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I nternational J ournal of Universal Pharmacy and Bio Sciences 3(3): May-J une 2014
INTERNATIONAL JOURNAL OF UNIVERSAL
PHARMACY AND BIO SCIENCES
IMPACT FACTOR 1.89***
ICV 5.13***
Bio Sciences Research Article !!!

STUDY OF VAGINAL HYSTERECTOMY FOR NON DESCENT UTERUS
Dr. Sowmya.K.*
1
, Dr. Ramalingappa Antartani
2

1
MBBS,MS(O.B.G),D.N.B., Assistant Professor, Department of OBG, JSS Medical College and
research institute, Mysore,Karnataka, INDIA
2
MBBS,M.D,D.N.B., Professor and unit chief, Department of OBG, Karnataka Institute of Medical
sciences, Hubli.

KEYWORDS:

Vaginal hysterectomy;
Non descent uterus,
Debulking technique.
For Correspondence:
Dr. Sowmya.K.*
Address:
MBBS,MS(O.B.G),
D.N.B., Assistant
Professor, Department of
OBG, JSS Medical
College and research
institute,
Mysore,Karnataka,
INDIA.
Email: sowsheshu@gmail.com


ABSTRACT
Aim: To study feasibility of vaginal hysterectomy for non-descent
uterus. Methods: A prospective study of 1 year from October 2005 to
September 2006 was conducted in Karnataka institute of medical
science, Hubli. In this study, 60 patients requiring hysterectomy for
benign gynecological disorders who did not have any uterine descent
were recruited for this study. NDVH was performed in mobile uterus, up
to 14 weeks size, and with adequate vaginal access. Various debulking
techniques like bisection of uterus, enucleation of fibroid, myometrial
coring were used to deliver the uterus. Results: Total of 60 cases of
hysterectomy was done through vaginal route. Mean age of patient was
38.0 yrs, with parity between Para II and IV, 10 cases (16.6%) were
obese. Main indication for hysterectomy was fibroid uterus
(31.6%).Average size of uterus 10-12 wks. Debulking technique was
used in 37(38%). Average time taken was 40 min. Average blood loss
was 100ml .Post operatively patients were comfortable and discharged
on 3 rd post-operative day. Conclusion: Vaginal hysterectomy for non-
descent large uterus is safe and feasible when it is combined with
debulking techniques.
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INTRODUCTION:
Although hysterectomy can be done by abdominal or vaginal or laparoscopic route, 70% of these
operations and in a few centers as many as 85% are done abdominally. The ease and convenience with
which hysterectomy can be performed through a wide open abdominal incision, plus lack of technical
expertise, with confounded fear of failure of procedure when hysterectomy is done by vaginal route
has led many to continue to perform abdominal hysterectomy for non-descent uterus. The need of the
hour is the minimally invasive surgery leading early to discharge from hospital, early resumption of
work, scar less surgery. Though laparoscopy assisted vaginal hysterectomy (LAVH) and total
laparoscopic hysterectomy (TLH) is gaining more popularity, it is associated with higher cost
1
, longer
duration of operation, and need for specially trained personnel. Vaginal hysterectomy in larger sized
uterus is facilitated by bisection, myomectomy, bisection, coring and clampless approach.
2
The purpose of this study is to evaluate the advantages of vaginal hysterectomy and to analyze
technical feasibility of vaginal hysterectomy when combined with various debulking techniques.
MATERIAL AND METHODS
The present study was undertaken in Department of Obstetrics and Gynaecology, Karnataka Institute
of Medical Sciences, Hubli from Oct 2005 to Sep 2006
In this study, 60 cases of vaginal hysterectomy by Modified Heaney's technique were studied pre-
operatively, intra-operatively and post-operatively in detail and analyzed. Follow up of these patients
was done from one to six months.
Cases with non-prolapsed benign pelvic conditions having a uterine size ranging from NORMAL TO
FOURTEEN weeks of gestational size were selected in this series. Patients were selected irrespective
of age/ parity/ associated medical disorders, history of previous laparotomy/ obesity etc. Uterine size in
these patients varied between normal sizes to fourteen weeks of gestational size. Trial of vaginal
hysterectomy was given in two cases wherein the uterine size was between 12-14 weeks size and
successfully completed the hysterectomy, through vaginal route in both the cases
Uteri more than 14 weeks size, with restricted uterine mobility, with difficult vaginal access, complex
adnexal pathology were excluded from study. Complete evaluation of the cases was done
thoroughly pre-operatively, before posting the patient for surgery. In doubtful cases regarding the
uterine size and mobility and associated adnexal pathology, the vaginal hysterectomy was decided
after examining the patient under anesthesia. Salpingo-oophorectomy and other necessary
operations for associated conditions were done, where ever it was feasible.
Procedure:
All cases were done under regional anaesthesia, either spinal or epidural. After cleaning and draping,
cervix was held with volsellum. Saline infiltration was done in all cases. Anterior incision was made at
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cervicovaginal junction .The pubo-vesico-cervical ligament was cut and bladder mobilized upwards.
Both anterior and posterior pouches were opened one after another. Uterosacral and cardinal ligaments
were clamped, cut and ligated. Clamping of uterine vessels was done bilaterally. Next in bigger sized
uterus debulking techniques like uterine bisection, morcellation, myomectomy or combinations of
these were performed as and when required. In case of fibroid with bigger sized uterus bisection was
done after ligating the uterine arteries and myomectomy was done to ease limitation of space for
further proceedings. In case of fundal fibroid only those myomas were removed which were interfering
with delivery of the fundus. In total hysterectomy, last clamp was on uterine cornu containing round
ligament, ovarian ligament and medial part of fallopian tube. To remove ovaries, round ligament was
clamped separately followed by clamping of infund ibulopelvic ligament. After delivery of the uterus
(with ovaries) hysterectomy was completed in usual fashion.
Data regarding age, parity, uterine size, intraoperative debulking technique used, estimated blood loss,
length of operation, complications and hospital stay were recorded. All patients received 3 doses of
prophylactic injectable antibiotics. Postoperative catheterization with foleys catheter was done in all
cases for 24 hours. Patients were followed up from 4 weeks to 6 months
Results
AGE INCIDENCE
Table 1: Age Incidence Number of Cases According To Age Group
Age in years Present study (60)
25-30 4
31-40 25
41-50 26
51-60 5
61-70 -
The youngest patient who got operated was 25 years and oldest was of 60 years .41% (25) of
the patients were between 31 to 40 years and mean age was 38.05 years
Table 2: Parity Distribution of cases according to parity
Parity Total no of
cases(n=60)
Nulliparous 1 1.6%
Para-I 8 13.3%
Para-II 10 25%
Para-III 14 16%
Para-IV 27 45%

