uterine volume an aid to determine the route and technique
TRANSCRIPT
I
“UTERINE VOLUME : AN AID TO DETERMINE THE ROUTE AND TECHNIQUE OF HYSTERECTOMY ”
BY Dr. SMITHA SURENDRAN
M.B.B.S.,
Dissertation submitted to the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.
In Partial fulfillment Of the requirement for the degree of
MASTER OF SURGERY
IN
OBSTETRICS AND GYNAECOLOGY
Under the guidance of
Dr. D.B. DHARMA REDDY M.D.,D.G.O., Professor
DEPARTMENT OF OBSTETRICS & GYNAECOLOGY J.J.M. MEDICAL COLLEGE
DAVANGERE – 577 004. 2011
II
Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore
DECLARATION BY THE CANDIDATE
I declare that this dissertation entitled “UTERINE VOLUME: AN AID TO
DETERMINE THE ROUTE AND TECHNIQUE OF HYSTERECTOMY” has
been prepared by me under the direct guidance and supervision of
DR. D.B DHARMA REDDY M.D., Professor of Obstetrics and Gynecology, J.J.M
Medical College, Davanagere. This dissertation has not been submitted by previously
by me for the award of any diploma or degree, to any other university.
PLACE: DAVANAGERE (Dr. SMITHA SURENDRAN)
DATE:
III
CERTIFICATE BY THE GUIDE
This is to certify that dissertation entitled “UTERINE VOLUME: AN AID
TO DETERMINE THE ROUTE AND TECHNIQUE OF HYSTERECTOMY”,
is a bonafide research work done by DR. SMITHA SURENDRAN in partial
fulfillment of the requirement for the degree of Master of Surgery in Obstetrics and
Gynaecology.
PLACE: Davangere
DATE:
Dr. D.B. DHARMA REDDY, M.B.B.S, M.D
Professor, Department of Obstetrics and Gynecology, J.J.M. Medical College Davangere – 577004
IV
ENDORSEMENT BY THE HOD, PRINCIPAL / HEAD OF THE
INSTITUTION
This is to certify that dissertation entitled “UTERINE VOLUME: AN AID
TO DETERMINE THE ROUTE AND TECHNIQUE OF HYSTERECTOMY”,
is a bonafide research work done by DR. SMITHA SURENDRAN under the
guidance of DR. D.B DHARMA REDDY M.D., Professor of Obstetrics and
Gynecology, J.J.M Medical College, Davanagere.
Dr. DAKSHAYINI B.R., M.B.B.S, M.D
Professor and Head Department of O.B.G. J.J.M. Medical College Davangere – 577004 Date :
Place : Davangere
Dr. H.R. CHANDRASHEKHAR M.D
Principal, J.J.M. Medical College Davangere – 577004 Date :
Place : Davangere
V
COPYRIGHT
Declaration by the Candidate
I hereby declare that the Rajiv Gandhi University of Health Sciences,
Karnataka, shall have the rights to preserve, use and disseminate this dissertation /
thesis in print or electronic format for academic / research purpose.
Date: (Dr. SMITHA SURENDRAN)
Place: Davangere
VI
ACKNOWLEDGEMENT
It gave me great pleasure in preparing this dissertation and I take this
opportunity to thank everyone who have made this possible.
I take this opportunity to convey my heart felt gratitude and sincere thanks to
my guide Dr. D.B. DHARMA REDDY, M.D.,D.G.O., Professor of Obstetrics and
Gynecology, Department of OBG, J.J.M Medical College, Davanagere, who with his
exhaustive knowledge and professional expertise has provided able guidance and
constant encouragement through out the course of my study and in the preparation of
this dissertation.
I am greatful to Dr. Rajshekhar M.D., Professor and Director of P.G. Studies,
for his constant support and suggestion throughout my Post Graduate Studies.
It gives me immense pleasure to thank Dr. B.R. Dakshayini M.D., Professor
and H.O.D, of O.B.G for her valuable guidance during this study.
I express sincere thanks to my professors Dr. T.G. Shasishidhara, M.D.,
Dr. V.S Raju, M.D., Dr. K.C. Nataraj,M.D., Dr. Manjunath,M.D.,
Dr. H.N. Mallikarjunappa, M.D., Dr. H.M. Shivamurthy, M.D., and Dr. Shukla
Shetty, M.D., Dr. Prabhakhar M.D., Department of O.B.G for their valuable help and
encouragement.
I am also grateful to my professors Dr. Ravi Gowda, M.D., Dr. Shoba
Dhananjaya, M.D., Dr. A.C. Ramesh, M.D., Dr. Sarvamangala, M.D., Dr. Agasimani,
M.D., Dr. Vanitha, M.D., Dr Sapna I.S., M.D., and Dr. Anitha, M.D.,
I am also thankful to my readers Dr. Sowbhagya Koujalagi M.D.,
Dr. Shashirekha, M.D., Dr. Bandamma, M.D., Dr. Veena G.R., M.D., Dr. Smitha A.J.,
M.D., Dr. Lakshmi Devi, M.D., Dr. Anuradha M.D., Dr Girija, M.D., and Dr. Nivedita,
D.G.O.,
VII
I am also thankful to Asst. Professors Dr. Ashwini M.S., Dr. Halesh M.S.,
Dr. Madhu K.N. M.S., Dr. Saroja M.S., Dr. Abhinetri M.S., Dr. Latha M.S., and
Dr. Charitha M.S.,
I am extremely grateful to Dr. H.R. Chandrashekhar , M.D., Principal J.J.M
Medical College and Dr. H. Gurupadappa, M.D., Director of P.G Studies and
research, J.J.M Medical College Davanagere for their valuable help and cooperation.
I am indebted to my Husband, Parents , Parent in-laws and My brother
and My daughter Sraddha for their constant encouragement for fulfilling my dream
of becoming an Obstetrician and Gynecologist.
My sincere thanks to all post graduate colleagues, friends and special thanks
to Dr. Vani and Dr. Megha for their whole hearted support.
My sincere thanks to Superintendents of, Chigateri General Hospital,
Bapuji Hospital and Women and Children hospital.
I thank all my patients, who formed the back bone of this study without
whom, this study would not have been possible.
I also thank to Mr. Mahesh, Librarian , JJMMC, Davangere
My special thanks to, Mr. Thomas of Thomas Computers for their
Meticulous typing and styling of this script .
I am grateful to the ALMIGHTY for showering his blessings on me.
Place: Davangere
Date: (DR. SMITHA SURENDRAN)
VIII
ABBREVIATIONS
A.H. - Abdominal hysterectomy
LAVH - Laparoscopic Assisted Vaginal Hysterectomy
NDVH - Non Descent Vaginal Hysterectomy
TAH - Total Abdominal Hysterectomy
TLH - Total Laparoscopic Hysterectomy
VH - Vaginal Hysterectomy
IX
ABSTRACT
OBJECTIVE: to assess the value of uterine volume estimated sonographically, in
decision making for route and technique of hysterectomy.
METHODS: uterine volume was measured ultrasonographically in 50 cases posted
for hysterectomy. Intraoperative difficulties, accessibility and ease of surgery were
noted. Also, uterine weight postoperatively was compared with the volume.
RESULTS: Vaginal hysterectomy was done without difficulty up to 300cm³. With
uterine volume >300cm³, debulking was required. With uterine volume>500cm³, i.e.,
approximately>16 weeks pregnant uterus size the surgeons preferred abdominal rather
than vaginal route.
Uterine volume correlated well with the uterine weight measured post operatively.
CONCLUSION: considering the uterine volume rather than the level of fundal
height for assessing the feasibility of vaginal hysterectomy has proved useful.
KEY WORDS: hysterectomy, uterine volume.
X
CONTENTS
1. Introduction ---------------------------------------------------------------------- 01
2. Aim of the Study----------------------------------------------------------------- 02
3. Review of Literature ------------------------------------------------------------ 03
4. Materials and Methods --------------------------------------------------------- 45
5. Observation and Results ------------------------------------------------------- 47
6. Discussion ----------------------------------------------------------------------- 51
7. Summary ------------------------------------------------------------------------- 53
8. Conclusion ----------------------------------------------------------------------- 54
9. Bibliography --------------------------------------------------------------------- 55
10. Annexure ------------------------------------------------------------------------
a. Proforma ---------------------------------------------------------------- 58
b. Master Chart ----------------------------------------------------------- 62
XI
LIST OF TABLES
Sl.
