A Comparison of Intraoperative and Postoperative Morbidity in Women Undergoing a Nondescent Vaginal Hysterctomy by Debulking Procedures vs the Conventional Method

INTRODUCTION

In the scenario of hysterectomy of an undescended uterus via the vaginal route, the nondescent vaginal hysterectomy concept has gained a huge momentum recently because of its lesser intraoperative and postoperative morbidity, better outcome, and better patient acceptance. The overall morbidity and mortality is lower when compared to the abdominal hysterectomy, as it has additional advantages of no abdominal wound, no disturbance to the intestine, and no general peritoneal insult. Thus, it is significantly useful in operative management of a undescended uterus such as functional uterine bleeding, leiomyoma, adenomyosis, and dysplastic uterus. Performing NDVH via the conventional method has certain limitations: it can be done in multiparous uteri of a normal size but quite difficult in cases including uterine enlargement beyond 12 weeks in addition to hypertrophic elongation of the cervix (which causes a highed up anterior pouch) and in cases with endometriotic adhesions, etc. In these cases, debulking procedures are being used to reduce the bulk of uterus to facilitate the vaginal delivery of the uterus. A debulking procedure is indicated when, during the course of procedure, after the Mackenrodt’s and uterosacral ligament complex has been ligated and both anterior and posterior pouches have been opened, it becomes apparent that the traction applied on the cervix fails to move the uterus any further in downward direction. These procedures include a bisection of the uterus, morcellation, circumferential incision CIMR, spiral incision, and traction for uniform uterine enlargement as in adenomyosis, DUB, and chronic PID with parametritis. For irregular uterine enlargements such as fibroids and cervical hypertrophy, procedures available are wedge excision, myomectomy—internal (tunneling), external, and cervical wedge. It is only natural to believe that these procedures would increase the time of surgery, prolong anesthesia, increase intraoperative blood loss, and increase the incidence of bladder and rectal injuries and postoperative sepsis. The present study is done to compare intraoperative and postoperative morbidity in patients undergoing a nondescent vaginal hysterectomy via debulking procedures vs conventional methods.

AIMS AND OBJECTIVES

To study and compare intraoperative and postoperative morbidity in women undergoing a nondescent vagina hysterectomy by a debulking procedure vs the conventional method.

MATERIALS AND METHODS

The study was conducted at the Department of Obstetrics and Gynaecology, Sarojini Naidu Medical College, Agra from July 2017 to July 2018.

Group I—multiparous women with an enlarged uterus (more than 12 weeks size) undergoing NDVH by the conventional method will form the control group.

Group II—multiparous women with an enlarged uterus (more than 12 weeks size) undergoing NDVH by the debulking procedure will form the study group.

DISCUSSION

Removing a normal-sized uterus vaginally in uncomplicated cases is a simple and safe procedure requiring no elaborate setup and yields a promising postoperative outcome. Large-sized uteri can be removed in whole up to 10–12 weeks via some form of a debulking procedure, also reffered to as a reduction technique. Reduction techniques have enabled us to remove many uteri that ordinarily would fall prey to a laparotomy.