In our series, 51(86) of the patients were between para II to para V and one patient was nulliparous.
Incidence of obesity was 10 cases (16.6%) in our series.
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Table 3:- History of previous laparotomy

In our series there were 2(3%) cases who had previous history of laparotomy. (Caesarean section
(L.S.C.S)) In our series 40(68%) cases had undergone minilap tubectomy and 3(6%) patients had
undergone laparoscopic sterilization.
Table 4: Size of the uterus
Distribution of the cases according to the size of the uterus
Cases (n=60)
Normal 24 40%
6 weeks 12 20%
7-8weeks 4 6.6%
9-10weeks 9 15%
11-12weeks 5 8.3%
13-14 weeks 2 3.3%
14-16wks 4 6.6%

In our series, in 40 (66%) patients the uterine size was normal to bulky. These cases were easy and
ideal to operate through vaginal route. In 9 (15%) cases, uterine size was 8-10 weeks and in another 7
cases (11.6%) the uterine size varied between 10-14 weeks size. The maximum size of the uterus that
was operated in our series was 14 weeks.
Table 5: Main indications for vaginal hysterectomy
Indication Total (n=60)
Fibroid uterus 19 31.6%
DUB 49 48.3
Adenomyosis 4 6.6%
Chronic cervicitis 6 10%
Myomatous polyp 3 5%
Cervical dysplasia

Major indications for vaginal hysterectomy in our series were fibroid uterus (31.6%) and D.U.B
(49%). 6(10%) had chronic cervicitis, 4(6.6%) had adenomyosis and 3(5%) fibroid polyp.
Cases Percentage
total (60) 2 3.00%
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Table 6: Debulking technique
Surgical Procedure Total (n=60)
Removal of intact
uterus
37 61.6%
Bisection of uterus 12 20%
Bisection with the
enucleation of
myoma
10 16.6%
Morcellation /
wedge resection
1 1.6%

In our series 37 (61.6%) of uterus were removed intact. Bisection of the uterus was done in 12 (20%)
of the cases. Bisection with enucleation of myoma was done in 10 (16.6%),morcellation was done in 1
case (1.6%).
In our series there was no case of laparotomy. There was no difficulty in delivering the uterus in 47
(87.5%) cases. In the remaining cases there was slight difficulty in delivering the uterus because of
obesity, large uterus and narrow vaginal space. There was no bladder, ureteric, Intestinal and renal
injuries. Average blood loss was 100ml. In 10 (16.6%) cases there was moderate amount of blood loss,
where in the duration of the surgery was prolonged and the uterine size was big. In no case was blood
loss severe. Average time taken was 40 minutes. Only 2 patients required 60 or more minutes.
Table 7:- Associated operations done
Distribution of cases according to the associated operations done
Associated operation Our series (60)
Posterior colpoperineorrhaphy 01 1.6%
One or both tubes removed 2 3.3%
One or both ovaries removed 2 3.3%
Plastic operation on urethra
for incontinence
- -