No Tables
Page
No
1 Non gravid uterine size and uterine volume estimated sonographically 16
2 Uterine Volume compared with weight Uterine Weight (g) 16
3 Uterine Volume in cm3 and VH 16
4 Peroperative Score Under Anesthesia 23
5 Indications for Hysterectomy 47
6 Comparison of Uterine Size and Uterine Volume 48
7 Comparison of Uterine Volume and Uterine Weight 48
8 Route of Hysterectomy for all the cases 49
XII
LIST OF GRAPH
Sl. No Graph Page
No
1 Age Distribution 47
XIII
LIST OF FIGURES
Sl. No Figures Page
No
1 Radiographic Calculation of Uterine Volume 17
2 Incision on the Posterior vaginal wall 29
3 Incision on the Anterior vaginal wall 29
4 Mobilization of the bladder 30
5 UV Fold of Peritoneum 30
6 Uterosacral Clamp 32
7 Uterine Clamp 32
8 Adnexal Clamp 33
9 Bisection of Uterus 33
1
INTRODUCTION
Hysterectomy is the most common non pregnancy related surgical procedure
performed on women in India. The main indication for vaginal hysterectomy remains
the treatment of uterovaginal prolapse where as the other common indications of
surgery like enlarged uterus, menstrual abnormalities are treated by the abdominal
route, unless associated with a significant degree of prolapse. This may be attributed
to personal preference, but mainly to lack of training as experience leading to
reluctance to perform the procedure by vaginal route, in cases of enlarged uterus,
absence of uterine descent, previous pelvic surgeries.
The feasibility of vaginal hysterectomy is judged primarily on the findings at
bimanual pelvic examinations, especially under anesthesia. Though bimanual pelvic
examination gives three dimensional idea of the size of the uterus, in actuality for
decision making, only one dimension, uterine length (which denotes the uterine size
in weeks), is utilized by almost all gynecologists.
The present study is to show that pre-operative sonographic estimation of
uterine volume helps in decision making for the choice of route of hysterectomy as
well as for anticipating problems during hysterectomy.
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AIMS AND OBJECTIVES
� To prove that uterine volume rather than fundal height is useful in assessing
the route and technique of hysterectomy and in anticipating ease or difficulties
during surgery.
� To prove that vaginal hysterectomy could be successfully done for uterine size
of up to 500 cm3 by various techniques of debulking.
3
REVIEW OF LITERATURE
HISTORICAL ASPECT
The operation of hysterectomy is one of the most common in surgical practice.
But the removal of the uterus differs from the removal of the other organs in that it
can be performed either by an open incision in the abdomen or, by via naturals, the
access provided by the vaginal approach.
Vaginal hysterectomy has been performed many centuries before abdominal
hysterectomy was attempted.
The origins of vaginal hysterectomy are lost in the mists of time. The first was
reportedly performed in AD 120 by Soranus in the city of Ephesus which was then
situated in Greece but is now on the Turkish coast just North of Bodrum. According
to the medical historian Leonardo, the procedure performed by Soranus was the
removal of an inverted uterus that had become gangrenous and had turned black in
colour.
The uterus, and often the bladder were invariably part of these early surgical
excisions, and patients often died.
Schenck of Grabenberg reported 26 cases during the early part of the 17th
century and operation was also perfomed in by Andreas de Crusce in 1560 and
Vallmeor of Nuremberg in 1675.
In 1670 a case of Faitt Howard, a 46 year old peasant women who performed
the operation on herself was well documented and reported by Percival Willonghby.
An early midwife and life long friend of William Harvey who famously discovered
4
the secret of blood circulation. Apparently while she was carrying a heavy load of
coal, one day Faith’s uterus prolapsed completely and frustrated by this frequent
occurrence, she grabbed the offending organ, and pulled as hard as possible and cut
the whole lot with a short knife and faith lived for many years after this with “water
passing from her insensible day and night obviously from a vesicovaginal fistula.”
THE FIRST ELECTIVE VAGINAL HYSTERECTOMY
Baudelocque from France introduced the technique of artificially prolapsing
and then in favorable cases cutting away the uterus and the appendages. He performed
23 such procedures during the last 16 years following 1800 but gave Lauvariol the
credit for having performed the first operation in France. Most of these procedures
were performed on the puerperal uteri and were undertaken on an emergency basis.
The first planned vaginal hysterectomy was performed by Osiander of
Gattingen in 1801. He didn’t report the case until he had operated his 9th patient.
In 1810 Wriskberg in a prize essay read before the Vienna royal academy of
medicine advocated vaginal hysterectomy for cancer and two years later Paletta
performed the operation.
Conrad Langenbeck from Gattingen had read Wrisberg’s paper and also report
of Paletta and this encouraged him to perform first deliberately planned Vaginal
Hysterectomy for Carcinoma in 1813. He however didn’t report the operation until
1817. Because of the abuse that he was subjected to be probably regretted even doing
it.
5
FURTHER DEVELOPMENTS IN TECHNIQUE AT THE END OF THE 19TH
CENTURY:
In 1829 Recamier pointed out the necessity of isolating and controlling the
uterine vessels. Surgeons from France were successful in designing clamp methods
for securing the ligaments and vascular pedicles and they devised remarkable
morcellation and hemi section techniques and even proposed vaginal approach for
pelvic inflammatory disease.
The first vaginal myomectomy was done by Anussat in France in 1940. In
1843 Esselman of Nashville successfully removed an inverted myomatous uterus
vaginally.
Lawson Trait in 1882 reported 30 cases with 33% mortality rates for vaginal
hysterectomy done for fibroids provided the size of the fibroid allowed it.
In 1880 Schroeder a German presented his technique of opening the cul-de-sac
and pulling the fundus through posteriorly and then cutting the bladder flap, the broad
ligament were ligated with a single ligature or in separate portions from above
downwards. The peritoneum was closed, stumps of ligament sutured into the vagina
everting them around the T shaped drainage tube which was removed between the
stumps.
In 1894 Richelot reported on an operative manual of vaginal Hysterectomy
with vertical and oblique morcellation of the anterior wall of the uterus.
In 1893 Schuchardt of Germany performed the first extensive vaginal
hysterectomy for cervical cancer. The abdominal operation was refined by Wertheim
and vaginal operation by Schauta both of Vienna.
6
Morcellation originated as a mean for the removal of large, pedunculated,
submucous myomas in the pre-anesthetic, pre-antiseptic era. The concept was
pioneered by in the 1830’s by Dupuytren and Velpeau, but it was Amussat, of France
(on 11 June 1840) who is credited with performing the first vaginal excision of an
enlarged submucous myoma by morcellation and enucleation ; the specimen weighed
440gms. The deliberate removal of the entire uterus by morcellation promptly
followed the development of reliable methods of vaginal hysterectomy by the
Viennese surgeons Czerny, Billroth, Muller and others, beginning in 1879. Muller
published the first description of vaginal hysterectomy by midline hemi section in
1882. Vaginal hysterectomy by wedge morcellation was introduced soon thereafter by
Pean, Segond and Richelot of Paris and by Jacobs of Brussels, between 1883 and
1890.
Significant contribution to morcellation techniques was made by Pryor of New
York and Doyen of Paris in 1890’s. Pryor popularized vaginal hysterectomy by hemi
section as an effective approach to the treatment of advanced pelvic inflammatory
disease, achieving a remarkable 0.4% mortality rate in 228 consecutive cases. Doyen,
whose career extended from 1885 through the First World War, described a very
efficient method of morcellation enlarged, solid myomas with coring tubes.
Intramyometrial coring was introduced by Lash, of Chicago, in 1941. In his
representation to the Chicago Gynecological society, Lash advocated the method as
means of reducing uterine size without entering the uterine cavity in cases of
pyometra, and with cancers of the isthmus and corpus. Although his rational was
questioned, the technique was well received for the treatment of benign uterine
enlargement.
7
HYSTERECTOMY
Hysterectomy is the most common surgery performed by a gynecologist.
There are many indications for hysterectomy and the uterus can be removed using any
variety of techniques and approaches including abdominal, vaginal or laparoscopic.
