Vaginal hysterectomy

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Presentation Transcript

Vaginal hysterectomy : 

Vaginal hysterectomy

DEFINATION : 

DEFINATION Vaginal hysterectomy consist of removing uterus by vaginal route & subsequently closing the space previously occupiedby uterus.

INDICATION : 

INDICATION U/V prolapse DUB Small fibroid Sterlization Premalignant conditions of cx (CIN)

CONTRAINDICATONS : 

CONTRAINDICATONS Uterine size > 12 wks. Endometriosis PID Narrow sub pubic arch Long n narrow vagina Where its essential to remove ovaries.

ADVANTAGES : 

ADVANTAGES No abdominal wound No signifcant distrubance of intestine Less pot operative discomfort Easier mobilization Earlier discharge from hosp:

Pre-op preparation : 

Pre-op preparation Pt: being brought into hosp:.shortly before surgery Appropriate pre-op assesment i/v line Shave pvt parts Antibiotics

Preoperative Evaluation : 

Preoperative Evaluation Evaluation of Pelvic Support Uterine mobility Evaluation of Pelvis Angle of pubic arch > 90 Vaginal canal : ample Post vaginal fornix : wide & deep

Surgical Considerations : 

Surgical Considerations Patient Positioning: dorsal lithotomy Avoid nerve injury  adequate padding Vaginal Preparation : povidone-iodine solution Suture Material : synthetic absorbable polyglactin or polyglycolic acid suture & atraumatic needle

Procedure : 

Procedure Grasping & Circumscribing Cervix Anterior & posterior lips of cervix grasped with tenaculum Infiltrate sub_epithelium tisue with Inj:Adernaline 1 in 4,00000 N/S(20ML) 2-3cm above 0S Circumferential Incision in vaginal epithelium at junction of Cx

Fig 22.15 Circumferential Incision in vaginal epithelium : 

Fig 22.15 Circumferential Incision in vaginal epithelium

Procedure : 

Procedure Dissection of Vaginal Mucosa Vaginal epithelium dissected from underlying tissue & pushed bluntly (verticaly from down) Circumscribing incision just below bladder reflection (d/t initial incision too close to external os  greater dissection bleeding) Continue dissection in correct cleavage plane. Dvision of cervico vaginal ligament with (angled) scissor. Deflect bladder

Fig 22.16 Dissection of Vaginal Mucosa : 

Fig 22.16 Dissection of Vaginal Mucosa

Procedure : 

Procedure Posterior Cul-de-Sac Entry Stretching vaginal mucosa & underlying connective tissue  Peritoneal reflection of PCDS identified Vaginal mucosa dissected in wrong plane hysterectomy begun extraperitoneally by clamping and cutting uterosacral & cardinal ligaments close to the Cx

Fig 22.17 Posterior Cul-de-Sac Entry : 

Fig 22.17 Posterior Cul-de-Sac Entry

Procedure : 

Procedure Elevate CX Vaginal epithelium of post: fx can drawn down Create tension on tissue behind CX Pouch of doulus cn be opened now

Fig. 22.19 Interrupted suture to approximate peritoneum & vaginal cuff for hemostasis : 

Fig. 22.19 Interrupted suture to approximate peritoneum & vaginal cuff for hemostasis

Procedure : 

Procedure Uterosacral Ligament Ligation Retraction of lateral vaginal wall & countertraction Cx, uterosacral ligaments clamped  Incorporating lower portion of cardinal ligaments

Fig. 22.19 Uterosacral Ligament Ligation : 

Fig. 22.19 Uterosacral Ligament Ligation

Procedure : 

Procedure Clamped perpendicular to uterine axis, pedicle cut close to clamp and sutured Small pedicle (0.5 cm) distal to clamp: optimal

Fig. 22.20 Uterosacral ligaments transfixed to posterolateral vaginal mucosa : 

Fig. 22.20 Uterosacral ligaments transfixed to posterolateral vaginal mucosa

Procedure : 

Procedure Entry into Vesicovaginal Space (Cul-de-Sac) Cx downward traction Using Mayo scissors,or open moistened 4 * 4 gauze sponge, bladder advanced Vesicovaginal peritoneal reflection easily identified at this point, vesicovaginal space entered.

Procedure : 

Procedure Cardinal Ligament Ligation Traction on Cx continued, cardinal ligaments, clamped & cut. Suture is ligated. Significant part of cardinal ligament already incooperated during clamping of utero-sactal ligament

Fig. 22.21 Cardinal Ligament Ligation : 

Fig. 22.21 Cardinal Ligament Ligation

Procedure : 

Procedure Uterine Artery Ligation Uterine vessels clamped along side of uterus, cut, & suture ligated to incorporate anterior & posterior leaves of the visceral peritoneum Single suture & single clamp technique Desending branch may already have bee included in previous clamp(if uterus is small)

Fig. 22.22 Uterine Artery Ligation : 

Fig. 22.22 Uterine Artery Ligation

Fig 22.23 Entry into Vesicovaginal Space : 

Fig 22.23 Entry into Vesicovaginal Space

Procedure : 

Procedure Delivery of the Uterus Tenaculum placed onto uterine fundus in successive fashion to deliver fundus posteriorly or anteriorly(Doderlein’s manoeuvre

Fig 22.24 Delivery of the Uterus : 

Fig 22.24 Delivery of the Uterus

Procedure : 

Procedure Uteroovarian & Round ligament Ligation Posterior and anterior peritoneum opened, remainder of broad ligament and uteroovarian ligaments clamped, cut, & ligated Transfixation or simple tie.

