In this introductory remark at workshop on vaginal hysterectomy where Dr Shirish Seth was operating faculty. I spoke “lets promote and propagate vaginal hysterectomy which is an indigenous surgery in line with PM Modi’s mission of MAKE IN INDIA. Vaginal hysterectomy is like Aam admi surgery which is in the best interest of patients and has best scientific evidences in its favour." Let us not be driven by glamour,gadgets and gimmicks."

1. Dr. Rajesh Gajbhiye
Consultant Gynecologist & director
Mauli Women’s Hospital,Nagpur.

2. Hysterectomy can be performed in different ways
most of the indications are
DUB,Fibroids,adenomyosis .
 The best way to tackles is vaginal hysterectomy
which is safer ,do not require gadgets and can be
mastered by everybody.
 We should not fall prey to the Gimmicks,gadgets
and glamour and subject our patients to such
surgeries which may be associated with higher
rates of complications ,which may be iatrogenic
also

3.  We should promote and propagate vaginal
hysterectomy which is a indigenous surgery,
natural surgery. In accordance with our PM
Modi’s Misssion make in India.
 we should upgrade our skills to do vaginal
hysterectomy which is like a Aam Admi Surgery.

4.  Intial in our residency only indication of vaginal
hysterectomy was prolapse.The concept of Non
Descent was not there. slowly second degree
then NDVH
 Then most of the contraindications and relative
contraindications were challenged like Previous
LSCS,Big fibroids nulliparity, even mild to mod
endometriosis,even bening adenexal masses all
have been conqured,and the scope goes on
increasing till date.

5. Previously 80% of Hysterectomies were Abdominal A:V
80:20
Now 70 % are Vaginal Hysterectomies V:A 70:30
It differs from center to center

6.  Now if cervix is accessible and mobility is there
then vaginal hysterectomy should be thought of
and now we say Trial of vaginal if not then you
can always convert to other route.

8.  In this era of evidence based medicine clear
scientific evidence exists to determine the
superiority for selection between all three
methods available, that is vaginal hysterectomy
(VH), total laparoscopic hysterectomy –
laparoscopic or laparoscopic assisted vaginal
hysterectomy (TLH or LAVH), and abdominal
hysterectomy (AH).

9.  2009 Cochrane Database Systemic Review
TLH- Increased operation time ,operation theater
occupancy and higher complication rate.
VH should be performed in preference to AH where
possible.
If VH is not possible, TLH may avoid the need for
AH.

10.  The EVALUATE hysterectomy study, a multicenter
randomized trial showed TLH was associated
with a significantly higher risk of major
complications and took longer time than AH.
 Several studies show a clear benefit of the vaginal
route over the abdominal, and only when VH is
not possible is TLH preferred, though it is
associated with higher bladder and ureteric
trauma.

11.  Donnez presented a series of 3190 laparoscopic
hysterectomies for benign diseases from 1990 to
2006, wherein complications of TLH/LAVH were
compared with those of AH and VH .
If VH can be performed safely then LAVH does
not come in consideration.
LAVH/TLH replace AH

12. 1. Lysis of adhesions
2. Treatment of pelvic endometriosis
3. Difficult oophorectomy
4. Fibroid that complicates VH
5. Evaluation of abdominal/pelvic cavity.

13.  Recent advances and innovation in surgery has
changed the views of Gynecologists.
One of the most dramatic change in the route of
removal of the uterus during the last few years
is switching over from abdominal to vaginal
irrespective of its
Descent
Volume (fibroids, Adenomyosis)
Previous surgeries on it.

14.  Natural Entrance
 Direct approach to cervix
and Uterus
 Indications are increasing
 More Gynec are adopting
 Public Awareness is
increasing
 More demand for Stitch-
less Surgery
NDVH

15.  No need of costly
equipments
 Regional /local
anaesthesia
 Less Anaesthetic
complications
 No Iatrogenic
complications
 Rapid recovery
 Short hospital stay
 Learning curve short

16. Nonavailability or nonaccessibility of
laparoscope or laparoscopists in 80% of
world population makes VH a popular
choice.
In resource constraint country like India,we
cannot rely on costly gazette based
surgeries.
Vaginal route is the least invasive, most safe,
and economical form amongst the available
routes and techniques of hysterectomy.

