Frequently asked questions about non-descent Vaginal Hysterectomy

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What is non-descent vaginal hysterectomy:

A hysterectomy comes from Greek word hystera means "womb" and ektomia means "a cutting out of" may be the surgical removal from the uterus, usually performed by a gynecologist. Hysterectomy may be total - removing the body, fundus, and cervix from the uterus; often called "complete" or partial that is removal of the uterine body while leaving the cervix intact; also called "supracervical". It is the most commonly performed gynecological surgical treatment. In 2003, over 600,000 hysterectomies were performed in the usa alone, which over 90% were performed for benign conditions. Such rates being highest in the industrialized world has resulted in the main controversy that hysterectomies are now being largely performed for unwarranted and unnecessary reasons. Is the hysterectomy done vaginally. It is a very simple operation.When vaginal space is adequate and uterus is normal sized or bulky and patient does not require BSO then it is best to NDVH.

For many years involvement in learning about and helping to develop alternatives to hysterectomy, it has been instrumental in refining the use of the laser in an office setting to treat pre-malignant diseases of the cervix. Non-descent vaginal hysterectomy may be a preferred technique over laparoscopic hysterectomy for benign diseases of uterus where extensive pelvic dissection is not required.

Removal of the uterus renders the individual unable to bear children (as does elimination of ovaries and fallopian tubes) and has surgical risks in addition to long-term effects, so the surgical treatment is normally recommended when other treatments are not available. It is expected the frequency of hysterectomies for non-malignant indications will fall because there are good alternatives in many cases.

What is fact and what is not?

Non Descent Vaginal hysterectomy is performed entirely through the vaginal canal and has clear cut advantages over abdominal surgery such as fewer complications, shorter hospital stays and shorter healing time. Abdominal hysterectomy, the most common method, is used in cases such as after caesarean delivery, when the indication is cancer, when complications are expected or surgical exploration is required.

The best type of study is a randomized prospective study, in which subjects are matched before treatment, and then randomly selected to undergo hysterectomy or some other treatment. Obviously, this is a difficult type of study to do, but studies that evaluate subjects before as well as after treatment are still better than retrospective studies. In addition, statements that sound logical may or may not be correct. Such statements need to be tested before being accepted as true. There are many situations in which less extensive surgery may be preferable. There also are times when a hysterectomy may be the best alternative. Each situation is unique. Vaginal hysterectomy was shown to be superior to LAVH and some types of laparoscopic surgery (sufficient data was not available for all types of laparoscopic surgery), causing fewer short- and long-term complications, more favorable effect on sexual experience with shorter recovery times and fewer costs. Hysterectomy is not a religion that one believes in. It is not a political position that one individual for or against. It is a surgical procedure that like any other surgical procedure has both advantages and disadvantages.

Complication after hysterectomy?

Although improvements in medical care have shortened the time required to recover from a hysterectomy, it is still a major operation. There is a small risk of serious complications and even death. These risks need to be compared to the risks of other treatments or no treatment at all, and should be compared to other risks we take in everyday living. There is also pain associated with major surgery. It is found that newer techniques of pain control have greatly reduced this, so most women who are otherwise in good health are able to go home the next day after a vaginal hysterectomy, and two days after an uncomplicated abdominal hysterectomy. Levels of estrogen fall sharply once the ovaries are removed, removing the protective effects of estrogen around the cardiovascular and skeletal systems. This condition is often referred to as surgical menopause, although it is substantially not the same as a naturally occurring menopausal state; the former is a sudden hormonal shock towards the body that causes rapid start of menopausal symptoms such as hot flashes, as the latter is a gradually occurring loss of hormonal levels during a period of years with uterus intact and ovaries capable of producing hormones despite the cessation of menstrual periods. When just the uterus is taken away there is a 3 times and the higher chances of cardiovascular disease. If the ovaries are removed the danger is seven times greater. Several studies have found that osteoporosis i.e. reduction in bone density and increased chance of bone fractures are associated with hysterectomies.

It has been attributed to the modulatory effect of estrogen on calcium metabolic process and the drop in serum levels of estrogen after menopause may cause excessive loss of calcium resulting in bone wasting. Hysterectomies are also linked with higher rates of cardiovascular disease and weakened bones. Anyone who has undergone a hysterectomy with both ovaries removed routinely have reduced testosterone levels when compared with those left intact. Reduced levels of testosterone in women is predictive of height loss, which might occur due to reduced bone strength and density, while increased testosterone levels in women are of a greater sense of sexual desire.

Urinary incontinence and vaginal prolapse are well known negative effects that develop rich in frequency many years after the surgery. Typically, those complications develop many years following the surgery. Because of this exact numbers are not known, and risk factors are poorly understood. It's also unknown when the selection of surgical technique has any effect. It's been assessed that the risk for urinary incontinence is approximately doubled within few years after hysterectomy. One long term study found many fold increased risk for surgery to fix urinary stress incontinence following hysterectomy. The risk for vaginal prolapse depends on factors for example number of vaginal deliveries, the problem of those deliveries, and the kind of labor. Overall incidence is approximately doubled after hysterectomy.

Hysterectomy could cause an increased risk of the relatively rare renal cell carcinoma. Hormonal effects or injury of the ureter were considered as possible explanations. Elimination of the uterus without taking out the ovaries can create a situation that on rare occasions can result in ectopic pregnancy because of an undetected fertilization that had yet to descend in to the uterus before surgery. Two cases happen to be identified and profiled in an publication of the Blackwell Journal of Obstetrics and Gynecology; over 20 other cases have been discussed in additional medical literature

What are the types of hysterectomy?