The gynecologic surgeons should not only be technically adept at these various
procedures, but also should use history, physical examinations and discussions with
the patient to match the surgical procedure in order to obtain the most satisfactory
outcome. Rate of hysterectomy varies between 6.1~8.6 per 1000 women of all ages.
Women between the ages of 20 and 49 years constitute the largest segment of the
women undergoing the procedure.
INDICATIONS
Uterine leiomyomas are consistently the leading indications for hysterectomy.
Acute Conditions
� Pregnancy catastrophe
� Severe infection
� Operative complications
Benign Diseases
� Leiomyomas
� Endometriosis
� Adenomyosis
� Chronic infection
� Adnexal mass
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Cancer or pre-malignant disease
� Invasive cancer
� Pre-invasive disease
� Adjacent or distant cancer
Discomfort
� Chronic pelvic pain
� Pelvic relaxation
� Stress urinary incontinence
� Abnormal uterine bleeding
Extenuating circumstances
� Sterilization
� Cancer prophylaxis
TYPES OF HYSTERECTOMY
� ABDOMINAL
� VAGINAL
� LAPAROSCOPIC
Types of ABDOMINAL HYSTERECTOMY
• Total hysterectomy – removal of the whole of uterus including the cervix
• Subtotal hysterectomy – in this the vaginal part of the cervix and a variable
part of the supravaginal cervix is not removed. Advantages of this type are that
it is technically easier and involves less risk to the ureters, bladder and rectum.
It reduces the risk of subsequent prolapse by preserving the integrity of the
supporting ligaments. As it does not disturb the anatomy and the length of the
vagina coitus is not affected.
9
Disadvantage is that the cervix remains a potential site for cancer. Also, the
remaining portion of the cervix causes symptoms like, chronic discharge, and
dyspareunia. Menstrual or ovulation bleeding can also occur, especially if the isthmus
is not removed.
� Panhysterectomy – here the uterus is removed along with the tubes and
ovaries. The term is best discarded in favor of the descriptive term total
abdominal hysterectomy with bilateral salpingo oophorectomy.
� Radical hysterectomy – Rutledge has defined five classes of hysterectomy,
depending on the extent of excision
Class I – Extrafascial hysterectomy with bilateral salpingo oophorectomy
Class II – Modified radical hysterectomy which is the original Wertheims
hysterectomy. In this the medial half of the cardinal and uterosacral ligaments are also
removed as well as the pelvic lymph nodes which are enlarged.
Class III – Radical hysterectomy, Includes complete pelvic lymph node dissection,
removal of whole of the cardinal and uterosacral ligaments and upper � of the vagina.
Class IV – Extended radical hysterectomy. Includes removal of the periureteral
tissue, superior vesical artery and up to ¾ of the vagina.
Class V – Partial exenteration. Here portions of the distal ureter and bladder is also
dissected.
� Pelosi Minilap Hysterectomy- here hysterectomy is done through an
abdominal incision of 2.5- 5 cm depending upon the size of the uterus.
10
LAPAROSCOPIC HYSTERECTOMY
The use of the laparoscope with hysterectomy was first reported in 1989 by
Reich et al, who suggested using the laparoscope as a mode of access for
hysterectomy. Three months later, Kovac reported a procedure that combined the use
of the use of laparoscope with vaginal hysterectomy and the term laparoscopic
assisted vaginal hysterectomy was suggested.
Initially the terms laparoscopic and laparoscopic assisted vaginal hysterectomy
was used interchangeably to describe any method of hysterectomy in which
laparoscope was used. Various studies were conducted to define the role of
laparoscopy in hysterectomy and its advantages over abdominal and vaginal routes.
In 1993, Kovac and Reich attempted to define the use of the laparoscope with
hysterectomy. The following definitions were proposed:
DIAGNOSTIC LAPAROSCOPY FOLLOWED BY VAGINAL
HYSTERECTOMY- the use of intraoperative laparoscopy to determine the patient’s
feasibility for a vaginal hysterectomy. This procedure is performed only when there
are concerns about the presence of extrauterine pathology that might limit the
performance of a vaginal hysterectomy.
LAPAROSCOPIC ASSISTED VAGINAL HYSTERECTOMY- the laparoscopic
assessment has discovered and documented certain conditions that require surgical
management such as dissection of adhesions, excision of endometriosis and if
necessary, removal of the ovaries followed by completion of the procedure via the
transvaginal route.
11
LAPAROSCOPIC HYSTERECTOMY- the use of LAVH plus ureteral
identification and laparoscopic ligation of the uterine arteries by electro surgery,
sutures or staples. The uterosacral and the cardinal ligaments are ligated vaginally.
TOTAL LAPAROSCOPIC HYSTERECTOMY- the uterus and the adnexal
structures are removed through the laparoscopic access. In this procedure, the junction
of the vagina and the cervix is separated and the vaginal cuff is closed and suspended
laparoscopically.
Laparoscopic hysterectomy is an efficient modality for the vaginal surgeon in
the presence of adnexal disease, but does not replace the less expensive, quicker, and
probably safer vaginal hysterectomy. Laparoscopic surgery is now termed ‘minimally
invasive surgery ‘. But when it comes to hysterectomy, the vaginal route has been
proven to be the most minimally invasive type of hysterectomy.
VAGINAL HYSTERECTOMY
Vaginal hysterectomy is the procedure of choice whether there is uterine
prolapse or not. As a rule, uterus without surrounding pathology descends when
traction is given under anesthesia. Uterine descent becomes progressively easier as the
uterosacral and mackenrodt’s ligaments are cut. An enlarged uterus also can be
removed by various techniques of debulking. So, when a hysterectomy is to be
undertaken, it should be the endeavor of every gynecologist to consider the vaginal
route first unless there is any contraindication to the same.
12
UTERINE VOLUME
High resolution Transvaginal sonography has been widely available since mid
1980’s and has gained acceptance as an integral part of Gynecologic and early
obstetric sonographic examinations. Transabdominal sonography is performed
through the full urinary bladder and provides a wider field of view than the
Transvaginal approach. This provides better visualization of superficial structures
remote from the Vagina than the Transvaginal approach. The Transvaginal approach
bypasses attenuating tissue and allows a high frequency probe to be placed close to
the target organs. It demonstrates anatomic details of uterus, ovary and adnexa which
cannot be duplicated by TAS. Using TAS, visualization of the pelvic organs is limited
by body habitus owing to sonic attenuation of the intervening anterior abdominal
wall, subcutaneous and properitoneal fat.
Ultrasound utilizes high frequency sound waves and the resultant echoes
generated by these waves to evaluate fluids within a tissue medium. Essentially, the
sound waves (1-5 MHz) are transmitted through the tissue via the probe / transducer.
The sound waves travel through the tissue until reflected back to the probe. The
intensity and time of wave transmission / reflection are assessed, and a 2-D image is
displayed on the monitor. These calculations are preformed on millions of wave
pulses and subsequent reflections (echoes) per moment in time.
Generally TAS with full bladder is done first. For TAS we use a curvilinear
probe of medium (5MHz) to low (3.5 MHz) frequency. Transverse, axial and sagittal
scanning planes are performed through the short and long access of the uterus.
Transvaginal probe insonate at higher frequencies of 7~9 MHz, with improved spatial
resolution over the lower frequency TAS probes. TV probes is covered with a
13
protective sheath usually a condom and adequate coupling gel is applied. Here sagittal
and semi coronal planes are imaged.
Uterine volume is a vital piece of pre operative information. The normal
uterine volume varies between 30~80 cm3. It is important to assess the uterine volume
as often the fundal height may be the same in two fibroids, but uterus may be bigger
in transverse or antero-posterior diameter. The volume may be calculated by
multiplying length by breadth by antero-posterior diameter by 0.542. Various studies
also formulated a close positive correlation between estimated uterine volume and
actual uterine weight. Equation was:
Uterine weight (gms) = 50.0+0.71 x volume (cm3)
With utilization of this equation uterine size in vivo can thus be expressed as a
concrete objective value instead of weeks size by comparison with pregnant uterus.
