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With the increasing rate of cesarean sections, it is imperative that the the number of cases with the scar on the uterus are going to increase.Cases who have had a scar on the uterus secondary to some surgery on the uterus ,for example,myomectomy also contribute.
Adhesions are the commonest consequence of any surgery on the uterus .And when we contemplate hysterectomy in such cases,taking care of these adhesions is a task.
These adhesions are
1) Between the bladder and the uterus (Commonest) .Generally an area of 2-3 cms over the lower uterine segment ,or just over the superior surface of the cervix and the lower part of the body of the uterus,at the level of uterine artery pedicle ,is the site where the adhesion of the bladder is the densest.To dissect the bladder away,one has to go through the lateral utero-vesical window or Sheths space.After taking the semilunar incision on the cervix,one can enter this space by either a finger or an artery forcep from the either of the corner angles of the incision,anteriorly.One would find a space which is devoid of any adhesions. Using this as a guide,start the sharp dissection of the scar close to the surface of the uterus ,bit by bit.till  one opens the anterior pouch.

2) Parietal adhesions

These are the consequence of any surgery of the abdomen.Omentum and at times the bowel is  stuck to the parietal surface obscuring the approach to the uterus. Many a times the bladder is pulled up and adherent to the anterior abdominal wall,making it difficult to separate.

3) Adhesions between the rectum and the uterus post surgery are rare.

Now when we consider the route of hysterectomy in such cases,it is my firm opinion that vaginal route is the best route ,because

a) one does not have to encounter the parietal adhesions before actually reaching the uterus,as one has to by abdominal or the laparoscopic route. These parietal adhsions are well settled ones and there is no need to disturb them.

b) one just has to dissect about 2 to 2.5 inches of the surface of the uterus to push the bladder away. This is closest and easiest by the vaginal route.

I believe the use of laparoscope is limited to tackle any band of adhesion which is pulling the uterus up

In case the bladder is accidentally nicked ,it is important to identify it on table and suture it off in 2 layers with 3-0 delayed absorbable suture.

Post Workshop
The first National Live Operative Workshop on Vaginal Hysterectomies at Akola on 21st Nov. was a huge success.
Delegates from all over the country (Assam,West Bengal,Karnataka , Andhra Pradesh, Gujarat ,Maharashtra ,TamilNadu )
traversed the distance, to be there for the workshop. Faculties included the legendery,Dr. Shirish Sheth,Dr. Vyomesh Shah,Dr. Vanita Raut, Dr. Sunil Shah and Myself.
Practically vaginal hysterectomies for all the possible indications ie12 wks,16 wks size fibroids,prev.one LSCS with fibroid,previous 2LCS with an adnexal cyst ,prolapse with sacrospinous fixation ,conventional vaginal hysterectomy,vaginal hyst. by hydrodissection technique were covered with good to and fro interactions.Vaginal Hyst. using biclamp (bipolar current) was also demonstrated.We concluded by free interactions with the expert faculties. I hope at the end of the day everybody would have had the feeling that vaginal route for hysterectomy ,be it for any indication,is within ones reach

As is evident from the earlier blogs,I am an ardent promoter of vaginal hysterectomy, which I believe is the primary r0ute for any hysterectomy,barring a few conditions.Literature supports my belief.But unfortunately,this route now is being pushed to background amidst the glitter and glamor of laparoscopic surgery.Though laparoscopy has revolutionized an approach of many surgeries,certainly lap. hysterectomy is not one of them.
A traditional belief is that vaginal hysterectomy is technically difficult and not feasible in many indications.This is a wrong notion and more of a psychological block..Considering these aspects,We have arranged a live surgical workshop ,to be conducted by vaginal surgeons of national and international fame which would serve as good learning platform for one and all.

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There are various conditions in which a child can have mental handicap.It is indeed a challenge rearing such a child.When some of these girls reach puberty and start menstruating,matters go from bad to worse.Moreever one has to give a thought to the fact that such girls are at the risk of sexual assault and consequent pregnancy. So how can  we stop a girl from menstruating is question which is frequently asked by the parents.There are some medical methods like Hormone injections or implants ,but they are temporary methods,have some undesirable side effects  and some of them affect ovarian function.I am of the firm opinion that  such girls should be subjected to hysterectomy,without removing the ovaries,as it is a permanent method and puts an end to the miseries involved with menstruation is such girls. A lot of literature supports this modality of treatment.The route of hysterectomy in such cases should be vaginal as far as possible,as there is no scar and recovery is very quick and painless. The patient can go home within 24 hrs. It is very impotant to counsel the family members before we arrive at the final decision