In our series 1(1.6%) posterior colpoerineorrhaphy was done, 2(3.3%) patients had unilateral salpingo-
ovariotomy and 2(3.3%) patients had bilateral salpingo-ovariotomy. (11.6%) patients had febrile
morbidity out of which 3 were due to urinary tract infection and in 1 (1.6%) it was due to right upper
limb thrombophlebitis and in one case the cause of the fever could not be identified. Patients were
ambulatory on the 2nd post-op day. Patients were comfortable post-operatively due to less intensity of
pain and required less sedation and analgesics.49(83%) of the patients were discharged on 5 days
though fit to be discharged on the 3
rd
day due to patient compliance. There was no mortality in our
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series. On follow up 2 patients had per vaginal spotting due to granulation tissue and were treated
successfully with chemical cauterization (copper sulphate).
Discussion:
Vaginal hysterectomy is usually avoided by many surgeons in absence of significant uterovaginal
prolapse, presence of uterine enlargement, adhesions and when there is need for oophorectomy. With
adequate vaginal access, vaginal hysterectomy can be easily performed. Multiparity, lax tissues
following multiple deliveries and decreased tissue tensile strength provide comfort to vaginal surgeon
even in the presence of uterine enlargement. Even in nulliparous with minimal descent the uterosacral
and cardinal ligaments are situated in close proximity to the vaginal vault once clamped and cut
produce first degree descent. Varma et al.
3
considered vaginal hysterectomy to be technically easier
because of the small cervical and uterine size in nulliparous women .In a study by Aubert Agostini
etal
4
out of fifty-two nulliparous patients hysterectomy was successfully done in 96.2% of cases. But
they noted increased operative time and complications in these patients. Our study included only one
patient in which hysterectomy was successfully completed without much difficulty.
In our series there were 2(3%) cases who had previous Caesarean section (L.S.C.S).In study by SS
Sheth
5
out of 200 cases vaginal hysterectomy was done in all except 3 cases.
In case of R. Rajan et al
6
, series there was history of laparotomy in 49(14.54%) cases. History of
previous laparotomy per se is not a contraindication for vaginal hysterectomy. It is the mobility and
size of the uterus which decides the route of surgery.In our series; we had no problem in doing vaginal
hysterectomy in these patients.
The other important reason for lower proportion of hysterectomies performed vaginally is presence of
uterine enlargement with leiomyomas or adenomyosis. According to Mazdisnian F et al
7
bulky uteri
can be dealt with various debulking techniques.
In our study, 60 patients without descent, In 9 (15%) cases, uterine size was 8-10 weeks and in
another 7 cases (11.6%) the uterine size varied between 10-14 weeks size. The maximum size of the
uterus that was operated in our series was 14 weeks. In our series 37 (61.6%) of uterus were removed
intact. Bisection of the uterus was done in 12 (20%) of the cases. Bisection with enucleation of myoma
was done in 10 (16.6%),morcellation was done in 1 case (1.6%). In Unger et al
2
series 30 women with
uterine enlargement between 200 to 700 gm underwent various debulking procedures.Kumar and
Antony
8
successfully carried out vaginal hysterectomies in 95% (76/80) and 60 of their patients
needed morcellation or hemisection or myomectomy. They consider vaginal hysterectomy safe upto 12
weeks size. Das and Sheth
9
use ultrasongraphic calculation of uterine volume for assessing the
feasibility of vaginal hysterectomy. They needed debulking for uteri with a volume of more than
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300cm3.We were successful in removing uterus upto 14 weeks size without increase in intraoperative
complications. With experience even uterus of larger size can be operated vaginally.
It has been demonstrated that ovaries are visible and accessible to transvaginal removal in most cases
10
. In our series, 2(3.3%) patients had right salpingo-ovariotomy and 2(3.3%) patients had left
salpingo-ovariotomy. In the Heaneys series
11
268 (47.43%) patients had undergone posterior
colpoperineorraphy and in 103 (18.21%) patients either unilateral or Bilateral salpingectomy was done.
The length of hospital stay reported by Dorsey JH et al
12
was 3.5 and 4.5 days for total vaginal and
total abdominal hysterectomy respectively. In our series hospital stay was 3 days. In our series in
30(50%) cases, the surgery was completed within 30 minutes. In 17(28.3%) cases the time required
was 45 mins. and in 14(23.3%) patients 60 mins. Only 2 patients required 60 or more minutes. This
depends on the experiences of the surgeon, uterine size, and uterine mobility. In Dewan et al
13
mean
operative time was 54.5 min (range 45-150 min). In Anthony ZK
8
series average time taken was
81.32min with where the uterine size varied between 14-18 wks.
Conclusion:
For properly selected patients with confirmed indications, vaginal hysterectomy is the preferred route
in the hands of experienced surgeons who are well-versed with the vaginal surgery. . A combination of
debulking techniques is often needed and the surgeon needs to be familiar with them.
The need of the hour is minimally invasive surgery, early discharge from the hospital, early
resumption of work, avoidance of disfiguring scar on the abdomen and cost-effectiveness of the
procedure are as important as cure of the disease. Vaginal hysterectomy fulfills these criteria to
absolute satisfaction.
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