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Painless hysterectomy, vaginally or laparoscopically assisted

 

Hysterectomy is traditionally performed through the abdominal route when the uterus is not prolapsed.This involves pain at the incision site. The majority of patients find it painful to turn over,walk,etc on the second post-operative day.The patient has to be hospitalised for 5-9 days and has to take rest from heavy jobs for a period of 3 months at least. In vaginal hysterectomy,the patient can usually go home on the third day itself.

 

Vaginal hysterectomy:
Advantages:

1.When the procedure is done entirely through the vaginal route, there is no incision on the abdomen.

As there is no incision on the abdomen, there is no chance of wound infection or incisional hernia.

2.The patient has very little pain and is very comfortable while bending,turning over,walking,etc from the second day itself.

3.Internationally, various studies have shown that ureteric injuries are fewer when hysterectomy is performed this way.

The patients normally go home on the 3rd post-operative day and are even allowed to travel by bus .

They can resume normal duties within 7-10 days of surgery.

Indications:
In the author's unit, vaginaly hysterectomy is the routine mode of hysterectomy and 99% of all hysterectomies are performed through the vaginal route.Uterus with fibroids upto the size of a six month pregnant uterus (uterus palpaable over the umbilicus) has also been succesfully removed through the vaginal route.  

When there are adhesions in the abdomen due to previous surgery or some other conditions like infection or endometriosis,

or if there is an ovarian cyst in addition to the pathology in the uterus, a Laparascopic Assisted Vaginal Hysterectomy may be done .

An instrument called the laparoscope is inserted through tiny holes in the abdomen and part of the hysterectomy is done using laparoscopic instruments. The rest of the job is completed vaginally.

This procedure also leaves the patient painfree and she can go home on the 3rd day itself.

Cost: Vaginal hysterectomy costs the same as Abdominal hysterectomy.

At Sun Medical Centre, in normal course of events, the rough cost may be just around Rs.35,000.totally. even with Laparoscopic assistance. 

Hysterectomy done in this manner is associated with pain in the days following surgery at the incision site. The patient is kept in the hospital for 5-7 days depending on the time taken for removing the stitches and wound healing. The patient has to convalesce at home for a month and she has to avoid lifting heavy objects for 6 months, the time taken for internal defects to heal. In the first few days after surgery, generally there is some amount of pain and assistance may be needed for getting up from bed, moving towards the toilet, etc, as abdominal incisions tend to be painful. The degree of mobility achieved by a patient after surgery varies from patient to patient depending on each patient’s pain threshold, length of incision, etc.

Vaginal hysterectomy:

Uterus is closest to the natural opening in the woman, the vagina. When hysterectomy is done vaginally, a cut is made into the vagina, and the attachments of the uterus to the body are severed through the opening thus made and the uterus delivered out. The incision on the vagina does not cause pain to the patient, as it is generally not as sensitive as the skin. Advantages:

1.When the procedure is done entirely through the vaginal route, there is no incision on the abdomen. As there is no incision on the abdomen, there is no chance of wound infection or incisional hernia.

2.The patient has very little pain and is very comfortable while bending, turning over, walking, etc from the second day itself after surgery. The patients normally go home on the 3rd post-operative day and are even allowed to travel by busThey can resume normal duties within 7-10 days of surgery.

3.Internationally, various studies have shown that ureteric injuries are fewer when hysterectomy is performed this way.

Disadvantage: Technically vaginal hysterectomy is more difficult to perform for the average gynaecologist and thus the facility is available only in selected centers with gynaecologists trained in the procedure. The cost of therapy is the same for both the procedures.

Laparoscopic hysterectomy:

Hysterectomy is completed using an instrument called the laparoscope. Laparoscope is an instrument through which the contents of the abdomen are visualized through a telescope introduced through a small 1cm incision below or in the umbilicus. The intra-abdominal organs are visualized on a TV screen via a CCD camera fitted on to the telescope. The connections of the uterus are severed through instruments inserted through small 5mm incisions on the abdomen and the final removal achieved through the vagina.

Laparoscopic assisted vaginal hysterectomy:

Sometimes, parts of the connections are released laparoscopically and the rest released vaginally. This is called laparoscopic assisted vaginal hysterectomy (LAVH). The after effects of hysterectomy are the same as if the procedure is done vaginally. There is minimal pain and hospital stay is reduced.

 

Which is the best route of hysterectomy?

Hysterectomy done by the vaginal or laparoscopic method is defininitely advantageous to the patient by way of comfort in the post-operative period as compared to abdominal hysterectomy. However, as traditionally hysterectomy was done by the abdominal route, the average gynaecologist is trained to do abdominal hysterectomy for most indications, except when the uterus is prolapsed.

Vaginal hysterectomy in a non descent uterus, laparoscopic hysterectomy, etc require special training, commitment on the part of the surgeon, and specialized equipment and back-up facilities like staff who can help use the instruments. Thus the odds that the procedure will be completed without opening the abdomen when the procedure is posted for laparoscopic or vaginal hysterectomy depends a lot on the skill of the operator.

The degree of pain after these procedures depends a lot on the indication for which hysterectomy is done and the amount of manipulations the operating surgeon does while doing surgery. Patients who have a lot of adhesions in the abdomen do tend to get more pain than patients who have no adhesions. Adhesions are found in patients with history of previous surgery, history of infections,in patients with endometriosis, etc.

It is claimed that laparoscopic surgery is assossiated with less pain compared to vaginal hysterectomy, but we do not have large studies to vouch for the fact.

Besides pain, larger uteri and presence of adhesions make hysterectomy more difficult whichever the route employed. Thus, when hysterectomy is done for large fibroids, or for women who have undergone surgery before, there is a greater tendency for the surgeon to employ the abdominal route for surgery. If the case is posted for vaginal/laparoscopic hysterectomy, there is a greater chance for inadvertent opening of the abdomen. In the hands of experts, there is less likelihood for opening the abdomen even when hysterectomy is done for such indications.

There is less chance for ureteric injuries when hysterectomy is done entirely through the vaginal route.

Otherwise, injury rates are comparable by all methods. Ureteric injuries were supposed to be higher in the laparoscopic group when staplers were used to clamp vessels. Most surgeons in India do not use this equipment, being costly.

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