Vaginal Hysterectomy

Overview and Advantages

• Shorter return to normal activities (mean difference -9.5 days vs. abdominal hysterectomy; 95% CI -12.6 to -6.4)
• Fewer perioperative complications than laparoscopic, robotic, or abdominal approaches
• Lower cost
• No abdominal wall entry

• Berek & Novak's Gynecology, p. 1417-1418

Indications

• Uterine prolapse / pelvic organ prolapse
• Abnormal uterine bleeding (fibroids/leiomyomata, dysfunctional uterine bleeding)
• Chronic pelvic pain
• Endometriosis (without extensive cul-de-sac disease)
• Adenomyosis
• Cervical dysplasia (CIN)
• Endometrial hyperplasia

Patient Selection and Preoperative Assessment

• Prior vaginal delivery (nulliparity does not preclude VH - >90% of nulliparous patients can undergo successful VH)
• Previous cesarean section
• Previous pelvic surgery (alone)
• Obesity

• Narrow pubic arch (<90 degrees) - the single most predictive risk factor for failed VH
• Narrow vaginal introitus
• Adnexal mass or cul-de-sac disease (may require laparoscopy)
• Extensive adhesions / suspected malignancy
• Hip disease limiting leg abduction
• Berek & Novak's Gynecology, p. 1430-1431

Surgical Technique

Positioning

• High (dorsal) lithotomy position, buttocks just over table edge
• Hip flexion >60 degrees; knee flexion 90-120 degrees
• 10-15 degree Trendelenburg aids visualization
• Padding at all pressure points to prevent nerve injury
• Foley catheter inserted

Instruments

• Weighted speculum, Heaney/Heaney-Ballantine clamps, Breisky-Navratil retractors
• Heaney needle holders, curved Mayo scissors, right-angle retractors
• Vessel-sealing devices may be used for larger uteri

Anesthesia / Hemostasis

• Paracervical block with dilute vasopressin or lidocaine with epinephrine (hydrodissection + hemostasis)

Step-by-Step Procedure (key steps are in reverse order compared to abdominal hysterectomy)

1. Circumferential cervical incision - tenaculum applied to cervix; incision made at junction of vaginal epithelium and cervix
2. Posterior colpotomy - posterior cul-de-sac entered sharply with curved scissors; posterior peritoneum affixed to posterior vaginal wall
3. Uterosacral ligament division - clamped with curved Heaney clamps, divided, and ligated with delayed absorbable suture; tagged for later use in cuff repair and McCall culdoplasty
4. Anterior dissection - bladder dissected off cervix; anterior peritoneum identified and incised; right-angle retractor placed to elevate bladder
5. Cardinal ligament and uterine vessel division - serial bilateral clamping, dividing, and ligation; with each pedicle, uterus delivers further into vagina
6. Cornual pedicles - round ligament, fallopian tube, and uteroovarian ligament clamped as a unit under direct visualization; uterus freed and removed
7. Hemostasis check - inspect all pedicle sites
8. Colpotomy closure - angle stitches first (incorporating uterosacral ligaments); remainder closed horizontally with delayed absorbable suture (running, figure-of-eight, or interrupted)

• Sabiston Textbook of Surgery, p. 2801; Campbell-Walsh Wein Urology, p. 3714; Berek & Novak's Gynecology, p. 1432

McCall Culdoplasty

Concurrent Procedures

• Bilateral salpingo-oophorectomy (BSO): Can be performed vaginally but should have clear indications. In women under 50, elective BSO increases long-term cardiovascular and neurologic morbidity (especially without hormone replacement).
• Opportunistic salpingectomy: Now recommended at the time of hysterectomy to reduce ovarian cancer risk (bilateral salpingectomy with ovarian conservation).
• Postoperative cystoscopy: Recommended after hysterectomy to detect unsuspected ureteral/bladder injury.

Complications

Intraoperative

Postoperative

Sexual Function

• Campbell-Walsh Wein Urology, p. 3714-3715

Comparison with Other Routes

Key Teaching Points

1. VH is the preferred approach for benign hysterectomy when technically feasible.
2. Uterine mobility is the single most important preoperative selection criterion.
3. A narrow pubic arch (<90 degrees) is the strongest predictor of failed VH.
4. Nulliparity and prior cesarean section are not contraindications.
5. Steps proceed in opposite order to abdominal hysterectomy (posterior colpotomy → uterosacral ligaments → cardinal/uterine vessels → cornua).
6. Opportunistic salpingectomy is now standard at the time of hysterectomy.
7. Intraoperative cystoscopy should be considered to rule out urinary tract injury.

