1. Troubleshooting in NDVH
Dr. Narendra D. Gajjar MD,DGO.
ASHIRWAD HOSPITAL
CHIKHLI

2. 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 & midterm SOGOG 2015
Operative faculty in workshops - Non descent Vaginal Hysterectomy

3. 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

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

5. 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

6. 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

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

8. 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

9. 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

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

11. Size of uterus Size of uterus patients (%) Up to 8weeks 78%
>8 weeks & upto 12 wks %
>12 weeks & upto 16 weeks %
>16 weeks & upto 20 weeks %

12. 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

13. 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

14. 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

15. Position of patient

17. Ndvh videos

20. 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

21. 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

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

23. 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.

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

26. A well trained and an experienced surgeon can help in trouble

28. THANK YOU