Fig. 22.25 Uteroovarian & Round ligament Ligation : 

Fig. 22.25 Uteroovarian & Round ligament Ligation

Fig. 22.26 Removal of ovaries & tube by clamping infundibulopelvic ligament : 

Fig. 22.26 Removal of ovaries & tube by clamping infundibulopelvic ligament

Procedure : 

Procedure Peritoneal Closure Pelvic peritoneum not provide support & reforms in 24 hr after surgery, peritoneum need not reapproximate routinely Continuous absorbable 0-0 sutures begun at 12-o’clock position Suture continued in pursestring fashion incorporates distal portion of left upper pedicle & left uterosacral ligament

Procedure : 

Procedure Peritoneal Closure Tension applied to suture placed at beginning of procedure  incorporates posterior peritoneum & vaginal mucosa  high posterior reperitonealization  prevent enterocele formation.

Procedure : 

Procedure Vaginal Mucosa Closure Reapproximate in vertical or horizontal manner, c interrupted or continuous sutures In case, reapproximated horizontally with interrupted absorbable sutures Sutures entire thickness of vaginal epithelium Obliterate underlying dead space & anatomic approximation of vaginal epithelium  decreasing formation of granulation tissue

Mc Cal Culdoplasty : 

Mc Cal Culdoplasty Utero-sacral ligaments can sutured together

PREVENTION OF Vault prolapse : 

PREVENTION OF Vault prolapse Long suture from the previous united cardinal ligament fix into post: fx Suture from round ligament fix to lateral fx. It will also prevent heamatoma formation.

Procedure : 

Procedure Bladder Drainage After completion of procedure, bladder drained Bladder catheter or vaginal packing not mandatory unless anterior or posterior colporrhaphy or other reconstructive procedure

Fig. 22.28 Vaginal Mucosa Closure : 

Fig. 22.28 Vaginal Mucosa Closure

Fig. 22.27 Peritoneal Closure : 

Fig. 22.27 Peritoneal Closure

Intraopearative Complications : 

Intraopearative Complications Bladder Injury Most common intraoperative complications If bladder inadvertently entered, repair performed when injury discovered & not delayed until completion of surgery. Bowel injury Do not occur often If rectum entered, injury repaired with single or double-layer closure.

Intraopearative Complications : 

Intraopearative Complications Hemorrhage Intraoperative hemorrhage : result of failure to ligate significant blood vessel , bleeding from vaginal cuff, slippage of previously placed ligature, avulsion of tissue before clamping Most intra-operative bleeding avioded with adequate exposure & good surgical tech:

Post op complication ANESTHESIA : 

Post op complication ANESTHESIA Failed intubation: Inadequate ventilation Complcations related to anesthesia Anaphylactic reaction Respiratory deppression Cardiac arrhythmias Drug over dose

Post op complications : 

Post op complications Hemorrhage Infection Bowel Complications very rare(paralytic ilues=abd distension ,bowel damge=nausea,vomiting,anorexia,lower abd: pain Urinary tract: Flank pain soon after hysterectomy, ureteral obstruction suspected Infection:fever ,lower abd pain,burning micturation Retention: damage loin pain & pyrexia Haematoma Vault prolapse

Hemorrhage : 

Hemorrhage Patient’s condition stabilizes rapidly with IV fluids First , transfusion  follow serial hematocirt & vital signs Risk : hematoma later infected, necessitating surgical drainage Patient’s condition stable radiologic embolization

Hemorrhage : 

Hemorrhage Another option to perform abdominal exploratory surgery while patient’s condition stable This approach adds morbidity of a second procedure but avoids the possibility of patient’s condition deteriorating with continued delay or formation of a pelvic abscess Adequate exposure  peritoneum over hematoma opened, blood evacuated Bleeding vessels identified & ligated

Urinary Tract Complications : 

Urinary Tract Complications Vesicovaginal fistula: foley catheter inserted for prolonged drainage Up to 15% of fistulas close spontaneously with 4 to 6 weeks of continuous bladder drainage Closure not occurred by 6 weeks operative correction 3 to 4 monthes from time of diagnosis  reduction of inflammation and improve vascular supply Four-layered closure: Bladder mucosa Seromuscular layer Endopelvic fascia Vaginal epithelium

Urinary Tract Complications : 

Urinary Tract Complications Incidental cystotomy at time of hysterectomy: more common( than vesicovaginal fistula) Repaired correctly, rarely development of fistula

Prolapse of fallopian tube : 

Prolapse of fallopian tube Granulation tissue persist after attempts to cauterize or pain  remove Fallopian tube prolapse should be suspected

Discharge Instructions : 

Discharge Instructions Avoid strenuous activity for first 2 wks, increase activity level gradually Avoid heavy lifting, douching, or sexual intercourse Bathe as needed using shower or tub baths Follow regular diet Avoid straining for bowel movement or urination Imediately contact ur DR if excessive vaginal bleeding or fever Schedule return appointment

Depression : 

Depression Increase incidence of psychiatric symptoms after hysterectomy Twice after pelvic operation compared with other surgery

Sexuality : 

Sexuality Incidence of sexual dysfunction after hysterectomy : 10% ~ 40% Hysterectomy not cause psychiatric sequelae or diminished sexual functioning in most patients Best predictor of postoperative sexual functioning : patient’s preoperative sexual satisfaction