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.

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Before I go further, there are few things I would like to point out. First it might be worthwhile to review what “diagnosis” means. The dictionary meaning of diagnosis is

“to determine the identity of (a disease, illness, etc.) by a medical examination”.

Notice presence of the word ‘identity‘ in this definition and absence of the word ‘cure‘ in the same definition. Notice that at the start of above paragraph – I said suffering from ‘something‘. Diagnosis is all about giving a ‘name‘ to this ‘something‘. Diagnosis is not about subscribing a cure. As subtle as this may sound – in my professional experience I do come across many who confuse between a ‘diagnosis‘ and a ‘cure‘.

Second, cures or a treatment are always associated with disease/s or an illnesses. This means that for us to prescribe a treatment we doctors should have a reasonably good deduction or at a minimum a hypothesis of the name of the disease. And many a times attributing one possible name from millions of diseases out there can be quite a task and a possible reason for delays in patients getting the proper treatment. So next time when you are sitting in front of your doctor trying to describe your sufferings with the hope of getting a remedial treatment at the end of the conversation – keep in mind that your doctor in his/her mind may simply be trying to solve a puzzle of connecting the symptoms to a potential disease name. If we are able to connect it to the name, you would get the treatment (or the plan for the treatment) immediately. But if we are not, you would have to wait. Our focus then is to ease the patient by immediately addressing to their immediate symptoms and in parallel run some pathological tests – the aim of that again is to help us get to the ‘name‘. There are various ways in which we go about on this ‘name-finding’ mission (also called as the process of diagnosis). I will cover some of that in one of my future blog.

Ability to quickly diagnose depends on lots of things – how well you describe your symptoms/ailments; how well we doctors listen to that; how well we can sense the missing clues; our past experience levels in dealing with similar symptoms/ailments; or simply in how well we build our hypothesis based on what we hear from our patients. And both from the patient perspective and even from the doctor’s perspective – the need is to correctly and quickly complete this diagnosis process and move on to the treatment phase. The relief to the patient comes from the treatment phase and needless to say we also typically earn our bread-and-butter majorly from this phase only.

So to conclude – you might have heard this saying many a times- “what is in the name?“. Well, for many things in life it may not mean much – but when it comes to treating diseases, as I described above, for we doctors it means a lot! As patients you may or may not care of the name – but you should certainly care if your doctor knows about your disease name or not.

In this technique we infiltrate about 150 to 250 ml of saline, with or without adrenaline or vasopressin, the drugs which cause vasoconstriction. (I personally add 2-3 drops of adrenaline with a 20 gauge needle in 200 ml of saline, lest there is an absolute contraindication like severe hypertension or previous myocardial infarction). This saline is infiltrated under pressure with a no. 16 or 18 gauge needle, all around the cervix, just under the vaginal mucosa (skin of the vagina). Only about half a centimeter of the needle should go under the mucosa.

This technique works by two principles. First it serves as a tourniquet, so that all oozing small blood vessels are compressed and automatically the blood loss is prevented. Secondly it is easy to get the planes of dissection and that simplifies the surgery.

There are no complications or side effects of this technique. One of the fears which have been put forth in front of me is whether this will cause tissue necrosis?

I feel this is an unfounded fear and I have never encountered any tissue necrosis.

So to conclude hydro-dissection technique makes the art of vaginal hysterectomy simple, fast, and bloodless.

In my own experience there is hardly a blood loss of 5ml to a maximum of 10 ml. during the course of entire surgery.

When Manish was in process of writing his blog post, I recollect him asking me about my view points. It was a brief conversation, we agreed on few points and disagreed on some others, but could not conclude. After few days he forwarded me the link of his blog post after he had already published it. After reading his post, I felt that it was the quintessential Manish I have known for years. Manish has always had a bottoms-up and inclusive approach towards looking at any problem statement. While I respect this ability of his, however my dear brother should also know by now that there are always two sides of any given thing in the whole world. This is what I think Manish missed to bring out in his argument on this topic.

Let me make it clear – I am not here trying to advocate use of paternalism in doctors-patients relationship as many may implicitly assume that doctors like me would traditionally prefer to do that to our benefit.  In fact my argument against Manish’s hypothesis of Paternalistic Model being prevalent in India is that it is fast becoming inconsequent based on my experience of practicing medicine in India for more than decade and half now. And I am saying this even in a private setup as mine. Even if we were to assume that ‘we‘ doctors are keen in practicing this model, medical consumers a.k.a. patients themselves are changing in their ways and are in some ways providing us an implicit framework to provide them the services. Personal preferences, growing awareness, peer experiences, costs, and the easily available option of walking over to another provider are driving patients in India to force their view point on what kind of services they expect from us service providers. I do not think majority of my patients are coming to me because they are seeing a ‘parent‘ in me.

Medical practice has evolved tremendously in the last 20-30 years itself. The science and technology in healthcare itself is evolving in quantum leaps as we speak. The numbers of options or procedures to manage an illness are increasing day-by-day. Just as an example – just look at the number of options available for hysterectomy which I discussed in my previous blog post. If I had been practicing about 20 years back, the only surgery option available was Abdominal. Considering the limited choices available – I would have directly prescribed my patient to go under the knife. Many may consider this as the paternalistic approach – however I don’t think I would have had any additional options to share with my patient. However, today it is a different scenario. More the options mean that I have to get my patient into a discussion wherein we jointly concur on the path-forward to be selected. As medical practitioners we have learnt that patient values are important for what is best for them. I personally also think that some of the examples given to explain paternalistic approach are very out-dated too.

Having said the above, I will also confess that part of me also believes that paternalism justifiably has a place in Healthcare even today especially in the scenarios where the patients (or their family members) are most vulnerable and may not be in the situation to make appropriate decisions for themselves. This vulnerability may be because of perceived fear of their sickness (plenty of studies have shown that patients are unable to take the proper decision for themselves especially when they are scared), prevailing social environment or simply having the inability to understand the options or implications. A paternalistic decision made by doctors in such scenarios is necessary and justifiable. I call this as Judicious Paternalism. It is also important to note that as doctors we are taught and trained in solving problems in an exploratory way. However, most of the patients in my experience are unfamiliar to decision-analysis process.

Regardless of my arguments above – many of the points which Manish mentions in his blog about reducing illiteracy; inability of one doctor to get a complete grasp of a complex machinery like human body; or the increasing incidences where doctor’s morality is getting challenged – are all very valid and well put. His coercion to medical consumers for taking responsibility in their own personal healthcare decisions because physicians cannot or do not know their complete wants, needs, interests or fears may be valid too. However, I will possibly attribute them to many a times in our weaknesses in not able to properly communicate with our patients. Trust us – and I can say this on behalf of many of my peers too – that we are continuously making efforts to improve on this aspect. Though all these points are very valid – however – do keep in mind that for a patient their safe bet at the end of the day would be their doctor’s judgement only!

I know that Manish is all for consumerism in Healthcare. And as a doctor I don’t mind it too if patients want that. However my contention is that consumerism should augment joint partnership in doctor-patient relationship rather than trying to pit one against the other.

In any regards, I am keen in hearing your view point too besides what I or Manish think. While I may not have agreed completely with Manish’s view, I enjoyed this opportunity to get into this debate with him. This certainly seems to be more enjoyable than some of the nasty fights we both have been involved in our teenage years. Hope Manish recollects those!