Uterus
Size based on age:
Prepubertal
Length 2 – 4.4 cm
NOTE: uterine growth begins at 7-8 yrs. and continues to ~20yrs
Adults of Reproductive Age
Nulliparous: Length 6 – 8.5 cm
Width 3 – 5 cm
AP 2 – 4 cm
14
Multiparous: Length 8 – 10.5 cm
Width 4 – 6 cm
AP 3 – 5 cm
Postmenopausal: Length 3.5 – 7.5 cm
(>5 years) Width 2 – 4 cm
AP 1.7 – 3.3 cm
ADVANTAGES
1. Confidence and clues on how to access a fibroid site for enucleation or
morcellation.
2. Knowledge about the uterine volume will guide the surgeon as to whether
uterine delivery is possible from anterior or posterior operative space or
whether the uterus needs debulking before an attempt at delivery.
3. Provide information on endometrial thickness which is a must in all women
with menorrhagia to exclude suspected endometrial malignancy.
4. Detect pathology such as ovarian cyst or renal tract pathology.
15
Table – 1 : Non gravid uterine size and uterine volume estimated sonographically
Size Volume (cm3) Normal 30-80
Up to 8 weeks 81-200 9-12 weeks 201-300
13-16 weeks 301-450 17-20 weeks 451-600 21-24 weeks 601-750
Table -2 : Uterine Volume compared with weight Uterine volume (cc)
(excluding cervix 10 15cc) Uterine Weight (g)
<50 30-65 51-100 48-124
101-300 96-352 301-400 270-458 401-500 270-458
>501 360-576
Table -3 : Uterine Volume in cm3 and VH
Uterine Volume (cm3) Possibility of VH
� 100 Easy, average gynecologist should be able to do it
101-200 Interested gynecologist should be able to do it easily
� 201 - 400 Best performed by a gynecologist with expertise
� 300 - 350 Needs debulking
� 401- 500 Be scheduled as tentative or trial VH; needs debulking Consider / availability of LAVH and / or abdominal
hysterectomy
16
Fig. 1 - Radiological measurements for Calculation of uterine volume
In the above view, the length, height, and width of the uterus are captured for
volume measurements
MRI
Is a superior modality for-
1. Evaluation of adnexal mass
2. To confirm adenomyosis
3. Doubtful ultrasonography regarding location of fibroid
MYOMA MAPPING
Precise localization, measurement and characterization are essential for the
appropriate clinical management of fibroids. The optimal selection of patients for
medical therapy, noninvasive procedures, or surgery depends on these. Imaging
17
techniques available for confirming the diagnosis of myomas include sonography,
saline-infusion sonography, hysteroscopy,and MRI.
Transvaginal sonography is the most readily available and least costly
technique and may be helpful for differentiating myomas from other pelvic
conditions. Large myomas may be best imaged with a combination of transabdominal
and transvaginal sonography. Sonographic appearance of myomas can be variable, but
frequently they appear as symmetrical, well-defined, hypoechoic, and heterogenous
masses. However, areas of calcification or hemorrhage may appear hyperechoic, and
cystic degeneration may appear anechoic.
Sonography may be inadequate for determining the precise number and
position of myomas, although transvaginal sonography is reasonably reliable for uteri
<375 mL in total volume or containing four myomas or fewer. Saline-infusion
sonography uses saline inserted into the uterine cavity to provide contrast and better
define submucous myomas, polyps, endometrial hyperplasia, or carcinoma. Magnetic
resonance imaging is an excellent method to evaluate the size, position, and number
of uterine myomas and is the best modality for exact evaluation of submucous myoma
penetration into the myometrium .The advantages of MRI include no dependence on
operator techniques and the low interobserver variability in interpretation of images
for submucous myomas, intramural myomas, and adenomyosis when compared with
transvaginal sonography, saline-infusion sonograms, and hysteroscopy.
Fibroids may be accessible or inaccessible
18
Accessible fibroids -
1. Cervical
2. low on the uterine body
3. on the posterior wall
4. closer to the internal os
5. closer to accessible endometrium on the serosal wall
6. 5-7 cm in size with uterine size not more than 12-14 weeks, or
7. not more than 7-9 cm In size with uterine size not more than 14-16 wks
Inaccessible fibroids -
1. High anteriorly placed or fundal fibroid with uterus greater than 12-14 wks
2. When distantly placed in the uterus
3. Large broad ligament fibroid
4. If the angle between the lateral cervical surface and the ascending uterine wall
is reduced from 140˚ to 90˚ the difficulty in vaginal hysterectomy increases.
CHOICE OF APPROACH
About 75% of the hysterectomies are abdominal. With the introduction of
laparoscopically assisted hysterectomy, there has been a resurgence of interest in
vaginal hysterectomy. Transvaginal surgery is a special province of gynecologic
surgeon and vaginal hysterectomy is a showcase operation.
The diagnosis may make the choice of approach obvious in some patient,
where as in others the decision to proceed with hysterectomy or not depends on the
19
promise of low morbidity and a rapid return to functionality offered by a vaginal
hysterectomy (VH).
By definition, if the uterine vessels are ligated transvaginally, the procedure is
described as laparoscopic assisted vaginal hysterectomy (LAVH). If the uterine
vessels are ligated, coagulated or stapled through the laparoscope the operation is
laparoscopic hysterectomy. The marketing appeal appears to be removing the uterus
through three or four small key hole abdominal incisions. This method does not
appear to offer any advantage over vaginal hysterectomy.
There have been several large reviews of the results and complications of
abdominal, vaginal and LH techniques. VH is least invasive, least expensive route
with least morbidity and with most rapid post operative recovery. Operating time was
shortest for VH and longest for LAVH. The length of hospital stay was similar for
both VH and LAVH. Intra and post operative complications were more common with
abdominal hysterectomy (AH). In VH early ambulation was possible. They can be
allowed on regular diet earlier than AH.
As advantages of vaginal hysterectomy become more evident, various
guidelines were put forward to assign the patients prospectively to vaginal, abdominal
or LAVH. This was based on uterine size, presumptive risk factors and the clinical
immobility or inaccessibility of the uterus or adnexal structures.
The ACOG established some guidelines for the route of hysterectomy by
stating that the choice depends on the patient’s anatomy and the surgeon’s experience.
20
PRE-OPERATIVE ASSESSMENT
Examination under Anesthesia
The final assessment on which the surgeon should base his decision about the
route of hysterectomy depends on the careful examination under anesthesia just
before beginning the operation. The decision for the route of hysterectomy may be
reverted after this assessment.
STEP 1: Size and mobility of the uterus
In addition to the size the uterus has to be evaluated in all dimensions. An
antero-posterior or lateral enlargement reduces space around the uterus making VH
more difficult. Mobility of the uterus is assessed both antero-posteriorly as well as
laterally. This provided an accurate assessment of parauterine space. Slightly
restricted mobility is no longer a contra indication for an experienced surgeon.
STEP II: Descent of the Cervix
If the cervix is visualized on introduction of the Sims speculum, it indicated
descent. The descent of cervix is also assessed by volsellum test. Volsellum is
applied on the anterior lip and cervix is pulled downwards. Physiological descent of
the uterus is up to first degree. If there is less than first degree descent, one should
proceed with VH cautiously (Possibility of adhesions should be kept in mind)
STEP III: Mobility of vaginal mucosa
Applying a volsellum on the anterior cervical lip and then on the posterior
cervical lip and moving the uterus up and down gives a fair idea of the mobility of the
vaginal mucosa.
21
STEP IV: Depth of fornix
The length of the fornix is assessed by measuring the distance between the
cervix at the level of external os and the lateral fornix. If the fornix is shallow with
short cervix placed distally VH becomes difficult.
STEP V: Assessment of fibroids
The decision on what size of the uterus should be attempted vaginally is
dependent on the experience of the surgeon. Accessibility of the fibroid and its
position is also important. Fibroids distally placed broad ligament fibroid or those
fundal and anterior diffusely enlarging the uterus are inaccessible and difficult to
debulk. Consideration is also given to laxity or rigidity of tissues and availability of
space, which is essential in these cases where debulking, may be required.
STEP VI: Vaginal and Pelvic Accessibility
The breadth of the vagina should be assessed and should be at least two finger
breadths especially at the fornix. The pelvis is assessed by subpubic angle and the
inter-tuberous diameter. The subpubic angle should be at least 80 degrees and the
inter-tuberous diameter should be at least four knuckles tight (9 cm).
