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1. Troubleshooting in NDVH
Dr. Narendra D. Gajjar MD,DGO.
ASHIRWAD HOSPITAL
CHIKHLI
www.ashirwadhospitalchikhli.com

2.  MD,DGO
MD. From B.J.Medical college ahmedabad 1980
Has been awarded many prizes for outstanding
acedemic achievements
In pvt practice - more than 33 yrs
Past President SOGOG & Chairperson SOGOG
2012 & midterm SOGOG 2015
Operative faculty in workshops - Non descent
Vaginal Hysterectomy
2

3. • Hysterectomy is the most common major gynecological
surgery
• Cochrane data & other trials:
vaginal hysterectomy is preferred over abdominal
hysterectomy
• Laparoscopic hysterectomy is a suitable option of abdominal
hysterectomy but not an option of vaginal hysterectomy

4. INDICATIONS
• DUB 40%
• Fibroid 20 %
• Adenomyosis 13%
• PID 10%
• CIN 5%
• Cervical Polyp 4%
• Complex adnexal mass -- 2%
• Endometrial polyp 5%
• Postmenopausal bleeding 3%

5. PREVENTION OF TROUBLE
• Patient selection
• Success depends upon :
-knowledge of anatomy of pelvic organs
- dexterity, skill and experience
- good operative technique
-confidence of surgeon
- Skilled anesthetist
- Better instruments
- Expert assistants
- Better visualization

6. • Many contraindications have become relative indications.
• Few important points
NDVH – made easy….
-1st degree descent is not mandatory
- large uterus / fibroid 14 to 16 wekks
- previous surgery on uterus - CS
- Mobile adnexal mass / ovarian cyst
- Nulliparity is not a contraindication
- Oophorectomy is possible vaginally
- Atrophic changes / shallow fornices Or in case of
cervix flushed with vagina
Experience converts contraindication in to indication

7. • Absolute Contraindications
advanced Genital tract malignancy
Uterus more than 16-18 weeks size
Previous VVF repair
Frozen pelvis
adnexal pathology demanding other routes

8. TO AVOID TROUBLE
• Perfect knowledge of pelvic anatomy
• Pelvic Examination to assess
- size & mobility of uterus
- stretching the cx downward to
know acquired descent
- assessment of fornices & available
space between Cx & lateral vaginal
wall

9. NDVH IMPORTANT STEPS
- Incision on vaginal wall
• Separation of bladder & opening ant
peritoneum
• Opening the post peritoneum
• Clamping utero sacral & Mackenrodt’s lgts
• Clamping ,cutting & ligation of uterine artery pedical

10. • clamping of round ligament, fallopian tube and ovarian
ligament/ infundibulo pelvic lgt.
• Removal of uterus and or ovaries
• Vault and vaginal angles closure

11. SIZE OF UTERUS
• Size of uterus patients (%)
• Up to 8weeks 78%
• >8 weeks & upto 12 wks 13 %
• >12 weeks & upto 16 weeks 5.5%
• >16 weeks & upto 20 weeks 4.55%

12. FIBROIDS
• Larger the uterus greater
the need of experience
more skill
patience
desire & determination for VH
Assessment of size , depth & location of fibroid , mobility
& availability of uterus free space should be confirmed by
USG & Examination under anesthesia

13. PREVIOUS SCAR ON
UTERUS
• scar of cs/ myomectomy/hysterotomy
• Bowel surgery/ bladder surgery
- sharp dissection
- tissue identification
- traction on cervix
- recognition and repair of injury

14. OT SETUP
• Good instrumentation
• Long & Broad bladded Sims speculum ,
side wall retractors.
Helping hand of another expert surgeon
stand by laparotomy
Strong decision making on the part of surgeon

15. POSITION OF PATIENT

17. NDVH VIDEOS

20. VARIUOS KINDS OF
TROUBLES
• NO DESCENT
• OBLITERATED FORNICES
• DIFFICULT BLADDER DISSECTION
• BLEEDING FROM BLADDER PILLARS AND VESICAL PLEXUS
• OBLITERATED CUL DE SAC AND ADHESIONS IN POSTERIOR FORNIX
• INABILITY TO OPEN POSTERIOR PERITONEUM
• BLEEDING FROM POSTERIOR VAGINAL WALL AND VAGINAL ANGLES
• INSECURE PEDICLES

21. • INJURY TO BLADDER
• INJURY TO RECTUM
• BLEEDING FROM UTERINE VESSELS
• INABILITY TO BRING DOWN UTERUS
• OMENTAL ADHESIONS ON UTERUS
• OBLITERATED UTEROVESICAL POUCH OF PERITONEUM
• UTERUS ADHERENT TO ANTERIOR ABDOMINAL WALL
• LARGE UTERUS /FIBROIDS
• UTERUS DIFFICULT TO DELIVER VAGINALLY
• BLEEDING FROM OVARIAN PEDICLES

22. • SECONDARY HEMORRHAGE
• HEMATOMA BETWEEN VAULT AND BLADDER
• THERMAL INJURY TO BLADDER BY VESSELS
SEALERS
• FISTULA
• VAULT GRANULATION
• VAULT INFECTION

23. • Vaginal hysterectomy in woman with non-descent and
moderately enlarged uterus is safe.
• morcellation
• coring
• Bisection
• amputation of cervix
• oblique cut on uterus
are often needed and the surgeon needs to be familiar
with them.
• With experience, operative time, blood loss and
complications can be reduced considerably.
• This scarless approach should be chosen as a preferred
method of hysterectomy.

25. • It is better to avoid trouble rather then inviting
trouble.
• Training and Development of skill are essential

26. • A well trained and an experienced surgeon can help in
trouble

28. THANK YOU