17.  Laparoscopic surgeons are striving to reduce the
scar on abdomen from
multiport ------ minilaparoscopy
------single port
THEN WHY NOT VAGINAL WHICH IS
TOTALLY SCARLESS

18.  Anaesthesia related
 Trocar related
 Procedure related
 Instrument related
 Patient related

19.  PREVIOUS LSCS
 ENLARGED UTERUS
 OPPHORECTOMY/BENIGN ADENEXALMASS

20.  Cervicofundal sign by Dr Shirish Sheth to see for
dimpling implying that there were dense
adhesion with the anterior abdominal wall. Such
case do LAVH.
 Put speculum in post vaginal wall and see if the
cervix is high up and behind pubic symphysis.

21.  Scarred vesico-vaginal space can make the
dissection more difficult ,whether the approach
is Abdominal or Vaginal.
 Vaginal approach is less difficult because one
can enter in to the plane through 'surgical
window' -least scarred area.
Scarred area

23. Try to Push finger laterally on the
cervix.There is a loose covering
tissue leads to broad ligament.
This is called Surgical Window.
As a rule Bladder is non adherent
and free in its lateral one fifth.
Use this window to enter over the
ant.surface of BL.
Once you enter the broad
ligament,come medially by
hooking the index finger .Then
we will see VC ligament .cut the
tissues by Sharp dissection with
scissor under finger protection
and you will be in right space to
s see VC peritoneal fold.

24.  For a uterus upto 12 weeks' size or 250–
300 cm3 volume, it is in the best interest of
patients to perform VH.
 For greater sizes or volumes, after ligating
uterines various debulking procedure like
bisection,morcellation,coring.

26.  Anterior-Posterior bulge is easier to tackle than Transverse
Bulge
 Appropriate insertion of Myoma Screw is of real help in
enucleating the fibroid and for pulling force to drag out.
 While Clamping remain nearer to Uterine border

28.  If hysterectomy can be performed vaginally,
neither route for the hysterectomy should be
changed to other than vaginal nor ovaries be
preserved, when they need to be removed, simply
because hysterectomy is to be performed
vaginally.
 Difficult and it is mandatory to remove ovaries,
one could add laparoscopic assistance.
 benign mobile adnexa for salpingo-
oophorectomy at vaginal hysterectomy.

29. Round Ligament
Cornual Pedicle

30. After ligating the round ligament …clamps are applied over
infundibulo pelvic ligament..cut it to remove tube and ovary
….then ligate the pedicle
Infundibulo pelvic
Ligament
Tube and
Ovary
Tube and Ovary removed

34.  Removal of
large simple
ovarian cyst
after removal
of Uterus

38.  While cutting the pedicle do not fashion or else
the intervening area may bleed.
 Always transfix the pedicle. Take a bite from the
tip of the pedicle.
 While tightening the knot put one thumb near
the knot on one thread and pull the other thread
till the knot is tight. Always take double throw.

39.  Haemostasis is the most important step. After the
hysterectomy is over checking of hemostatis by
putting a surgical pad inside. I keep one of the
thread of TO pedicle long as this pedicle goes out
of vision so by pulling the thread you can
visualise the pedicle.

40.  Anchor the uterosacral to the vault of vagiina.this
gives vault support.

41.  Our doubts are traitors and make us lose the
good, we oft might win by fearing to attempt” by
Shakespeare is so true and applicable for all
those who do not perform VH in the absence of
contraindication and have doubt about
succeeding.

42.  In choosing a hysterectomy technique in women
with benign gynecological conditions without
prolapse, there is no doubt that the vaginal route
is safest, least invasive, economical, cosmetic, and
natural route
 This has the best scientific evidence in its favor
and is the route of choice for most women.
Unfortunately, however, the vaginal route
(though backed by strong evidence) is used in
less than 40% of cases instead of the desirable
and possible 70–90%.

44. Thank you