PER OPERATIVE SCORE
Per operative clinical score taking into consideration all factors responsible for
the success of surgery was evolved. The score varied from a minimum of zero to a
maximum of twenty.
22
Table – 4 : Peroperative Score Under Anesthesia Score 0 1 2
Size of uterus < 8 Wk 8~10 Wks > 10 wks Mobility of uterus Good Fair Poor Intertuberous distance > 4 knuckles 4 knuckles < 4 knuckles Subpubic angle > 90 degree 90 degree < 90 degree Digital exam of vagina 3 finger loose 3 finger tight 2 finger tight Mobility of vaginal mucosa Good Fair Poor Fornix depth > 1 finger crease 1 finger crease < 1 finger crease Descent with volsellum > 1 degree 1 degree < 1 degree Surgeon's experience > 10 yrs 5~10 Yrs < 5 yrs History of previous surgery NIL 1 > 1
ABSOLUTE CONTRA INDICATIONS OF VAGINAL HYSTERECTOMY
� Uterine volume > 500 cm3 (depends on surgeons experience)
� Previous vesicovaginal or rectovaginal fistula repair
� Cervix flushed with vault
� Adnexal pathology
� Very limited vaginal space
� Severely restricted uterine mobility
� Poor per operative score
ASSESSMENT OF FITNESS FOR SURGERY
Physical:
There should be a general and systemic examination to reveal fitness for
surgery.
Investigations:
Opinions of physicians and anesthetist about fitness for surgery, precautions if
any to be taken and the preferential mode of anesthesia are essential. Also cardiologist
23
opinion for women, in geriatric age group, have an abnormal ECG, past history of
cardiac disorders, have hypertension or diabetes.
� Complete blood count
� Blood group and RH typing
� Blood sugar
� Serum creatinine and blood urea
� HBSAg and HIV
� BT, CT, PT and platelet count
� Urine routine examination
� Chest radiograph
� ECG
� Ultrasonongraphy
ASSESSMENT FOR ANESTHESIA
Neuraxial block (Subarachnoid, Epidural or combined spinal epidural) is the
primary regional anesthetic technique of choice. Epidural anesthesia often relieves the
extra load on the circulation, provides safety and remains ideal choice in high risk
cases. They provide optimum intra operative and post operative pain relief.
Advantages of using regional anesthesia
� Decreased blood loss
� Decreased transfusion requirements
� Improved intra operative and post operative pain control
� Decreased length of hospital stay
� Decreased incidence of post operative emesis
� Decreased incidence of post operative deep vein thrombosis
24
ABDOMINAL HYSTERECTOMY
Operative Techniques
Positioning: Patient is placed in the supine position in the operating table.
Abdomen from xiphoid to the mid thighs is painted and draped. Abdomen is
opened by Pfannenstiel incision (preferred cosmetically) or Maylard or cherney’s
incision. The pelvis and the abdominal organs are palpated and examined for any
pathology. A slight Trendelenberg position is achieved and bowels packed.
The uterus is elevated out of the pelvis and straight Kochers applied to each
side of the cornu to include the origins of the tubes and round ligament approximately
1 cm from the uterine wall. When the uterus is elevated the round ligament becomes
taut which is then clamped, cut and ligated. The round ligament tie is left long. The
retroperitoneal space is now opened and the course of ureter is identified. If the
ovaries are to be preserved, another clamp is applied to the tube and the ovarian
ligament, clamped, cut, transfixed and ligated. If the ovaries are to be removed the
infundibulopelvic ligament is identified and elevated and the clamp is placed on the
lateral side of the ovary, clamped, cut and ligated. Procedure is repeated on the
opposite side.
Next step is to dissect the bladder from the anterior cervix. For this UV fold of
peritoneum is identified and opened with Mayo’s scissors. The peritoneal incision is
extended laterally to reach up to the round ligament pedicle taking care not to injure
the ureter. Now bladder is mobilised down either by blunt or sharp dissection. This
dissection is continued up to the lower limit of the cervix. The lower limit of the
25
cervix is readily identified by the indentation as the cervix ends and the anterior fornix
begins.
Next the uterine vessel (ascending branch) is clamped at right angles to the
uterine long axis. The pedicle is divided, cut and ligated. Now the parametrial tissue is
divided by applying clamps parallel to the cervix, squeezing the paracervical tissue
off the side of the cervix, clamped, cut and transfixed. The cervico vaginal junction is
identified and ensured that bladder is reflected well beyond this. Large Zepplin
clamps are used to clamp the vagina below the cervix. These clamps include the base
of the cardinal ligaments laterally, the uterosacral ligament posteriorly, and the
vaginal wall anteriorly and posteriorly. The clamps are applied from each side with
the tips meeting at the middle. The vagina is now divided with knife or scissors and
the uterus is delivered out. A single figure-of-eight suture is placed between the tips
of the two clamps to close the mid portion of the vagina. A Heaney suture ligature is
placed on each side of the lateral clamps with the second bite going through the
uterosacral ligament posteriorly. Inclusion of the uterosacral and the cardinal ligament
provides excellent support for the vaginal apex.
The pedicles are inspected carefully for any bleeding and ensured that
complete hemostasis is achieved. Mops and instrument count ensured and abdomen
closed in layers.
CERVICAL MYOMA
Initial steps are similar to plain abdominal hysterectomy. After the anterior
flap of peritoneum is separated, bladder is mobilised down. An incision is put over the
capsule of the fibroid and with finger the exact plane of cleavage between the tumour
and the capsule is defined. Enucleation of the tumour is carried out by traction with
26
volsellum and digital separation of the tumour from its capsule. Hysterectomy is then
proceeded with.
In case of posterior cervical myoma, we have to bisect the uterus posteriorly to
get access to the fibroid. Then the plane of cleavage is created and the tumour is
enucleated out.
BROAD LIGAMENT FIBROID
These are divisible into two classes. The first variety is the true broad ligament
myoma that springs from the muscle fibres normally found in the myometrium. These
may be found in the round ligament, ovario uterine ligament or in the connective
tissue surrounding the ovarian and uterine vessels. These tumours when small are
easy to enucleate. But sometimes they may attain enormous size pushing upwards
stretching the fallopian tube and often burrows between the layers of the pelvic
mesocolon on the left side, the bowel itself lying on the tumour. Here the plane of
easy cleavage can be identified between the muscularis of the intestine and the surface
of the tumour. The ureter and the vessels supplying the intestine can be in danger and
great care is necessary not to damage them.
The false broad ligament myomas are those where the tumour arises from the
lateral uterine wall or the cervix and bulges between the layers of the broad ligament.
These tumours can be enucleated if possible, but when large or associated with other
fibroids in the uterus hysterectomy may be done.
The true ligament myomas can be differentiated by the fact that they are
entirely separate from the uterus, which they displace but do not deform. The uterine
artery lies beneath and the inner side of the tumour while the ureter is displaced
27
inwards and posteriorly. These can be removed by enucleation or sometimes
hysterectomy may be needed in case of adherent or highly vascular tumours.
NON DESCENT VAGINAL HYSTERECTOMY
Operative Technique
Positioning: The lithotomy position with both hips and knees hyper flexed and a
15~30 degrees head down tilt is a good position for non descent vaginal
hysterectomy. It not only provided good access to the vagina, but also moves the
bowel away from the pouch of Douglas. The buttocks should be should be slightly
over the edge of the table to facilitate posterior retraction without hindrance to
instruments.
The labial sutures applied and bladder is evacuated with a metal catheter to
ensure it is empty. The cervix is held with volsellum and transverse incision is made
on the anterior vaginal wall. The incision is deepened through the entire length with
simultaneous traction on the cervix. The subepithelial tissues can be seen retracting
upwards. The incision is further deepened to cut the pubo-vesico-cervical ligament,
till the rough surface of the cervix is seen. While incising the pubo -vesico-cervical
ligament the bladder is seen withdrawing upwards. 20ml of 1 in 200,000 adrenalin (1
ampoule of adrenalin in 200ml of saline) can be infiltrated in the line of incision to
reduce the bleeding and keep the operative field clear.
The next step would entail pushing the bladder up using steady traction with
sponge on a holder until the shiny peritoneum of the utero-vesical (UV) fold is
visualized and picked up with an artery forceps. The UV fold of peritoneum is incised
and is extended on either side with fingers and retractor introduced.
