Evaluation Of Clinical Effect For Difficult Vaginal Hysterectomy

Background:Hysterectomy is one of the most classical and basic gynaecological operations. There are three main approaches:total abdominal hysterectomy (TAH),total vaginal hysterectomy(TVH) and laparoscopic hysterectomy (LH). After reviewing advantages and disadvantages of the various techniques for hysterectomy, the experts reach an unified view:ACOG(The American College of Obstetrics and Gynecology Committee)opinion and two Cochrane reviews of abdominal, laparoscopic and vaginal hysterectomies conclude that:Vaginal hysterectomy is associated with better outcomes and fewer complications than laparoscopic or abdominal hysterectomy and when vaginal hysterectomy is not possible, laparoscopic hysterectomy has advantages over abdominal hysterectomy. Recently with the development of the pelvic surgeries, the advocacy of the minimal invasive concept and the improvement of the surgeons’ skills, the traditional indications of vaginal hysterectomy have been expanded gradually and the traditional contraindications have been challenged which make some "difficult" vaginal hysterectomy be carried out safely and effectively. We analyze the data through the operative time, blood loss, complication rates and some other indexes to discuss the surgical skills and clinical effect of the difficult vaginal hysterectomy and to expand the indications of difficult vaginal hysterectomy.Objective:1. To investigate the feasibility and safety of difficult vaginal hysterectomy;2. To expand the indications of vaginal hysterectomy and provide scientific evidences for the wide clinical applications. Materials and methods:We collected the operative cases for benign pathology of uterus during January2009to January2012, which contained175patients underwent difficult TVH,70patients underwent TAH, and compared the intra-operative and post-operative information between each group. Normally considered contraindications to the vaginal route were:moderate to excessive uterine enlargement, previous cesarean or pelvic surgeries and adnexal pathologies. Patients with uterine prolapse were excluded. The clinical outcomes and complication rates were analyzed even with regards to the type of contraindication.Data were analyzed by SPSS17.0. The t-test and ANOVA were used to test the continuous variables. The chi-square test and Fisher exact test were used to test the categorical variables. Results:The average operation time, the volume of hemorrhage intra-operation, days of bowel function recovery, days of after-surgery stay of difficult TVH group[(70.68±4.57)min,(228.43±24.92)ml,(1.95±0.06)d,(4.50±0.19)d]were significant lower than that of TAH group[(104.17±9.56)min,(362.79±65.85)ml,(2.20±0.13)d,(7.25±1.25)d](P<0.05). The overall incidence of the complications of difficult vaginal hysterectomy was9.71%. The patient characteristics and the incidence of complications did not differ among the groups of contraindications (P>0.05). A linear relationship between the uterine weight and the operative time was not statistically confirmed although the latter increased with the weight of the uterus (P>0.05). The average operation time, days of bowel function recovery, days of after-surgery stay of uteri12tol6weeks group[(67.59±5.64)min、(1.92±0.07)d、(4.37±0.26)d]were not significant lower than that of uteri larger than16weeks group[(78.52±13.63)min、(2.04±0.17)d、(4.57±0.57)d](P>0.05). The volume of hemorrhage intra-operation of uteri12to16weeks group[(212.53±33.80)ml] were significant lower than that of uteri larger than16weeks group[(316.19±83.47)ml](P <0.05). Conclusion:1. Difficult vaginal hysterectomy has advantages of minimal invasive surgery and is better than that of trans-abdominal hysterectomy under conditioned circumstances.2. The incidence of the complications of difficult vaginal hysterectomy implemented on the basis of hierarchical management depending on the vaginal surgical indications don’t increase and also the feasibility and safety of difficult vaginal hysterectomy can be ensured.3. The surgery approach for uterus larger than20gestational weeks should be considered comprehensively.