Troubleshooting in NDVH Dr. Narendra D. Gajjar MD,DGO. ASHIRWAD HOSPITAL CHIKHLI www.ashirwadhospitalchikhli.com

MD,DGO MD. From B.J.Medical college ahmedabad 1980 Has been awarded many prizes for outstanding acedemic achievements In pvt practice - more than 33 yrs Past President SOGOG & Chairperson SOGOG 2012 & midterm SOGOG 2015 Operative faculty in workshops - Non descent Vaginal Hysterectomy

Hysterectomy is the most common major gynecological surgery Cochrane data & other trials: vaginal hysterectomy is preferred over abdominal hysterectomy Laparoscopic hysterectomy is a suitable option of abdominal hysterectomy but not an option of vaginal hysterectomy

INDICATIONS DUB 40% Fibroid 20 % Adenomyosis 13% PID 10% CIN 5% Cervical Polyp 4% Complex adnexal mass -- 2% Endometrial polyp 5% Postmenopausal bleeding 3%

Prevention of trouble Patient selection Success depends upon : -knowledge of anatomy of pelvic organs - dexterity, skill and experience - good operative technique -confidence of surgeon - Skilled anesthetist - Better instruments - Expert assistants - Better visualization

Many contraindications have become relative indications. Few important points NDVH – made easy…. -1st degree descent is not mandatory - large uterus / fibroid 14 to 16 wekks - previous surgery on uterus - CS - Mobile adnexal mass / ovarian cyst - Nulliparity is not a contraindication - Oophorectomy is possible vaginally - Atrophic changes / shallow fornices Or in case of cervix flushed with vagina Experience converts contraindication in to indication

Absolute Contraindications advanced Genital tract malignancy Uterus more than 16-18 weeks size Previous VVF repair Frozen pelvis adnexal pathology demanding other routes

To avoid trouble Perfect knowledge of pelvic anatomy Pelvic Examination to assess - size & mobility of uterus - stretching the cx downward to know acquired descent - assessment of fornices & available space between Cx & lateral vaginal wall

Ndvh important steps - Incision on vaginal wall Separation of bladder & opening ant peritoneum Opening the post peritoneum Clamping utero sacral & Mackenrodt’s lgts Clamping ,cutting & ligation of uterine artery pedical

clamping of round ligament, fallopian tube and ovarian ligament/ infundibulo pelvic lgt. Removal of uterus and or ovaries Vault and vaginal angles closure

Size of uterus Size of uterus patients (%) Up to 8weeks 78% >8 weeks & upto 12 wks 13 % >12 weeks & upto 16 weeks 5.5% >16 weeks & upto 20 weeks 4.55%

fibroids Larger the uterus greater the need of experience more skill patience desire & determination for VH Assessment of size , depth & location of fibroid , mobility & availability of uterus free space should be confirmed by USG & Examination under anesthesia

Previous scar on uterus scar of cs/ myomectomy/hysterotomy Bowel surgery/ bladder surgery - sharp dissection - tissue identification - traction on cervix - recognition and repair of injury

Ot setup Good instrumentation Long & Broad bladded Sims speculum , side wall retractors. Helping hand of another expert surgeon stand by laparotomy Strong decision making on the part of surgeon

Position of patient

Ndvh videos

VARIUOS KINDS OF TROUBLES NO DESCENT OBLITERATED FORNICES DIFFICULT BLADDER DISSECTION BLEEDING FROM BLADDER PILLARS AND VESICAL PLEXUS OBLITERATED CUL DE SAC AND ADHESIONS IN POSTERIOR FORNIX INABILITY TO OPEN POSTERIOR PERITONEUM BLEEDING FROM POSTERIOR VAGINAL WALL AND VAGINAL ANGLES INSECURE PEDICLES

INJURY TO BLADDER INJURY TO RECTUM BLEEDING FROM UTERINE VESSELS INABILITY TO BRING DOWN UTERUS OMENTAL ADHESIONS ON UTERUS OBLITERATED UTEROVESICAL POUCH OF PERITONEUM UTERUS ADHERENT TO ANTERIOR ABDOMINAL WALL LARGE UTERUS /FIBROIDS UTERUS DIFFICULT TO DELIVER VAGINALLY BLEEDING FROM OVARIAN PEDICLES

SECONDARY HEMORRHAGE HEMATOMA BETWEEN VAULT AND BLADDER THERMAL INJURY TO BLADDER BY VESSELS SEALERS FISTULA VAULT GRANULATION VAULT INFECTION

Vaginal hysterectomy in woman with non-descent and moderately enlarged uterus is safe. morcellation coring Bisection amputation of cervix oblique cut on uterus are often needed and the surgeon needs to be familiar with them. With experience, operative time, blood loss and complications can be reduced considerably. This scarless approach should be chosen as a preferred method of hysterectomy.

It is better to avoid trouble rather then inviting trouble. Training and Development of skill are essential

A well trained and an experienced surgeon can help in trouble

THANK YOU