28
29
30
The next step consists of picking the loose fold of the posterior vaginal wall at the
cervico-vagina junction with allis tissue forceps and giving a bold incision to open the
vagina and pouch of Douglas and retractor introduced. The uterosacral-Mackenrodt’s
complex is then lifted with the index finger, clamped, cut, transfixed and ligated. The
procedure is repeated contra laterally. Ligatures are held long for suspending the vault
later.
The next step would be to secure the uterine vessels with the anterior and
posterior folds of peritoneum, cutting and ligating without transfixing. There is no
advantage to double clamping and or double ligation of the vessels if they are
properly tied.
The final step entails clamping the broad ligament and fundal structures into
two clamps – One above and one below.
The penultimate step would be to identify the anterior and posterior folds of
peritoneum simply by holding the vaginal walls with allis tissue forceps and finding
the peritoneal folds behind the vaginal edges. The peritoneum is transversely sutured
in a continuous fashion. The sutures which were left long after ligating uterosacral-
Mackenrodts complex are used for the closure of the vaginal vault. The anterior and
the posterior edges of the vagina are closed with continuous interlocking sutures using
vicryl 1 by fixing the stumps of the adnexa to the vaginal vault.
31
32
33
The vagina is packed lightly using a ribbon gauze pack soaked in betadine. A
Foley’s catheter is placed and both packed and catheter is removed the morning after
surgery.
Volume Reductive Vaginal Hysterectomy
Recent interest in minimally invasive hysterectomy for enlarged uterine has
rekindled a need for effective Transvaginal techniques of uterine removal. These have
two components: Detachment of all lateral attachments of uterus and reduction of
uterine volume.
Currently employed strategies of volume reductive surgeries include uterine
bivalving / bisection, myomectomy, wedge morcellation and intra myometrial coring.
These techniques are safe and facilitate the vaginal removal of the moderately
enlarged and well supported uterine without increasing perioperative morbidity. They
reduce the operative time hemorrhage and lower post operative complications.
Bisection
The simplest form of debulking is bisection. After Mackenrodt’s ligament and
uterine vessels of both sides have been clamped, cut and ligated, the cervix is grasped
on both sides and the uterus is bisected sagittally towards the fundus using a scalp.
Bisection is carried out always under direct vision and always through the
uterine cavity to maintain anatomical orientation; lateral deviation at the level of the
fundus will result in increased bleeding. The apex of the incision is pulled into view
with clamps applied bilaterally to its edges and the process is continued.
34
Complete bisection allows half the uterus to be delivered through the vagina
and the ovarian pedicle to be secured. Myomas in the line of incision may be bisected
together with uterus or enucleated and removed separately if they present a barrier to
uterine descent.
Myomectomy / Enucleation
Myomectomy is frequently combined with bisection when myoma is seen
bulging after bisection. Smaller myomas are removed in one piece while larger ones
may be morcellated and removed in fragments. The most accessible and the largest
fibroid is selected, the lower portion of the proximal large fibroid is grasped and
separated from the uterine walls circumferentially by finger dissection.
Morcellation
Morcellation is carried out on the uterus when despite bisection or
Myomectomy, no further descent is possible. Morcellation can be done in form of
wedge resection (Pryor technique) or slicing method.
Pryor technique is well suited to a broad sub pubic arch. After division the
uterine arteries, bladder is retracted and the anterior uterine wall divided in the
midline as high as possible. Beginning at the cervix, wedge shaped pieces of uterine
wall are cut bilaterally from the edges of the midline incision as the everted edges of
the incisions are serially grasped and pulled further down while the bladder is
retracted to expose more of the uterine tissue. What appears of the uterine tissue is
again split in the midline and from each side a wedge of tissue is symmetrically
removed. Large myomas are enucleated when they are encountered either digitally or
with clamp traction and scissors dissection from surrounding myometrium as in
35
conventional Myomectomy. When the cornu comes into view it is sometimes helpful
to excise a large midline wedge from the fundus the base of which is top of the uterus.
On its removal, the adnexa will come still further into view. At this point, the adnexal
attachments are divided and the remaining posterior uterine wall may be removed
intact or hemi-sected.
Slicing Method
Goel et al improvised slicing method to deal with problems of Adenomyosis.
After bisecting the uterus the inner surface is exposed and the myometrial tissue is
sliced off the uterus layer by layer. Care is taken not to pierce the serosa so as to avoid
the inadvertent injury to intraperitoneal structures. Once the bulk is removed,
hysterectomy is completed.
Intramyometrial Coring (Lash Procedure)
Coring is best suited to the removal of smoothly enlarged globular uterus, but
is applicable to most uteri of moderate size. As for hemi-section it may be
complimented by interspersed myomectomies. As this maneuver is continued the
enlarged uterine fundus delivers as an elongated sausage shaped mass caused by
inversion of the serosa and fundus in a process likened to peeling a banana. For
maximum effect the incision should be maintained close to the serosa and parallel to
the uterine cavity avoiding creation of multiple planes. Coring demands less cervical
traction than other morcellation techniques and requires less room beneath the sub
pubic arch than the semi section.
Volume reductive vaginal hysterectomy is an indispensable technique for
large uterus and should be practiced more frequently. Vaginal hysterectomy for large
36
uterine aided with reduction technique has clear surgical advantages for its economy
and better patient satisfaction.
Clampless Procedure
The clampless procedure for NDVH is a novel approach for the vaginal route
of removal of the uterus. It is particularly useful because one is working in the narrow
confines of the vagina and using clamps would mean occupying more space. It is
particularly useful in women with large uterus and in nulliparae. Here the surgeons
identifies and ligates each stumps instead of clamping and ligating. Then applies
traction on the ligature and cuts close to the uterus.
Ligasure Vessel Sealing System in NDVH (Biclamp)
Is a new hemostatic system based on the combination of pressure and bipolar
electrical energy and is able to seal vessels up to 7 mm in diameter.
The ligasure consists of:
a. A bipolar radio-frequency generator- This delivers a low voltage, high power
current using a continuous feedback and computerized algorithm that recognizes
vessel sealing by alteration in tissue impedance.
b. Hemostatic clamp – this resembles a Heaney forceps and is available in different
lengths. All forceps have an integrated electric system: the two branches of the
forceps function like the two electrodes of a bipolar forceps. The jaws of the
forceps have a broad, smooth, steel coating which prevents tissue from sticking
to the forceps and thereby reduces the risk of carbonization.
37
Mechanism of action:
1. Mechanical; flattening and compression of the two sides of the vessel and
displacement of blood.
2. Thermal: it delivers a controlled high power current at low voltage to melt the
collagen and elastin in the tissue leading to permanent fusion of the vascular
layers and obliteration of the lumen by forming a seal zone.
Advantages:
1. More efficacious in achieving hemostasis in spaces with limited access for
surgical suturing and thus subject to slippage and dislodgement.
2. Operator independent
3. Shorter operating time
4. Decrease in hospital stay
5. Avoidance of secondary bleeding
6. Reduced post operative pain: due to absence of tissue necrosis and foreign
bodies (sutures) reduces the resorption process and phagocytosis thereby
reducing pain.
7. Training curve is minimal : relatively easy to learn
Complications:
1. skin/ mucosal burns
2. Thermal necrosis of the ureter
3. Thermal wounds in the digestive tract
4. Hemorrhage
38
These vessel sealing system have made VH simpler, quicker and more cost
effective. For patients they represent substantial progress with respect to the pain
experienced and shorter hospital stay.
Medical Debulking
Myomas are very responsive to estrogenic stimulus. GnRH agonists are used
for the suppression of the endogenous production of this hormone and thereby achieve
reduction in the size of the fibroid. GnRH is administered intramuscularly as
leuprolide acetate 3.75mg once a month for two doses or subcutaneously at 0.5mg/day
for 8 weeks. The size of the uterus reduces in about 4 weeks, with the greatest effect
seen at 12 weeks of therapy. The uterine volume is debulked by 30- 40%. With
GnRH, the gynecologist achieves an endocrinological oophorectomy. This also helps
in correcting anemia pre operatively.