Vaginal hysterectomy was performed in 1813 by Langenback in Germany and in 1829 by John Collens Warren in Boston. In 1894, surgeons from France were successful in designing clamp methods for securing the ligaments and vascular edicles, and devised morcellation and hemidissection techniques and even proposed the vaginal approach for pelvic inflammatory disease.¹ Intramyometrial coring was introduced by Lash² of Chicago in 1941, who advocated the method as a means of reducing uterine size without entering the uterine cavity in cases of pyometra and with cancers of the isthmus and corpus. Chauveaud and Fernandez³ did a retrospective study in a university hospital analyzing 148 total hysterectomies in women without vaginal deliveries performed from 1991 to 2000 and found that the mean operation time was 87 minutes in patients undergoing a hysterectomy via the abdominal route. Alwani et al. and Balakrishnan^4,5 compared the efficacy of vaginal hysterectomy (VH) and abdominal hysterectomy (AH) of undescended uterus and found that NDVH via the debulking procedure have several benefits over AH in terms of early ambulation mean days 1.75 in VH vs 2.25 days in AH, less need of analgesic doses postoperatively in 2.80% cases of VH/in 5.11% cases of AH, resumption of bladder/bowel activity in 8.62% cases of VH/in 18.75% cases of AH, and hospital stay of pt of VH for mean days of 4.44 and patient of AH for mean days of 6.96. Studies done by Jain et al. and Sushil et al.^6,7 in 170 cases showed that NDVH offers several benefits over AH in terms of less intraoperative blood loss, less febrile morbidity, low postoperative complications, fast recovery time, less hospital stay; thus the vaginal route is the choice of operation. Multiple authors have suggested less intraoperative blood loss and better postoperative outcomes in vaginal hysterectomies compared to laparoscopic and abdominal hysterectomies.^8–13

In our study in the VH group, maximum cases belonged to the age group of 36–40 years (Table 1). Maximum cases (i.e., 40 cases) were fourth para and above. An estimated 48% cases had complaints of DUB, 32% had fibroid uterus, 8% cases had adenomyosis, and 12% cases had PID. In patients of AH, maximum cases (i.e., 36% cases) are of the age group 36–40 years. Maximum cases (66%) were third para. An estimated 52% cases had complaints of DUB, 20% had fibroid uterus, 12% had adenomyosis, and 16% had PID (Table 1).

In 42% cases, only one sponge got completely soaked in patients of VH. In maximum cases (36%), one sponge got moderately soaked with blood in patients of AH (Table 2) and this was statistically significant. Of the 100 cases, there were no cases of bladder and bowel injury. There were 8 cases who required blood transfusion postoperatively and 2% cases had to be converted into abdominal route during surgery in group of NDVH patients. No surgical complications were seen and 6% cases required blood transfusion postoperatively in the group of AH patients. Maximum number of cases required 46–50 minutes for NDVH and 26–30 minutes for AH (Table 2).

Maximum cases (56%) required catheterization for 36–48 hours and 36% cases got mobile in 37–48 hours after surgery in NDVH group, while in patients of AH, 40% required catheterization for 36–48 hours. Moreover, 42% cases got mobile in 25–36 hours (Table 3).

The postoperative complaints and in followup complains, febrile morbidity was noticed in 12 cases (Table 3). Bleeding per vaginum was noticed in 6 cases and 8 cases complained of urinary tract infection in patients of NDVH. However, in patients of AH, febrile morbidity was noticed in 4 cases and urinary tract infection in 2 cases (Table 4).

Above results show that no appreciable difference was found in the nondescent vaginal hysterectomy performed in the debulking procedures group when compared to the conventional nondescent vaginal hysterectomy group as far as intraoperative complications, postoperative catheterization, postoperative duration of intravenous drip, reappearance of bowel sounds, postoperative mobilization, and postoperative duration of hospital stay are concerned.

CONCLUSION

An enlarged uterus tests the patience, surgical ability, and enthusiasm of thegynecologist. Whatever be the reason for uterine enlargement, one thing stands out in common and that is, a grossly reduced working space in the vagina. Depending on the type of the enlargement, be it uniform or irregular, bisection of the uterus, morcellation, coring, spiral incision and traction, wedge excision, myomectomy, and cervical wedge have been put to use with appreciable success in the vaginal delivery of large-sized uteri during a vaginal hysterectomy.

By virtue of conserving operating time and avoidance of an undue pull on the suspensory ligaments, a better postoperative recovery, lesser morbidity, and better overall acceptance of the procedure is achieved.

The debulking procedure, though may appear to be more mutilating, provide the surgeon the above-said advantages.

It is therefore recommended that when the going becomes difficult in delivering the uterus in masse, there should be no hesitation in adopting a particular debulking procedure as the situation may demand.

REFERENCES

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