TEALE FENNING

farha · Century Club Joined: 18 May 2007 Posts: 144

: A 55 years old lady is scheduled for vaginal hysterectomy for uterine prolapse.
a)Describe the principles of vaginal hysterectomy (10 marks)

After 5 years, she presented with vaginal vault prolapse
.
b) Define post-hysterectomy (apical) vaginal prolapse (2 mark)

c) Counsel this lady of the options available (8 marks)

Nick Raine-Fenning · Posted: Wed Apr 30, 2008 5:32 pm Post subject: Re: vaginal hystrectomy

Nice question farha .. can I suggest a subtle change to make it more RCOG-like?

A 55 years old lady is scheduled for vaginal hysterectomy for uterine prolapse;

a) Describe the principles of vaginal hysterectomy (10 marks)

After 5 years, she presented with vaginal vault prolapse:

b) Define post-hysterectomy (apical) vaginal prolapse and outline the predisposing factors (3 marks)

c) Counsel this lady of the options available to her (7 marks)

farha · Century Club Joined: 18 May 2007 Posts: 144

As you wish boss

Xerxes I · Posted: Sun Jun 08, 2008 12:55 pm Post subject:

A 55 years old lady is scheduled for vaginal hysterectomy for uterine prolapse;

a) Describe the principles of vaginal hysterectomy (10 marks)

Ok, let's bubble
Pronciple's of vag hyst....

Introduction
preferred method of hysterectomy, if feasible, according to systematic reviews. Cheaper, better complication profile and accpetable post op morbidity. High patient saatisfaction.

Pre op,
patient selection, size matters, nodefinitive limit, depends on experience and patient's anatomy. useful to have a pelvic USS before hand to see if any major fibroid and also to see how ovaries are.

Mobility and descent not an issue in this patient

Consent.

Riask of bladder, bowel and ureteric injury. Post op bleeding and vault haematoma in particular important. Possibility to convert to abdominal.

intraop and techniques,
EUA

(dicided not to go into step by step details, I don't think they want that, or do they?)

deflect bladder important, using sharp and blunt dissection, be careful.

If bladder injury suspected, methylen blue as if recognised, can be dealt with easily

post fornix or anteriior whichever easier to be opened into peritoneal cavity.

When opening post fornix, careful as there might be bowel in the pouch.

Good haemostatic sutures. Don't pull on the uterine pedicles!

If vault comes down to introitus, Sacrospinous fixation should be done at the same time. this should be discussed with patient beforehand.

McCall's culdoplasty should be performed to decrease the risk of enterocele.

suturing cardinals and uterosacrals to the vagina to prevent vault prolapse.

peritoneal closure not recommended as lenghens the operation without any benefits.

Foley's +/_ pack,

Post op: routine, mobilise, LMWH etc

Xerxes I · Posted: Sun Jun 08, 2008 1:36 pm Post subject:

After 5 years, she presented with vaginal vault prolapse:

b) Define post-hysterectomy (apical) vaginal prolapse and outline the predisposing factors (3 marks)

Definition: if the vault comes down two a point that is 2 cm less than vaginal lenghth away from the introitus, it's vault prolapse. (this is the most stupid way of describing a simple thing!). Previous vag hyst due to prolapse is associated with a higher risk of post hysterectomy vault prolapse.
Other general risk factors like age, chronic cough, asthma, smoking etc. It is thought that genetic plays a part, quality of collagen etc etc

Xerxes I · Posted: Sun Jun 08, 2008 1:50 pm Post subject:

c) Counsel this lady of the options available to her (7 marks)

conservative:
do nothing if asymptomatic.

If symptomatic prolapse, PFE unlikely to solve the problem but may have a role in reducing recurrence post op, nobody knows.

Ring pessary may be tried but may fall out if deficient perineum, shelf is appropriate if not sexually active

Sacrospinous fixation is good, risk of pudental artery injury,
deviates vaginal axis,

If sexually active, abdominal (or lap) sacrocoplopexy is a good one. good results, better sexual function but more morbidity.

Only Ant+Post repair is not enough

Coldocleisis if recurrent and no sexual activity ever again.

There are some more but I can't remember, suturing the vault to the anterior abdominal wall, etc etc, they don't work anyway (or better said, no evidence that they do.

drhatta · Joined: 20 Feb 2007 Posts: 32 Location: Malaysia

When Q says Describe the principles of 'any' surgery... what r the salient points one have to include?