Complications
a) Failed vaginal hysterectomy or conversion to Laparotomy-
Reasons of failure of VH are many, like, difficulty in opening the anterior and
the posterior pouches due to adhesions or myomas, restricted mobility of the uterus,
error in the judgment of the uterus, inaccessible fibroids and also the inexperience of
the surgeon.
b) Hemorrhage – the most common complications of hysterectomy is bleeding
which occurs in 4.7% of patients regardless of the route of hysterectomy.
39
c) Bladder injury
d) Rectal injury
e) Ureteric injury
f) Anesthetic complications
g) Infections – UTI, vaginal cuff abscess
40
REVIEW OF LITERATURE
Uterine volume an aid to determine the route and technique of hysterectomy
Shirlina D, Shirish S (2004) conducted a study to assess the value of uterine
volume, estimated ultrasonographically to decide the route and technique of
hysterectomy. 98 women scheduled for hysterectomy of benign conditions with
uterine volume �700cm³ were included in the study. A correlation was estimated
between the uterine volume and the post operative weight of the uterus. With
increasing uterine volume undue vaginal wall retraction and traction on the cervix
were required. When the volume was between 101 – 200 cm 3 vaginal hysterectomy
was easy. For volume more than 300cm3, debulking was required. He concluded that
with experience, expertise and favourable pelvic factors vaginal hysterectomy can be
done up to uterine volume up to 500cm3. Preoperative sonographic assessment of
uterine volume will prove of immense help in determining the route of hysterectomy
and anticipating the ease or difficulties during the surgery. It also provides added
advantages as it excludes adnexal pathology, confirms uterine size estimated
clinically and gives details on fibroids thus reassuring the surgeon.
Preoperative sonographic estimation of uterine volume: an aid to determine the
route of hysterectomy.
Seth SS, Shan NM (2002) conducted a study on 380 women with benign
mobile uteri up to 18- 20 wks pregnant uterus size. Preoperative sonographic
estimation was done in all the cases. No difficulties were encountered in the surgery
where the uterine volume was below 200cm3. For volumes above 400cm3, debulking
was always required. Vaginal hysterectomy failed in four cases with volumes of 500-
41
700cm3. For volumes greater than 400cm3, vaginal hysterectomy should be
considered on a trial basis. They concluded preoperative sonographic estimation can
give a better three dimensional idea of the size of the uterus.
Vaginal hysterectomy for the large uterus
Magos A, Bournas N, SinhaR conducted a study to assess the feasibility of
performing vaginal hysterectomy on enlarged uteri equivalent to 14-20 weeks size
(1996). Fourteen consecutive women with symptomatic fibroid uteri between 14- 20
wks of gestation in size on clinical examination were recruited to undergo vaginal
hysterectomy and monitored prospectively. The uterus was clinically mobile in all
cases and none had significant uterovaginal prolapse. All the cases were completed
successfully vaginally. Bisection morcellation were the most frequently used
techniques for reducing the size of the uterus. The average time was 30- 150 min.
There were no major complications. They concluded that vaginal hysterectomy was is
a safe and effective option for the removal of enlarged uteri up to at least 18- 20 wks
size.
Vaginal hysterectomy for women with a moderately enlarged uterus weighing
200- 700gm
Unger JB (1999) studied 30 consecutive women with uterine enlargement to a
weight between 200-700gm who underwent vaginal hysterectomy or laparoscopic
assisted vaginal hysterectomy. These patients with uterine enlargement were
compared to 160 women with uterus weighing < 200gm who also underwent VH or
LAVH. The two groups were compared for complications, operating time, hospital
stay, perioperative hemoglobin concentration change and use of vaginal debulking
and LAVH. In the enlarged uterus group operating time was significantly more and
42
80% needed morcellation. But hemoglobin change, hospital stay and major surgical
complications were the same. He concluded that although VH requires a modest
increase in operating time, it is safe and effective for the women with a moderately
enlarged uterus as for women with a uterus of normal size
Intramyometrial coring ad an adjunct to VH
S Robert Kovac(1986) reviewed retrospectively 902 hysterectomies, 727
performed vaginally and 175 abdominally. The technique of intramyometrial coring
was used in 76% of the VH group. Surgical indication, length of the surgery, length
of hospital stay and complications were analyzed. The evidence presented suggests
that intramyometrial coring may be used for the vaginal removal of many uteri for
which abdominal route has been traditionally the route of choice.
Size and weight determinants of non gravid enlarged uteri
FlickingerL, D Ablaing (1986) Uterine size was estimated in 66 women before
hysterectomy by bimanual examination, uterine sounding and pelvic ultrasound. The
results were compared with weight and dimensions recorded after removal. Uterine
volume was calculated assuming the shape of uterus to be an ellipse. The relationship
of uterine volume and weight was calculated using linear regression analysis. They
found greater error in estimation of uterine size by bimanual examination and uterine
sounding than the ultrasound. A close relation existed between the uterine size and the
uterine weight.
43
The relationship between ultrasonic volume and actual weight of pathologic
uterus
Kung FT, ChangSY(1996) assessed the correlation between the estimated
volume based on ultrasonic measurement in vivo and the actual weight of the diseased
uterus after hysterectomy, and then retrospectively tried to establish a simple equation
to convert the volume into weight in grams. The uterine volume was calculated by the
ellipsoid formula by ultrasonographic measurements. Actual weight immediately after
extirpation of the uterus was done. They found a close, positive correlation between
the estimated uterine volume and the actual weight.
Vaginal hysterectomy for enlarged uteri, with or without laparoscopic
assistance: randomized study
Darai E, Soriano D compared short term results of vaginal hysterectomy with
those of laparoscopically assisted vaginal hysterectomy in women with enlarged uteri.
Eighty women with benign disease of the uterus of weight >280gms were assigned
randomly to VH or LAVH. They found no difference in patient’s mean age, parity,
previous pelvic surgery, preoperative hemoglobin levels and mean uterine weight.
They concluded that VH can be successful even in women with enlarged uteri and
other conditions considered by some to contraindicate the operation.
Laparoscopically assisted vaginal hysterectomy offered no advantages over the
standard vaginal hysterectomy.
44
MATERIALS AND METHODS
Cases for the present study were taken from the Women and Children hospital,
Bapuji Hospital and Chigateri General Hospital, Davanagere from the period of Oct
2008 to July 2010. Total number of cases under my study was 50. These patients
admitted to Gynec wards of the above hospitals, were scheduled for elective inpatient
hysterectomy for various indications.
Data was collected i.e. patient’s age, indications for hysterectomy, detailed
clinical history which included patient’s complaints, duration, menstrual and obstetric
history, any significant past, family and personal history.
Clinical Examination includes
• A detailed general physical examination was done for built and nourishment,
blood pressure, pulse rate, presence or absence of pallor, lymphadenopathy
and pedal edema.
• Cardiovascular system and respiratory system were examined.
• Per abdominal examination done for any previous surgical scars any palpable
mass or tenderness.
• Vulvo Vaginal examination, perspeculum examination, bimanual examination,
done to identify any of the pelvic pathology.
Pre-operative investigations included hemoglobin percentage, urine for
albumin, sugar, microscopy, HIV, HBSAg, blood group and Rh typing, FBS/RBS,
blood urea, serum creatinine, ECG, pre-operative ultra sonography for large uterine
fibroid.
45
After making primary diagnosis, the choice of route of hysterectomy is
decided. The choice of the route depends on the following factors:
a. Surgeons experience
b. Assessment of the uterine size by bimanual examination
c. Assessment of the mobility and the descent of the uterus
d. Utrasonographic assessment of the uterine size and the volume
e. Myoma Mapping
Ease and difficulties encountered during surgery and time taken for the
surgery were noted. Post operative uteri was weighed and compared with the uterine
volume estimated pre operatively.
The study has
Inclusion criteria:
A. Women scheduled for hysterectomy with uterine volume <700cm³
B. Indications were benign disorders like DUB, fibroids, adenomyosis.
Exclusion criteria:
A. Uterine volume >700cm³ or uterine size 18 – 20 weeks size
B. Factors like restricted uterine mobility, presence of adnexal pathology.
46
OBSERVATIONS AND RESULTS
Total number of cases under study was 50. 39 cases under went vaginal
hysterectomy and 11 cases under went abdominal hysterectomy.
Graph – 1 : Age Distribution
Graph. 1 shows age distribution among both vaginal hysterectomy and total
abdominal hysterectomy groups. Maximum distribution is between 40~49yrs groups.
