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BISECTION, MYOMECTOMY AND CORING IN VAGINAL HYSTERECTOMY OF LARGE UTERUS

Shailesh Kore*, Anjali Sah**, Aparna Hegde**,Sushma Srikrishna**, Vr Ambiye***
Lecturer; **Registrar; ***Honorary, Head of Unit; Dept. of Obstetrics and Gynaecology, LTMMC and LTMG Hospital, Sion, Mumbai - 400 022.

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A study of 19 patients of vaginal hysterectomy done for large uterus of size equivalent to 8-16 weeks of gestation is presented.
Techniques like bisection, myomectomy and coring were used during vaginal hysterectomy. The procedure could be successfully done in all patients.

INTRODUCTION

Despite the evidence that vaginal route of surgery is associated with faster recovery and fewer complications, almost 50% of hysterectomies are done abdominally. The main indication for vaginal hysterectomy remains the treatment of utero-vaginal prolapse whereas the other common indications of surgery like enlarged uterus, menstrual abnormalities are treated by the abdominal route. [1] until and unless associated with a significant degree of prolapse. This may be attributed to personal preference but mainly to lack of training or experience leading to a reluctance to perform the procedure by vaginal route in cases of enlarged uterus, absence of uterine descent, previous pelvic surgeries or when hysterectomy has to be combined with oophorectomy. These views are held despite the evidence that the above factors are no more than relative contraindications for the vaginal route. Various publications and numerous literature also describe the use of vaginal hysterectomy in these situations. Here we report our experience with the use of vaginal hysterectomy in case of large uterus of a size equivalent to gestation of 8-16 weeks.

MATERIAL AND METHODS

At LTMG Hospital more popularly known as Sion Hospital, the Dept. of obstetrics and gynaecology has six functional units. During 2 year study period the total number of hysterectomies in our hospital were 1268. Out of which 722 were vaginal and 546 were abdominal. In our unit better known for its vaginal work, out of a total of 379 hysterectomies 291 were done vaginally. This data does not include radical hysterectomies done for malignancy. In this paper we have analysed 19 patients where vaginal hysterectomy was done in a bulky uterus of a size equivalent to a gestation of 8-16 weeks (Table 1).

TABLE 1 Material and methods
	Overall (6 Units)	Dr. VR Ambiye Unit
Total hysterectomies(2 yrs. study period)	1268	379
Vaginal Hysterectomy	722	291
Abdominal hysterectomy	546	88

Analysis of 19 cases of vaginal hysterectomy for bulky andenlarged uterus of size equivalent to 8-16 weeks gestation.

Most of the patients were in the age group of 40-45 years and were parous, a favourable factor for the vaginal route of surgery (Table 2).

TABLE 2 Age and parity
Age (yrs.)	No. of patients	Parity	No. of patients
35-40	3	1	2
41-45	9	2	3
46-50	4	3	6
50 and above	3	3 and more	8

Majority had complaints of menstrual irregularities and pain in abdomen. Only 2 patients had complaints suggestive of prolapse, one patient had a past history of LSCS. Apart from second degree prolapse in 2 symptomatic patient, more patients had first degree prolapse on per speculum examination. Clinically the largest size of uterus was equivalent to 15-16 weeks (Table 3). Clinically all cases had mobile uterus. Pre-op D and C / Cervical biopsy / Pap smear was done to rule out any uterine or cervical malignancy. Pre-op sonography was done to confirm the diagnosis; in our series 13 cases had fibroid and 6 cases had symmetric enlargement of uterus suggestive of adenomyosis. Sonography also helped to know the site, size and number of fibroid as well as to rule out any adnexal pathology which was helpful in planning of the surgery. Informed consent for vaginal hysterectomy sos abdominal hysterectomy was taken in all cases. All operative procedures were done by our Unit Chief or Lecturer.

TABLE 3 Age and parity
Size of uterus	No. of cases
(in weeks of gestation)
8-10	8
10-12	6
12-14	4
14-16	1

infiltration was done. Circumferential incision was taken and bladder was dissected. Anterior and posterior pouches were opened. Uterosacral / cardinal ligaments were clamped, cut and transfixed. Uterine vessels were clamped, cut and ligated. The next step depended on the size and characteristic of the uterus and included bisection, myomectomy, morecellation and lash technique (coring). It is very important that all these techniques are carried out only after securing uterine vessels as the operation becomes relatively bloodless after this. Fortunately, relationship of uterine vessels with isthmus remains unchanged even after enlargement of uterus making it easier to clamp it vaginally than abdominally.

