RESURGENCE OF NONDESCENT VAGINAL HYSTERECTOMY(NDVH)-THE NEED OF THE HOUR?.

Dhanya R Shenoy 1 and Prameela Menon 2 . 1. Junior Resident, Department of Obstetrics and Gynaecology, Amala Institute of Medical Sciences, Thrissur, Kerala-680555. 2. Associate Professor, Department of Obstetrics and Gynaecology, Amala Institute of Medical Sciences, Thrissur, Kerala-680555. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 02 December 2018 Final Accepted: 04 January 2019 Published: February 2019


ISSN: 2320-5407
Int. J. Adv. Res. 7 (2), 179-184 180 Introduction:-Hysterectomy is the second most common operation performed by gynaecologist, next only to caesarean section 1 . Estimates suggest that one in nine women will undergo hysterectomy in their lifetime. Hysterectomy has undergone many important changes recently. As minimally invasive technology continues to be developed and refined, surgeons must be discerning in choosing the safest, cost-effective surgical approach associated with best outcomes for each individual patient. The motive to try to suit the surgical procedure to modern medicine, which aims at maximum reduction of surgical damage, has led to the rediscovery of vaginal route.

Rationale of the study:-
Against the background that, theoretically abdominal exploration is likely to be a major surgery than the vaginal exploration; and the complications like paralytic ileus, incisional hernia, infection etc. are likely to be less with vaginal route, we are trying to find out if NDVH has an edge over the traditional TAH for benign conditions of the uterus, size less than 14 weeks. This comparative study analyses the surgical indications, intraoperative complications and clinical outcomes of patients who underwent Non Descent Vaginal Hysterectomy(NDVH) and Total Abdominal Hysterectomy (TAH) with a similar background.

Aim:-
To find out if NDVH is more safe, efficacious and patient friendly as compared to the traditional TAH for benign conditions of the uterus, size less than 14 weeks Objectives:-1. To compare safety of NDVH versus TAH in terms of intra and postoperative events like duration of surgery, amount of blood loss, intra and postoperative complications. 2. To find out if NDVH is more patient friendly than TAH in terms of postoperative pain and postoperative hospital stay 80 patients requiring hysterectomy for benign gynaecological disorders, uterine size less than 14 weeks was included in the study, the two groups consisting of forty cases each of NDVH and TAH respectively. As the number of TAH outnumbered NDVH cases, the very next TAH(with similar patient characteristics) performed after an NDVH was included in the study.

Materials and Methodology:-
Inclusion criteria:-Women undergoing hysterectomy for benign gynaecological disorders, uterine size less than 14 wks during the study period in AIMS, Thrissur.
Exclusion criteria:-1. Patients with uterovaginal prolapse 2. Patients with 3 or more prior major abdominal surgeries ( as they are more likely to have intra-abdominal adhesions)

Details of the study:-
The patient, after discussing the pros and cons of both the surgeries with the consultant, herself decided the route of surgery. All vaginal hysterectomies were performed without laparoscopic assistance and the need for BSO was decided by individual case scenario irrespective of the route of surgery.
Detailed history and examination was followed by the necessary preoperative investigations. All patients were followed up from the day of surgery till they got discharged from the hospital. There was no increase in intraoperative or postoperative morbidity, postoperative pain or duration of hospital stay with use of volume reduction procedures. 5. Technical difficulty was encountered in two cases of vaginal hysterectomy, due to adhesions and the contour of the fibroid expanding anteroposteriorly preventing descent. Conversion of vaginal hysterectomy to abdominal hysterectomy was associated with slightly increased blood loss and operative time. 6. Regarding visceral injuries, as we had only a small set of patients we encountered no significant changes in either of the two groups.

Chart 2:-Comparing days of hospital stay of NDVH and TAH
There was no mortality or significant morbidity at 6 weeks follow-up.
Discussion:-   (2015), with significantly higher febrile morbidity in patients undergoing TAH as compared to patients undergoing NDVH. 8,9,10 8,9,10 There was no case of vault infection in our study. Postoperative urinary tract infection and respiratory infection rates were comparable within the two groups, p=0.152 and p=0.237 (>0.05) using fisher exact test. Regarding the effect of volume reduction procedures in ndvh, there was no statistical difference between intra/postoperative complications, postoperative pain or duration of hospital stay when volume reduction procedures were undertaken. However there was significant increase in the operative time with the use of volume reduction procedures in NDVH p=0.03(<0.05), probably because these procedures were adopted only when there was difficulty in delivering out the specimen due to comparatively larger size uterus.
In our study, postoperative pain was significantly decreased during day 1, 2 and 3 following NDVH as compared to TAH. This finding was correlating with the study done by Rathinthra Nath Ray, 2015 11 and Shivan et al, 2017 12 where they found day3 mean pain score in NDVH as 2.88 and 1.8 and that of TAH as 6.48 and 2.88; with the difference in the pain rating score between the two groups to be very much statistically significant with a P value<0.05. 11  13 The Cochrane data base study also reports a shorter hospital stay and earlier return to normal activities for Vaginal Hysterectomy.  8 Harris WJ (1995) 9 Nidhi Sharma (2015) 10 Our study (2017 3 3.6 5.0 Kovac (2000) 4 2.8 3.9 Miskry et al (2003) 13 3 5 Our study 3.3 5.5