Minimally Invasive Vaginal Hysterectomy

NEED OF THE TIME

DR. KAWITA BAPAT

One Day hysterectomy

BAPAT HOSPITAL INDORE

One Day hysterectomy

“Technological change is like an axe in the hands of a pathological criminal.”

Albert Einstein

One Day hysterectomy

Hysterectomy • More than half a million hysterectomies/year

significant cost to healthcare system• By age 60

one in three women• Majority for benign indications

fibroids

bleeding

endometriosis

pelvic pain

One Day hysterectomy

Evolution Total abdominal hysterectomy

Total vaginal hysterectomy

Laparoscopially-assisted vaginal hysterectomy

Laparoscopic supracervical hysterectomy

Total laparoscopic hysterectomy

Minimally invasive vaginal hysterectomy

One Day hysterectomy

Goal

• What should be the new selection criteria

• What are the Challenges

• What is the Technique

• What are the new instrumentation

• What is the fun

One Day hysterectomy

Vaginal Hysterectomy

• most favourite procedure

developed in the past

• need not to be a procedure of the past

• We cannot allow it to die

• We are indeed vaginal surgeons trained in vaginal surgery

• we need to keep the procedure alive

One Day hysterectomy

Evolution in Electro surgery

Mono polar instrumentation to

conventional bipolar instrumentation to

now advanced bipolar instrumentation

Improved traditional bipolar

• vessel sealing• bipolar cutting• tissue impedance feedback• improved outcome in terms of the tissue effect

One Day hysterectomy

Modern Technology

One Day hysterectomy

General principle Classical steps of conventional surgery

+

Three new principle

1.only 2 other instruments

2.Application of clamp close to uterus

3.No traction

One Day hysterectomy

Sequence of operation

• vaginal circumferential cut around cervix

• Haemostasis around cervix

• haemostasis and additional amputation of uterine vessels

• Amputation of uterus at adnexa

• Adnexectomy with clamp

• Occlusion of vaginal vault

One Day hysterectomy

Technical challenges to the vaginal approach:

• Exposure • Haemostasis• Entry into the cul-de-sac• Large uterus• Ureteral injury• High adnexa

One Day hysterectomy

criteria in determining the route for hysterectomy

• level of suspicion for malignancy

• presence of an adnexal mass

• vaginal access

• assessment of the mobility of the uterus

• what the size of the uterus

• previous caesarian section.

One Day hysterectomy

Entry into the cul-de-sac

stay within the uterus

don’t abort

(If you cannot enter anteriorly

or even posteriorly)

at some point,uterus will come down and present itself

So delay entry until you have good dissensus and visualization

One Day hysterectomy

Large uterus

• Bifurcation of uterus

• Amputation of cervix

• Make uterus pear shape to apple shape

• morcellation technique

One Day hysterectomy

To avoid Uretral injury

• Mobilize bladder pillars superiorly

and laterally

• perform cystoscopy

present inadvertent

occult kinking of the ureters

bladder injury

One Day hysterectomy

• Thermal hemostasis

Need three steps• Positioning of clamp• Removal of clamp • Cutting with scissors

• Classical hemostasis with sutures

• Need six steps • Positioning of the clamp

• Severing of the pedicle using scissors

• Placing the suture with needle holder

• Knotting

• Removal of forceps

• Cutting of the suture with scissors

One Day hysterectomy

Prevention of accidents

1.Burns

Skin and mucosa

Positioning of clamp

Suctioning of surgical smoke

2. Thermal necroses at the ureter

3. Thermal wounds of digestive tract

4.Bleeding

Immediate & Secondary

One Day hysterectomy

ligature vessel sealing system

• low voltage

• high current

• Impedance feedback

• optimal pressure

One Day hysterectomy

Vessel sealing technology

• Ensures

reliable, Consistent

isolate vessels• thermal spread predictable • less energy delivery• the pedicles are smaller and therefore the

steam effects are much less lateral to the instrument

• . No Sticking and charring, reliable sealsOne Day hysterectomy

OCCLUSION OF VESSELS

Mechanical

Flattening

Compression

Thermal

Dehydration of tissues

Destruction of proteins

Hardening of the collagen One Day hysterectomy

Benefits of tissue fusion system

consistent control of energy delivery

zones are more flexible stronger

greater reduction of thermal spread

less charring and sticking

One Day hysterectomy

Reduction of pain• Good psychological preparation

• The multimodal anesthesia

• Non aggressive operative technique

• No forcible pulling of pedicle and ligaments

• Ensuring hemostasis through thermo fusion

One Day hysterectomy

Impact on pain Thermal haemostasis

• Reduces inflammatory and painful events

• Absence of necrotic tissue and foreign bodies

One Day hysterectomy

Technical limitations with laparoscopy

• counter intuitive hand movements

• unsteady images and big learning curves

• inefficient electrosurgical tools

One Day hysterectomy

MIVH FAST

NO CO2LATEST

RELABLEPAINLESS

SUTURELESSCONVIENIENTBLOOD LESS

LESS OT TIMECOST EFFECTIVE

EARLY RECOVERYLESS RECOVERY TIME

LESS DURATION OF STAYEXPERTISED TECHNIQUE

WORLD WIDE ACCEPTANCEINTERNATIONALLY ACCLAIMED

LESS DURATION OF ANAESTHESIANOT GOING THROUGH SEVEN LAYERS OF ABDOMEN

One Day hysterectomy

MIVH Height of cost cutting

One Day hysterectomy

CONCLUSION

great procedure

Future Is Here

One Day hysterectomy

Summary

• Good procedure

• Develop new criteria for selecting patients

• Think of utilizing new technology

and instrumentations

• For the benefit of your patients

and also for yourself.

One Day hysterectomy

One Day hysterectomy

Sufficiently advanced technology is

indistinguishable from magic

Thankyou