BISECTION
Bisection was the most frequently used technique in all but one patient. Cervix was grasped by volsellum bilaterally and the uterus was bisected in antero-posterior direction with knife with progressive reposition of volsellum till the fundus was reached and pedicles clamped. In a few cases complete bisection was required so that one half of the uterus could be delivered out into the vagina and pedicle secured. Apart from taking of tension on the infundibulopelvic ligament allowing the descent of the uterus it also helps in removal of small myomas during the course thus reducing the bulk of the uterus. The protection of bladder, rectum and vagina is very important in such procedures.

Myomectomy
Myomectomy was usually combined with bisection or morcellation. It was continued only till further descent of the uterus could be achieved.

Morcellation
Morecellation of large fibroid was done in one case along with bisection of uterus helping in decreasing the bulk and delivery of the uterus into the vagina.

Lash technique (coring)
In Lash procedure [2] (coring) the uterine wall was cut circumferentially few mm at a time maintaining constant traction of the cervix all the time. As the fibres are cut the uterus elongates. The next series of incisions are given at a higher level till the fundus could be delivered out.

Only bisection was required in 10 patients while lash technique was sufficient in 2 patients in adenomyosis of 14 weeks ize uterus (Table 4).

Once the uterine fundus could be delivered into the vagina the hysterectomy was completed in the usual fashion. Bilateral salpingo-oophorectomy was done in 2 patients. Thus in all 19 patients the procedure could be successfully completed vaginally. Post-op care was routine with post-op antibiotics.

The average operating time was 42.5 minutes with a range of 35-115 minutes. One patient required post-op blood transfusion. Two patients had macroscopic haematuria which cleared off within 24 hours. There were no other intra-op or post-op complications. The average hospital stay was 4.6 days (Table 5).

TABLE 4
Techniques used	No. of cases
Only bisection	10
Bisection with myomectomy	5
Bisection with myomectomy with morcellation	2
Lash technique (Coring)	2

 

TABLE 5 Results
Average operating time	42.5 min.
Blood transfusion	1 pt.
Macroscopic hematuria	2 pts.
Bilateral salpingo-oopherectomy	2pts.
Average hospital stay	4.6 days.

DISCUSSION

Though our experience of vaginal hysterectomy in large uterus is very limited the literature describes numerous publications in this field. The Magos et al in his series removed large uteri weighing more than 1000 grams vaginally successfully. [3] This clearly shows that vaginal hysterectomy should be considered even in cases of considerable uterine enlargement as it offers the women several benefits over abdominal surgery in terms of shorter anaesthesia, shorter operating time, reduced hospital stay, less morbidity less cost. [4]

Though laparoscopic surgery offers an alternative with its less invasive nature and its short hospital stay the operative time and cost is much more. Also bladder and ureteric injuries are more frequent in laparoscopic and abdominal surgeries. [4,5]

But for success in such difficult vaginal procedures proper selection of patients is important. Important consideration in such situations are good vaginal vault access, uterine mobility and absence of genital malignancy. Though rare in Indian women the vaginal vault access may be reduced in nulliparous, morbidly obese and some post menopausal patients. Uterine fixity or gross pelvic pathology should be ruled out by history or clinical examination before attempting vaginal surgery. Past multiple pelvic operations can pose a problem with dense adhesions. Magos et al and others have recommended the use of laparoscopy to rule out adhesions in such conditions prior to vaginal surgery p[3]

For proper vaginal vault access correct lithotomy position with well abducted and flexed hips is important. This allows the assistant to stand inside the patient’s legs giving an unobstructed view of the operating site allowing proper retraction.

The vital role of the two assistance can hardly be overemphasized. As everybody knows a poor assistant can make an easy job difficult and a difficult job almost impossible while a good assistant can make a difficult hysterectomy look relatively simple.

As Campbell said "The bulk of the uterus to be removed is not a contraindication to the vaginal route". [6] Within limits these words are true even today. Moderate enlargement of the uterus should not be looked upon as contraindication to vaginal hysterectomy and should certainly not be used to justify the use of abdominal and laparoscopic surgery.

REFERENCES

1. Amirikia H, Evans TN. Ten year review of hysterectomies. Am Journ Obst and Gynaec 1979; 134 : 431-7. 2.
2. Lash AF. A method for reducing size of the uterus in vaginal hysterectomies. Am Journ of Obst and Gynaec 1941; 42 : 452.
3. Magos A, Boyiras N, Sinha R, Richardson R. Vaginal hysterectomy for the large uterus. British Journal of Obstetrics and Gynaec 1996; 103 : 246-51.
4. Richardson RE, Bournas N, Magos AL. Is laparoscopic hysterectomy a waste of time. Lancet 1995; 345 : 36-41.
5. Kadar N, Lemmerling L. Urinary tract injuries during laparoscopically assisted hysterectomy. Am Journal of Obstetrics and Gynaec 1994; 170 : 47-8.
6. Campbell ZB. A report on 2798 vaginal hysterectomies. Am Journ of Obst and Gynaec 1946; 52 : 598-613.

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