Background: Vaginal hysterectomies have been associated with difficulties in patients who have had cesarean sections prior to such hysterectomies. However, the Purohit technique may obviate the problems and make it easier to perform these operations. Objectives: This research tested an approach designed to facilitate vaginal hysterectomy in patients with previous cesarean sections in the absence of fixed adhesions of uterine corpi to previous anterior abdominal scarring. Design/Method: An observational study was conducted in a private general hospital between February 2010 and June 2012. All candidates for hysterectomy for benign indications who had had previous cesarean sections were examined for the presence of clinical and sonographic signs of fixed adhesions of uterine corpi to anterior abdominal-wall incisions caused by prior cesarean sections. Candidates who had such adhesions were not given vaginal hysterectomies. Results: Sixty-four (64) consecutive candidates were selected for vaginal hysterectomies. Of these patients, 26 (40.62%) had 1 cesarean section, 33 (51.56 %) had 2 cesarean sections, and 5 (7.81%) had 3 cesarean sections. Four (4) patients had had prior pelvic operations. The uteri were smaller than 12 weeks' gestationsize in 62 (96.87%) cases. In 26 (40.62 %) cases, there were no obstruction to accessing the anterior cul-de-sacs and vaginal hysterectomies were performed using the Purohit technique. In 38 (59.37 %) cases, dense uterovesical adhesions obstructed access to the anterior cul-de-sacs and a posterioanterior approach was used to perform vaginal hysterectomy in these patients. Vaginal hysterectomy was completed in all 64 cases. Vaginal salpingo-oophorectomy was performed in 3 (4.68%) cases. The mean operative time was 78. 59 -33.15 (35-190) minutes. The mean weight of specimen uteri was 161.01 -108.87 (50-550) g. No patients needed conversions or blood transfusions. No patients had bladder, ureteric, or thermal injuries. Finally, there were no other major postoperative complications. Conclusions: In the absence of fixed adhesions of the uterine corpus to previous anterior abdominal scarring, vaginal hysterectomy for benign indications associated with previous cesarean section may be accomplished safely. The posterioanterior approach during vaginal hysterectomy may avoid unintended bladder injury in the presence of dense uterovesical adhesions caused by previous cesarean sections. ( J GYNECOL SURG 29:7)

No abstract

BackgroundObliterated posterior cul-de-sac has been a real surgical challenge during vaginal hysterectomy. The present study demonstrates an anteroposterior approach to accomplish the vaginal hysterectomy in cases faced with an obliterated posterior cul-de-sac.MethodsIn a retrospective study in private setup, 51 consecutive cases with obliterated posterior cul-de-sac during vaginal hysterectomy due to severe benign pelvic adhesions were studied to know the feasibility of the anteroposterior approach. The upper limit of uterus size was that of 16 weeks of gestation.ResultsVaginal hysterectomy was completed in 49 (96.08%) cases with obliterated posterior cul-de-sac due to severe benign pelvic adhesions. Two (3.92%) cases needed laparoscopic assistance to complete vaginal hysterectomy. Mean operation time was 109.92±40.13 (45–217) minutes due to the need for careful separation of adhesions from the uterus and indicated additional procedures. Mean weight of specimen uterus was 162±106.51 (40–460) grams. There was no major intra- or postoperative morbidity.ConclusionCompletion of vaginal hysterectomy was feasible using the anteroposterior approach in most of the cases with obliterated posterior cul-de-sac due to severe benign pelvic adhesions.

BackgroundLaparoscopic hysterectomy for benign indications in cases with ventrofixed uterus following previous cesarean section (CS) increases the surgeon’s concern of bladder injury. The present study describes a laparovaginal strategy to avoid bladder injury during laparoscopic-assisted vaginal hysterectomy (LAVH) in cases with ventrofixed uterus following previous CS.MethodsIn a retrospective study conducted in our private general hospital, we included consecutive cases of laparoscopically confirmed ventrofixed uterus associated with previous CS. These were from the cases who underwent LAVH for benign indications. Cases with uterus size >16 weeks of gestation were excluded. Patients’ clinical, intraoperative and postoperative characteristics were studied to evaluate the feasibility of the described laparovaginal strategy to prevent bladder injury during LAVH in cases with ventrofixed uterus.ResultsA total of 35 cases with ventrofixed uterus underwent LAVH during the study. Six (17.14%) cases had a history of one CS, while 29 (82.86%) cases had a history of previous two or more CSs. A supravesical loose fatty tissue plane (supravesical space) indicating reach to the bladder wall during laparoscopic lysis of the uterus from the anterior abdominal wall was successfully demonstrated in all the cases. The bladder flap preparation was avoided. Uterovesical adhesions were dissected by posteroanterior approach during vaginal phase of LAVH in all the cases. LAVH was successfully performed in all the cases. None of the cases had bladder injury, laparotomic conversion or other major complications. Mean operating time for LAVH was 149.71±38.36 minutes (70–200 minutes). Mean uterine specimen weight was 162.85±92.57 g (60–500 g). Mean postoperative hospital stay was 2.42±0.73 days (2–5 days).ConclusionIn spite of severe adhesions in cases with a ventrofixed uterus following previous CS, bladder injury can be avoided during LAVH by the described laparovaginal approach in the present study.Short synopsisThe described laparovaginal approach may avoid bladder injury during laparoscopic-assisted vaginal hysterectomy in cases with a ventrofixed uterus following previous cesarean section.

No abstract