वैजाइनल हिस्टेरेक्टॉमी (Vaginal Hysterectomy)

परिचय (Introduction)

संकेत - कब करते हैं? (Indications)

• Uterine Prolapse - गर्भाशय का नीचे खिसकना (सबसे आम कारण)
• Abnormal Uterine Bleeding - अनियमित या अधिक रक्तस्राव
• Fibroids (Leiomyomata) - गर्भाशय में रसौली
• Adenomyosis - गर्भाशय की दीवार में ग्रंथि ऊतक का बढ़ना
• Endometriosis - (बिना cul-de-sac disease के)
• Chronic Pelvic Pain - पुराना पेडू दर्द
• CIN / Cervical Dysplasia - गर्भाशय ग्रीवा की असामान्य कोशिकाएं

मरीज का चयन (Patient Selection)

ये VH के विरुद्ध नहीं हैं (Not Contraindications):

• Nulliparity (कभी नार्मल डिलीवरी न हुई हो) - फिर भी 90%+ मरीजों में VH संभव
• पहले C-section हुआ हो
• मोटापा (Obesity)
• पहले पेट की सर्जरी हो चुकी हो

ये VH को मुश्किल बनाते हैं:

• Narrow pubic arch (<90°) - यही सबसे बड़ा रुकावट कारक है
• Adnexal mass या cul-de-sac disease
• गंभीर adhesions
• संदिग्ध cancer

सर्जिकल तकनीक (Surgical Technique)

मरीज की स्थिति (Positioning)

• High Lithotomy Position - पैर ऊपर उठाकर
• नितंब मेज के किनारे पर
• 10-15 डिग्री Trendelenburg
• Foley catheter लगाएं
• Nerve injury से बचाव के लिए पैरों को proper padding दें

खास उपकरण (Instruments)

• Weighted speculum, Heaney clamps
• Breisky-Navratil retractors
• Curved Mayo scissors
• Heaney needle holders

ऑपरेशन के चरण (Steps of Surgery)

याद रखें: VH के steps, Abdominal Hysterectomy से उल्टे क्रम में होते हैं। Abdominal में पहले ऊपर से शुरू होते हैं; Vaginal में नीचे से।

Step 1 - Cervical Incision (गर्भाशय ग्रीवा का चीरा)

• Tenaculum से cervix को पकड़कर नीचे खींचें
• Vaginal epithelium और cervix के जोड़ पर चारों तरफ चीरा लगाएं
• Dilute vasopressin या lidocaine inject करें (खून कम करने के लिए)

Step 2 - Posterior Colpotomy (पीछे का रास्ता खोलना)

• Posterior cul-de-sac (pouch of Douglas) में scissors से प्रवेश करें
• Posterior peritoneum को vaginal wall से suture से जोड़ें
• Weighted speculum अंदर रखें

Step 3 - Uterosacral Ligaments काटना

• Heaney clamps से clamp करें
• Delayed absorbable suture से ligate करें
• Tagged रखें - बाद में cuff closure और McCall Culdoplasty में काम आएंगे

Step 4 - Anterior Colpotomy (आगे का रास्ता खोलना)

• Bladder को cervix से ऊपर dissect करें
• Anterior peritoneum पहचानें और खोलें
• Right-angle retractor से bladder को ऊपर रखें

Step 5 - Cardinal Ligaments और Uterine Vessels

• दोनों तरफ serial clamping, cutting, ligation
• हर pedicle के साथ uterus और नीचे आता जाता है

Step 6 - Cornual Pedicles (सबसे ऊपरी हिस्सा)

• Round ligament + Fallopian tube + Uteroovarian ligament - एक साथ clamp
• Uterus पूरी तरह free होकर बाहर आ जाता है
• Double ligature लगाएं, hemostasis जांचें

Step 7 - Colpotomy Closure (बंद करना)

