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Vaginal Hysterectomy: Techniques and Tips

Vaginal Hysterectomy: Techniques and Tips. Mickey Karram M.D. Director of Urogynecology The Christ Hospital Clinical Professor of Ob/ Gyn & Urology University of Cincinnati. Objectives. Describe the important factors in choosing the best route of hysterectomy

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Vaginal Hysterectomy: Techniques and Tips

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  1. Vaginal Hysterectomy: Techniques and Tips Mickey Karram M.D. Director of Urogynecology The Christ Hospital Clinical Professor of Ob/Gyn & Urology University of Cincinnati

  2. Objectives Describe the important factors in choosing the best route of hysterectomy Review some ways to optimize hysterectomy outcomes Discuss and show videos of techniques to perform vaginal hysterectomy

  3. Vaginal Hysterectomy “If you are going to have your tonsils removed, would you prefer they be taken out through your throat or through an incision in the side of your neck?” - Chassar Moir

  4. Minimize Bleeding During Vaginal Surgery • Preoperative assessment • Discontinue NSAIDS, ASA 2 weeks pre-op • Bleeding diathesis • Careful entry into proper tissue planes • Normal saline injection • Lidocaine 1% with epinephrine 1:200,000 • Pitressin

  5. Difficult Entry into Posterior Cul-de-Sac can be caused by: • Shallow Pouch of Douglas • Long cervix • Endometriosis • Posterior cervical or lower uterine segment myomas • Pelvic adhesions

  6. Difficult Entry into Posterior Cul-de-Sac • Traction-countertraction • Sharp dissection • Digital rectal exam • Extraperitoneal pedicle ligation • Palpation of cul-de-sac via anterior colpotomy • Division of posterior cervix

  7. Difficult Entry into Anterior Cul-de-Sac • Try to see the peritoneum before cutting • Traction-countertraction • Sharp dissection • Extraperitoneal pedicle ligation • Digital palpation of anterior reflection via the posterior cul-de-sac • Uterine sound in bladder; retrograde bladder fill

  8. Traction and Counter-traction help to increase the distance between the clamps and the ureter, thus minimizing the risk of ureteral injury during vaginal hysterectomy

  9. Use sharp dissection to separate the bladder from the cervix until you can see the peritoneal edge

  10. Clamp and ligate the pedicles in continuity to help avoid bleeding

  11. Route of Hysterectomy May the vaginal hysterectomy never be to gynecology what breech delivery has become to obstetrics. - George Morley

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