Indications No of cases
Fibroid 41
Adenomyosis 2
DUB 6
Endometrial Polyp 1
Age Distribution
0
5
10
1520
25
30
35
40
Age Group
No.
Of C
ases
Series1 1 13 34 2
< 30 30~39 40~49 >50
Table 5 – Indications for Hysterectomy
47
As per shown in Table 1, 82%, 4%, 12%, 2% had primary diagnosis of fibroid,
Adenomyosis, DUB and Endometrial Polyp respectively.
Table 6 : Comparison of Uterine Size and Uterine Volume
Uterine Size (In weeks) Uterine Volume
6-8 100-242
10-12 134-556
14-16 150-525
18 500-600
Table 2 shows comparison of uterine size in weeks with uterine volume. The
volume increased proportionally with increasing uterine size. However, variation by
50 to 150cm3 occurred commonly in proportion to uterine size.
Table 7 : Comparison of Uterine Volume and Uterine Weight
Uterine volume (ml) Uterine Weight (gm)
100-200 90-200
200-300 100-250
300-400 250-350
400-500 300-400
> 500 400-600
As shown in the above table 3, there is a positive correlation between uterine
volume and uterine weight measured post operatively.
48
Table 8 : Route of Hysterectomy for all the cases
Uterine Volume 100-200 201-300 301-400 401-500 >500
Number of cases 18 9 9 6 8
Route of Hysterectomy Vaginal Abdominal
17 1
9 -
8 1
4 2
1 7
Debulking 2 3 7 4 1
Uterus free pelvic space Plenty Adequate Decreased Inadequate Inadequate
Range of time required for surgery 30-45 30-45 30-50 30-60 45-60
As shown in Table 4, uterine descent, access excision and delivery of the
uterus encountered difficulty as uterine volume increased. The ease and difficulties
were as per expectations. When the volume was between 100 -200cm³, vaginal
hysterectomy was performed easily. In one case abdominal hysterectomy was
performed as per surgeon’s preference. For volume between 200-300 cm³, VH was
feasible, but required debulking in 3 cases. With uterine volume 300-400 cm³, one
case underwent AH as there was a left sided ovarian cyst. Of all the 8 cases, 7 cases
required debulking. For volume 400-500 cm³, trial of VH was considered for 6 cases
of which 2 underwent AH as they had posterior wall fibroid impacted in the pelvis
causing urinary retention. Of cases with uterine volume >500 cm³, one case
underwent VH. The volume was 515 cm³.
Debulking was done by bisection, morcellation and Myomectomy.
Morcellation was done in 11 cases of which 3 cases had uterine volume 200-300 cm³
49
and 9 cases had volume >300 cm³. Bisection was done for 14 cases of which 2 had
volume >200 cm³ and 12 had volume >300 cm³. Myomectomy was done in 3 cases
were the volume was >300 cm³.
The greater the volume, the longer it took to complete the hysterectomy. The
average time required increased by 10-15 minutes as the volume increased to more
than 400 cm³.
50
DISCUSSION
Of the 50 cases studied 39 underwent vaginal hysterectomy and 11 underwent
abdominal hysterectomy. The indications were benign disorders like fibroids,
adenomyosis and DUB.
The uterine volume of cases in the present study and the study conducted by
Shirish Seth is compared below
Uterine volume S Shirish study Present study
101- 200 27 18
201- 300 21 9
301- 400 7 9
401- 500 4 6
>500 3 8
In a study conducted by S S Seth in 98 cases, when the uterine volume was
>500cm³ , out of the 3 cases one case failed to be completed vaginally due to
adhesions and Laparotomy was resorted to. In the present study, out of 8 cases of
uterine volume>500cm³, only one case was done vaginally. Others were done
abdominally as per surgeon’s preference.
Magos et al have concluded that the size of the uterus equivalent to 20 weeks
gestational size should no longer be considered a contraindication to VH. He recruited
14 cases of symptomatic fibroid uterus between 14-20 weeks of gestational size on
clinical examination to undergo VH. All 14 hysterectomies+ oophorectomy or
salpingo oophorectomy were completed successfully vaginally by various methods of
51
debulking like bisection, morcellation, coring. There was no major intra or immediate
post op complications.
In another study conducted by S S Seth, 380 women with enlarged uteri of
size up to 18-20 weeks size underwent preop sonographic estimation of the uterine
volume. They were scheduled for VH. Up to 400cm³ no difficulties were encountered
for VH. For volume >400cm³, debulking was required in all cases as well as greater
skill of the surgeon. VH failed in 4 cases with the uterine volume 500- 700 cm³.
In the present study, it was observed that vaginal hysterectomy was done
without difficulty up to 300cm³ and with debulking up to 400cm³. With uterine
volume>500cm³, i.e., approximately>16 weeks pregnant uterus size the surgeons
preferred abdominal rather than vaginal route. So, it was concluded that up to 300cm³
of uterine volume, vaginal route of hysterectomy should be the preferred route and if
volume>400cm³, vaginal hysterectomy should be considered as a trial and proceeded
with. With uterine volume >300 cm³, expertise and pelvic factor play a major role in
determining the route.
52
SUMMARY
� This study was done to prove that uterine volume measurement was superior
to the clinical estimate of the uterine size in assessing the feasibility of vaginal
hysterectomy in enlarged uteri.
� The total number of cases under the study was 50 of which 39 cases
underwent vaginal hysterectomy and 11 cases under went total abdominal
hysterectomy.
� Age distribution for hysterectomy was 40~49 years.
� Most common indication was fibroid uterus.
� Uterine volume was measured pre operatively by ultra sonography which
correlated well with post operative uterine weight
� By bimanual examination, uterus > 12-14 weeks size were considered difficult
to do vaginally. But with uterine volume estimation, up to 500cm³, i.e., 16-18
weeks size can be done by vaginal route.
� The feasibility of vaginal hysterectomy diminished with increasing uterine
volume
� Debulking was required for all cases where uterine volume was > 400 cm3.
� Thus uterine volume is of immense help in anticipating difficulties during
hysterectomy in enlarged uteri.
53
CONCLUSION
Pre operative assessment of uterine volume will prove of immense help in
deciding the route of hysterectomy and in anticipating ease or difficulties during
surgery in cases of larger uterus. It proves to be an asset in counseling the patient and
her family members pre-operatively. For a patient decided for hysterectomy vaginal
route is the preferred one unless it is contraindicated. Vaginal hysterectomy is the
least invasive route, with least morbidity, least expensive and with most rapid post
operative recovery.
54
BIBLIOGRAPHY
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57
ANNEXURE 1
PROFORMA
NAME: IP NO:
AGE: DOA:
SEX: DOS:
OCCUPATION: DOD:
ADDRESS:
PRESENTING COMPLAINT:
Menstrual irregularity:
Pain abdomen:
MENSTRUAL HISTORY:
AOM: PMC:
LMP:
OBSTETRIC HISTORY:
Married life: Gravida: Para: Living:
Abortion:
Tubectomised:
58
PAST HISTORY:
FAMILY HISTORY:
PERSONAL HISTORY:
GENERAL PHYSICAL EXAMINATION:
VITAL SIGNS:
PR: BP: TEMPERATURE:
SYSTEMIC EXAMINATION:
CNS:
CVS:
RS:
PER ABDOMEN EXAMINATION:
Inspection:
Palpation:
Percussion:
Auscultation:
VULVOVAGINAL EXAMINATION:
59
PERSPECULUM:
PER VAGINAL EXAMINATION:
Hb- Blood group-
HIV- HBSAg-
Blood urea- Serum creatinine-
RBS- ECG-
Urine routine-
USG TRANSABDOMINAL
------- TRANS VAGINAL
UTERINE VOLUME compared with UTERINE WEIGHT(post operative)
Uterine volume(cm3) <100 101-200 201-300 301-400 401-500 >500
No of cases
Route of hysterectomy
Need for laparotomy
Need for debulking
Need to bisect
Uterus free pelvic space
Average time required for surgery
NO: OF DAYS IN HOSPITAL:
60
HYSTRECTOMY ABDOMINAL
VAGINAL
INTRA OPERATIVE COMPLICATIONS:
POST OPERATIVE COMPLICATIONS:
IMPRESSIONS:
ANNEXTURE II
MASTER CHART