• पहले angle stitches - uterosacral ligaments को शामिल करते हुए
• बाकी हिस्सा horizontal running या figure-of-eight suture से बंद करें
• Delayed absorbable suture (जैसे Vicryl) उपयोग करें

McCall Culdoplasty

• Closure के समय tagged uterosacral ligaments को एक साथ लाकर vault को support दिया जाता है
• यह vaginal vault prolapse और enterocele को भविष्य में रोकता है

साथ में की जाने वाली प्रक्रियाएं (Concurrent Procedures)

जटिलताएं (Complications)

ऑपरेशन के दौरान (Intraoperative)

ऑपरेशन के बाद (Postoperative)

यौन स्वास्थ्य पर प्रभाव (Sexual Function)

• Coital frequency में सुधार: 44.3%
• Deep dyspareunia कम: 19.7%
• Orgasm प्राप्ति में सुधार: 32.8%
• Overall satisfaction: 28.3%

तीनों तरीकों की तुलना (Route Comparison)

महत्वपूर्ण बिंदु - Exam के लिए (Key Points)

1. VH = पसंदीदा route जब भी technically संभव हो
2. Uterine mobility = सबसे महत्वपूर्ण preoperative factor
3. Narrow pubic arch (<90°) = सबसे बड़ा risk factor for failure
4. Nulliparity और C-section = contraindication नहीं
5. Steps = Abdominal से उल्टे (Posterior colpotomy → Uterosacral → Cardinal/Uterine vessels → Cornua)
6. Opportunistic salpingectomy = अब standard practice
7. Postoperative cystoscopy = urinary injury detect करने के लिए

Abruptio Placentae (Placental Abruption)

Kya Hota Hai? (Definition)

Simple shabdon mein: Bachche ko oxygen aur nutrition dene wala placenta, delivery se pehle hi uterus ki wall se ukhad jaata hai - is wajah se mama ko bleeding hoti hai aur bachche ko oxygen nahi milti.

Retroplacental abruption - 30 weeks' gestation mein - Creasy & Resnik's Maternal-Fetal Medicine

Incidence aur Timing

• Approximately 1% pregnancies mein hota hai
• Sabse zyada 24-26 weeks ke beech hota hai
• Yeh APH (Antepartum Haemorrhage) ka ek major cause hai

Types - Kitne Prakar ke Hote Hain?

1. Revealed (Apparent) Abruption

• Blood uterus se bahar aake vagina se nikal jaata hai (visible bleeding)
• Diagnosis asan hoti hai

2. Concealed Abruption

• Blood retroplacental clot mein phansa rehta hai - bahar nahi aata
• Zyada dangerous - kyunki andar hi andar bleeding hoti rehti hai
• Patient ka condition actual blood loss se zyada kharab dikhta hai

3. Mixed Type

• Dono milakr - kuch andar, kuch bahar

Yaad rakho: ~10% abruptions mein koi vaginal bleeding nahi hoti (concealed)!

Risk Factors - Kise Zyada Khatra?

Sabse Bada Risk Factor:

Maternal Causes:

Pathophysiology - Kyun Hota Hai?

Decidual vessels mein bleeding
        ↓
Retroplacental hematoma form hota hai
        ↓
Hematoma badhta hai → placenta aur uterine wall ke beech pressure
        ↓
Placenta alag hona shuru ho jaata hai
        ↓
Fetus ko oxygen supply kam ho jaati hai
        ↓
Agar >50% placenta separate → Fetal death likely

Clinical Features - Kaise Pehchane?

Classic Triad:

1. Vaginal bleeding (painful - yeh placenta previa se alag karta hai)
2. Abdominal/uterine pain - "woody hard uterus" (board-like rigidity)
3. Uterine tenderness + hypertonic contractions

Aur bhi features:

• Back pain (agar placenta posterior wall pe hai toh sirf back pain hoti hai)
• Fetal distress (CTG pe late decelerations, poor variability, bradycardia)
• Shock - jo actual vaginal bleeding se zyada severe lag sakta hai (concealed mein)
• Preterm labor ke saath present ho sakta hai

Severe/Massive Abruption:

• Extreme pain
• Hard, tonically contracting uterus ("woody hardness")
• Fetal death
• Usually preeclampsia ya cocaine use ke saath

Placenta Previa se Comparison (Exam Important!)

Diagnosis - Kaise Confirm Karte Hain?

