulting in prolapse. This illustrates the importance of normal; vaginal axis in the integrity of the vaginal support (Richter 1967, fun et al 1978).• In the technique described, round ligament was attached to the cardinal ligament. Some authors used, round ligament as part of vaginal fixation (Symmond’s et al 1982, Randall & Nichols 1971) to prevent posthysterectomy vaginal vault prolapse. I feel that the round ligament in that issue is trivial, however the used technique of attaching the round ligament to the cardinal ligament help to make peritonozation easier. This conclude that vaginal hysterectomy should be taken as an opportunity to prevent posthysterectomy vaginal vault prolapse by meticulous care of supporting ligaments.
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.• Always follow the rules:
Rules to follow:• Opening the POD in proper plane• Don’t 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
Epilog• Abdominal route: Surgery• Laparoscopic: Technological costly surgery• Vaginal: Art surgery
• If your only too; is a hammer you will see every problem as a nail.