Though time should not be the factor while doing any surgery,morbidity and blood loss does go up with the prolonged operating time.Same holds true for vaginal hysterectomy.I remember when I did my first few hysterectomies during the residency,I took almost 2- 2.30 hrs ,with a few requiring blood transfusions.Well surgical technique have since then come up by quite a good measure,.Again I would list some dos and dont do’s to speed up your time for vaginal hysterectomy.
1) Would again recommend using hydrodissection technique,as I have mentioned in the previous blogs
2) Adjust the height of the table according to the comfort of the assistant ,so that he/she does not have to bend too much.
3) Needless to stress the importance of proper light and good quality basic instruments
4) Do not make a clutter of too many retractors,mere anterior and a big size posterior vaginal retractor is enough,one can just adjust their position as per the need of a particular step.
5) I do not cut the lateral vaginal wall but retain its attachment with the uterosacral ligaments,s o that the the ligament retains its natural attachment to the vault and saves the time and effort to close it after the surgery.
6) Do not waste time in going after the Anterior pouch,just push or dissect the bladder up and secure it under the anterior wall Landens retractor,The Anterior pouch will open up on its own as one goes up,after securing the uterine arteries.
7)If the size of uterus is big or descent poor,use any debulking technique,or a vaginal myoma screw.
8) No need to close the peritoneum after the uterus is removed.
9) Use a good delayed absorbable suture,with proper surgical knots.
Using some of these modifications one can cut short the time to a great extent so much so that an average hysterectomy can get over in 30 to 45 mins.
Archive for June, 2011
How to reduce the surgical time for vaginal hysterectomy
June 11, 2011Unruptured 14 weeks live ectopic pregnancy
June 11, 2011This is a case of a 29 year old 2nd gravida with 14.2 weeks amenn. who was referred for bleeding per vaginum after a failed attempt of a second trimester termination in the peripheral hospital (Ultrasonography off course was not done.
Patient was hemodynamically stable,with mild pallor and a Hb of 9.5 grm percent. Per abdominal examination showed 14 weeks size non tender mass ,more towards the right of midline with audible fetal heart sounds on Doppler.Per vaginal examination findings were almost the same ,with a the fetus lying more towards the right side.
Patient was subjected for sonography (4-D) and the finding was something shocking,a live ectopic pregnancy of 14.2 weeks on the right side with good fetal movements and no gross anomalies.
After the basic workup was subjected to laparoscopy which showed right sided unruptured ampullary pregnancy witha minimal amount of blood in the Pouch of Douglas. With a linear incision on the antemesenteric border of the tube,the fetus was removed along with the placenta. Since there were quite a few bleebing points,right salpingectomy was done. The fetus was removed through the 10 mm port.Surfery was terminated after a through lavage.Patient recovered quickly,without any transfusions and was discharged after 18 hrs of surgery