1. Clinical Diagnosis (Most Important)

2. Ultrasound

• USG ka placenta previa rule out karne mein use hota hai
• 50% abruptions mein USG normal hota hai! - toh USG se abruption rule OUT nahi kar sakte
• Retroplacental hematoma dikhega agar >2 cm ho (retroplacental clear zone ka disappearance)
• "Jello sign" - intrauterine clot transducer se bounce karne pe hiilta hai

3. CTG (Cardiotocography)

• Continuous CTG mandatory hai
• Late decelerations, variable decelerations, prolonged bradycardia, sinusoidal pattern

4. Lab Tests

Kleihauer-Betke test abruption diagnose nahi karta - sirf Rh-negative mothers mein anti-D dose guide karne ke liye useful hai.

Management - Kya Karte Hain?

Immediate Steps (Sab cases mein):

1. 2 large-bore IV lines establish karo (hemodynamically unstable ho toh zaroor)
2. Continuous CTG shuru karo
3. Foley catheter - urine output monitor karne ke liye (>30 mL/hr chahiye)
4. Labs: CBC, platelet, coagulation profile, fibrinogen, type & crossmatch
5. Placenta previa USG se exclude karo
6. Obstetric anaesthesia team ko early involve karo

Delivery Ka Decision - Gestational Age Pe Depend Karta Hai:

Maternal/Fetal compromise?
        ↓
    YES → IMMEDIATE DELIVERY (usually C-section)
        ↓
    NO  → Gestational age?
           ├─ >34 weeks → Deliver without delay (conservative risk > prematurity risk)
           ├─ 20-34 weeks → Conservative management possible
           │    ├─ Betamethasone dena (lung maturity ke liye)
           │    ├─ Close monitoring
           │    └─ Tocolytics - controversial, cautious use
           └─ Advanced labor stage → Vaginal delivery try kar sakte hain

Route of Delivery:

• Cesarean section - agar maternal/fetal compromise ho
• Vaginal delivery - agar advanced labor mein ho aur mother-baby stable ho

DIC Management:

• Fresh Frozen Plasma (FFP)
• Packed Red Blood Cells (pRBCs)
• Platelets
• Cryoprecipitate (fibrinogen ke liye)

Complications - Kya Ho Sakta Hai?

Maternal:

• DIC (sabse serious) - fibrinogen < 150 mg/dL = severe DIC
• Postpartum hemorrhage
• Acute Renal Failure (hypovolemia se)
• Sheehan's Syndrome (pituitary necrosis)
• Couvelaire Uterus - blood uterine muscle mein infiltrate ho jaata hai (violet-blue appearance); uterine atony ka cause

Fetal/Neonatal:

• Fetal death (agar >50% placenta separate ho)
• Prematurity
• IUGR (Intrauterine Growth Restriction)
• Hypoxic-ischemic encephalopathy

20% fetal deaths abruption ke baad hospital presentation ke baad hote hain, aur 30% unme se 2 hours ke andar - isliye delay nahi karna chahiye!

Couvelaire Uterus (Special Mention)

• Severe abruption mein blood myometrium ke beech ghus jaata hai
• Uterus violet-blue/purple color ka dikhai deta hai intraoperatively
• Uterine atony ka cause banta hai → PPH
• Hysterectomy sometimes zaroori hoti hai

Key Points - Exam Ke Liye

1. Definition = Delivery se pehle placenta ka premature separation
2. Painful dark vaginal bleeding = Abruption (Placenta previa = painless)
3. Concealed = Zyada dangerous, 10% cases mein koi vaginal bleeding nahi
4. Biggest risk factor = Previous abruption history
5. USG se rule OUT nahi kar sakte - 50% cases mein normal aata hai
6. Most sensitive lab test = FDP (Fibrin Degradation Products)
7. DIC = Fibrinogen sabse pehle girega
8. >34 weeks + any compromise = Immediate delivery
9. Couvelaire uterus = Blood myometrium mein → purple uterus → atony → PPH
10. Kleihauer-Betke = Diagnosis ke liye nahi, sirf Rh-negative mein anti-D dose ke liye

• Creasy & Resnik's Maternal-Fetal Medicine; Rosen's Emergency Medicine; Grainger & Allison's Diagnostic Radiology