Preparation of Vaginal hysterectomy by electrosurgery (Purohit technique)

Has 3 sections

-- Instruments

-- Laboratory model training

-- Operation theatre experience

Instruments

• Towel 6
• Towel clip 6
• Steriware plastic 1
• Plastic apron 1
• Suction pipe 1
• Suction machine with tube 1
• Suction cannula curve 1
• Bipolar cable 1
• Sponge holder 1
• Large Sim’s speculum 1
• Alli’s forceps 9 inch long 6
• Vaginal wall retractor L type (4 inches blade) 2
• Assistant staff (may not be doctor) 2
• Monopolar pencil (disposable) 1
• Bipolar forceps /bipolar cutter/bipolar scissors/Harmonic focus etc/Bi-clamp- 9 inch long
• Bipolar Generator
• Scissors 9 inch long 1
• Right angle forceps (PTVH forceps) 9 inch 1
• Artery forceps 8-9 inch- 1
• Needle holder 8-9 inch 1
• Suture (Vicryl no 1) 1

For additional procedure

For Morcellation and myomectomy

• Scalpel knife
• Myoma screw
• Tenaculum (single tooth 26 cm) 1
• Cat paw clamp 1
• Large single blade Sim’s speculum 1
• Ovarian cyst aspiration
• 3mm bore long Veress needle( Soonawala needle,Kalelker,Mumbai) for suction aspiration of ovarian cyst
• Previous CS cases
• Uterine sound for uterine retroversion test in previous CS cases

To improve visibility

• For deep field of operation like IP ligament stump-
• Deaver’s retractor (1 inch width )2
• Briskey retractor 1
• LED overhead light
• Pelvic illuminator (R K Purohit) 1
• Fibre-optic cable 1
• Light source 1
• Roller gauze 1 pack
• Curve suction cannula
• For post operative pelvic lavage
• Ryle’s tube no 18 -1
• For Intraoperative lavage
• Normal saline 1 bottle 1
• Bowl 1
• Disposable syringe 20ml -1
• For submucosal hydro dissection and haemostasis
• Inj. Adrenaline or vasopressin
• For Sacrospinous fixation
• Atraumatic Alli’s forceps 1
• Deschamp ligature carrier (right and left) 1 each
• