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VAGINAL HYSTERECTOMY: OUR EXPERIENCE AT PAI HOSPITAL
Pai hospital has done thousands of hysterectomies for many years since it was started in 1985. Most of our hysterectomies were done abdominally. Only about 30% of our hysterectomies were done vaginally that too for cases of uterine descent. We always noticed that these patients were more comfortable and pain free than the ones operated abdominally.
Recently we changed our technique to doing most cases vaginally even for a non descended uterus and we have got excellent results and patient feed backs. One interesting fact that most patients feel surprised about is the swift recovery. Patients are up and about in 24 to 48 hours. Most of our patients are working ladies or busy home makers. These women get the full benefit of this surgery and can fully resume their busy schedule in less than a week.
Another important fact is that most ladies operated with this new technique are very thankful to the fact that their abdomen is totally scar less.
This is the future of modern gynaecological surgery. Non descent vaginal hysterectomy (NDVH) is here to stay. We will continue to bring you more ground breaking surgeries and treatment modalities in the near future.
SHOULD THE UTERUS BE REMOVED AT THE TIME OF BILATERAL OOPHORECTOMY (BOTH SIDES OVARIES REMOVAL)?
There are cases of ovarian cancer in which the finding at surgery indicate that the outlook is so poor that it is not worth adding hysterectomy to bilateral salpingooophorectomy.
It is important that women suffering from widespread pelvic infection or endometrisosis should be treated by hysterectomy with bilateral salpingo-oophorectomy (removal of uterus and both sides’ ovaries).
A uterus left in situ without the ovaries is functionless. Moreover, it is likely to be permanently damaged by the conditions mentioned above. Even if it is not, its chance of developing subsequent disease, including cancer, is quite high. Again, the presence of the uterus hinders hormone replacement therapy which the artificial menopause might call for and rules out a subfascial implant of an oestrogen. Generally, therefore, removal of both ovaries calls for simultaneous total hysterectomy.
With advances in assisted reproduction technology (ART), however, it is now possible for a woman who has undergone bilateral oophorectomy to receive into her womb an embryo conceived through oocyte donation and in vitro fertilisation and carry the foetus to term. These exciting new developments, therefore, make it necessary for each case to be treated on its own merits.
HYSTERECTOMY (UTERUS REMOVAL SURGERY) - AN OVERVIEW
Hysterectomy is the most common operation performed by the gynecologist, and it is the second most common major surgical. Only cesarean section is more common. There are many indications for hysterectomy, and the uterus can be removed using any of a variety of techniques and approaches, including abdominal, vaginal, or laparoscopic.
In most cases, a total hysterectomy with removal of the uterine body and cervix (lower part) is done; but in recent years, there has been a resurgence in the popularity of supracervical hysterectomy (only body is removed). The ovaries and tubes may or may not be removed along with the uterus, depending on the patient’s age and a variety of other factors.
THE AFTER-EFFECTS OF HYSTERECTOMY
Excluding the effects of oophorectomy, the result of hysterectomy are extraordinarily good---- provided the indication for it are good. There are no patient more grateful than those who have been relieved of the symptoms of leiomyomas, endometriosis and pelvic infection, and of intractable dysfunctional bleeding (excessive menstrual blood loss), by having their uteri removed. What then of the many women who, after hysterectomy, are left chronic invalids or full of complaints such as headache, depression, urgency of micturition, backache, nausea, pelvic pain, sexual unresponsiveness, dyspareunia, marital disharmony and the like?
There are many such, and for two main reasons:
These women suffered the same type of symptoms previously, or they are of the complaining type with a background of emotional disturbance. Often they are fussy, continuously demanding attention and sympathy from a husband who is perhaps too considerate. The very idea of having the womb removed surrounds them with an aura of mystery and fragility to the unknowing and unsuspecting male.
In the United States, women are referred to psychiatrists much more commonly after hysterectomy than after any other operation. This is not usually because psychiatric breakdown results from surgery: it is because hysterectomy is often performed for symptoms caused by psychiatric instability which is pre-existing.
Women and their husbands misunderstand what the operation involves. So they often expect to have menopausal symptoms, even though the ovaries are not removed. They may believe that coitus should not or cannot be practised after the operation; they may fear it will cause injury. Such happenings emphasise the need for the medical attendant to see that patients are counselled in these matters; it should always be explained clearly that hysterectomy by itself should have no physical effect except to cause amenorrhoea, and should not materially affect a woman’s way of life, sexual or otherwise.
The woman who puts on weight after hysterectomy blames the operation for it. The cause of the obesity is self-indulgence in foods, chocolates and sweets brought by sympathetic friends and relatives, and a refusal to resume full and natural physical activities quickly. The same is true even if both ovaries have been removed.
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DIFFERENT TYPES OF HYSTERECTOMY
This means total or subtotal hysterectomy carried out through an abdominal incision.
Here the approach is through the vaginal route. The tubes and ovaries can be removed as well if the need arises. This operation is technically difficult, but easy for the expert, even when there is no prolapsed of the uterus, provided the pelvis is relatively free from adhesions and the uterus is not larger than the size of a 10-week pregnancy. When the uterus is enlarged further by fibroids (leiomyomas), its vaginal removal is still possible if the tumours are shelled out during the operation. A large uterus can also be morcellated and removed vaginally.
Advantages of vaginal hysterectomy over Abdominal Hysterectomy
Vaginal hysterectomy is generally safer than abdominal hysterectomy and carries a very low mortality/ morbidity rate.
Postoperative shock and discomfort are negligible;
Often the patient scarcely knows she had an operation. Earlier ambulation decreases the need for nursing care. There is a lesser requirement for pain killers. Lung function is better.
Lesser bowel handling and early ambulation result in earlier return of bowel function and lesser requirement for intravenous fluids.
The operation is better tolerated by the elderly, the obese and those with associated medical disorders (heart or lung disease).
The operation leaves no abdominal scar and involves little risk of later complications such as hernia, adhesions and intestinal obstruction, and avoids others such as infection or wound dehiscence.
An associated prolapse of the vagina can be corrected at the same time.
Laparoscopy – assisted Vaginal Hysterectomy (LAVH)
Laparoscopy-assisted vaginal hysterectomy is of greatest benefit in those conditions in which vaginal hysterectomy is relatively contraindicated. It is used to convert an abdominal hysterectomy to a vaginal procedure.
Thus, LAVH is ideally suited in cases of endometriosis, known pelvic adhesions, pelvic inflammatory disease or adnexal masses where a vaginal procedure would not be possible (see above). It is also indicated in stage I endometrial cancer. LAVH permits laparoscopic assessment of the pelvis and dissection of pedicles up to the level of the uterine artery. The rest of the procedure can then safely be done from below.
Several types of LAVH can be performed depending upon the degree up to which surgery is carried out laparoscopically, e.g. adhesiolysis and resection of endometriosis, detachment of adnexa, bladder dissection, or uterine artery ligation, before proceeding to the vaginal hysterectomy. Several alternative laparoscopic techniques for hysterectomy have been described which include the following.
Laparoscopic Supracervical hysterectomy
In this procedure a subtotal hysterectomy is done laparoscopically and the fundus removed through an enlarged umbilical incision or via a posterior colpotomy. The advantages and disadvantages are the same as for a subtotal hysterectomy.
Advantages of LAVH
An abdominal procedure can be converted to a vaginal one, even in the presence of complications
Overall morbidity is reduced
Hospital stay and recovery time are less than that for abdominal hysterectomy.
Disadvantages of LAVH
Special equipment and training is required
Baseline cost is higher
Operative time is increased