Many ways are there to classify hysterectomy. Many terms are used in lay articles differently than by the medical profession. For example, many people think that a "total hysterectomy" means taking out the tubes and ovaries. Wrong! It means taking out the entire uterus, with or without removing the ovaries. In the old days, surgeons couldn't safely take out the entire uterus, so they would leave the cervix. This is called a subtotal hysterectomy. Recently there has been renewed interest in leaving the cervix. A special type of hysterectomy, called a radical hysterectomy is done for certain types of cervical cancer.

In medical terms, anything to do with the ovary uses the term "oopher" and the tube is referred to as the "salpinx" (or snake). Removing both tubes and ovaries is called a bilateral (meaning both sides) salpingo-oophorectomy, or "BSO". A BSO may or may not be done with any type of hysterectomy. The other major distinction, with multiple variations, describes how the uterus is removed. If it is removed through the vagina, the procedure is called a vaginal hysterectomy. If it is removed through an incision in the abdomen, it is called an abdominal hysterectomy. Removing the uterus with the cervix through the abdomen is called a total abdominal hysterectomy, or TAH. The ovaries may or may not be removed at the same time.

Why not do all hysterectomies this way?

A LAVH or LH is often less invasive than an abdominal hysterectomy, but more invasive than a vaginal hysterectomy. If the procedure can be done vaginally, then no incisions are needed in the abdomen. There are no data showing that LAVH is superior to vaginal hysterectomy (if it can be done safely). There are situations in which one cannot tell which is the best approach until, actual vision of the uterus and ovaries. In this situation it is often helpful to look with a small laparoscope, and make a decision based on what one had seen.

What is a "laparoscopically assisted vaginal hysterectomy" (LAVH)?

In laparoscopically assissted vaginal hyterectomy cornual structures are dealt abdominally laproscopically. When ahesiolysis is to be performed or oopherectomy is to be performed and surgeon finds difficulty in removing ovaries vaginally or there is a myoma then it is prefered over NDVH. Uterines are not dissected abdominally. Rest of the operation is performed vaginally as in NDVH. There is little debate that recovery is faster if the uterus is removed through the vagina without the need to make an abdominal incision. Some disease processes make the vaginal approach difficult or impossible. Such situations may include large ovarian cysts, extensive endometriosis, large fibroids, or unexplained pelvic pain where the gynecologists need to get a good look at the pelvic organs. In some situations, the surgeon may be able to insert a laparoscope, (a small telescope) through the belly button and be able to see the entire pelvis. Other instruments are inserted through other tiny incisions in the abdomen. These instruments can be used to perform parts of the hysterectomy, and to allow it to be completed through the vagina. In a laparoscopic hysterectomy (or LH) the entire (or most of the) procedure is done through the laparoscope.

Are there still reasons to do an abdominal hysterectomy?

Given enough hours in the day, a skilled laparoscopic surgeon can probably do almost any hysterectomy through the laparoscope. The problem comes in when the time and effort required puts the patient at increased risks for complications. New instruments are aiding in the removal of large tumors, such as fibroids, through the laparoscope. Still, many times the safest route may require an incision. In some operations, such as the removal of a gallbladder or ovarian cyst, most of the trauma and recovery is from the incision rather than from what is done inside. Recovery is much faster if these operations are done through the laparoscope. With a hysterectomy, however, much of the healing required is in the tissues around the uterus. So although recovery is faster when an incision is avoided, the difference is not as great as it is with some other operations.

What are the type of energy sources used in hysterectomy?

Types of energy sources Harmonic scalpel (Ethicon ) is ultrasonic cutting and coagulation device. advantages are There is minimal smoke and charring. When you use simple bipolar there is charring and sticking of the instruments. There is less lateral tissue damage. Great precision near vital structures as it works on lower temperatures. Risk of injury to the bladder and ureter is less. Bipolar has been used for many years for the dissection and skeletonization of the uterine arteries but greatest disadvantage is that there is always charring , smoke and sticking of the instruments. The Ligasure Combination of pressure and energy is used to create vessel fusion. There is melting of collagen and elastin in the vessel wall and a plastin like seal is formed. Lateral thermal spread is 2mm. There is no sticking and charring. Gyrus PK tissue management Provides vapor pulse coagulation (VPC) is also used in hysterectomy. Produces faster and uniform pulse energy in a controlled manner. Tissues are evenly coagulated. There is minimal thermal spread, less sticking and good haemostasis. It requires its own specialized generator. Enseal is again one energy source from ethicon. This electrode is having millions of nano conductive particles each acts like a discrete thermostatic switch to regulate the amount of the current. Less heat is required and there is no charring and sticking. Vessels are fused through compression, protein denaturation and renaturation. So the type of energy source to be used depends on surgeon’s choice and patient’s capicity to pay also. Surgeon must be aware of the energy souce and how to deal with the complications. Sources will continue to improve as the technology is advancing day by day.

In many sudy investigators conducted a study "To compare the three techniques of hysterectomy-total laparoscopic hysterectomy (TLH), laparoscopic assisted vaginal hysterectomy (LAVH) and non-descent vaginal hysterectomy (NDVH).

In conclusion it may be said that NDVH is good procedure in experienced hand compare to LAVH and TLH for small uncomplicated uterus in female with good vaginal access. However, One of the benefits of LAVH or TLH over NDVH is inspection of pedicles at the end of surgery can not de denied.

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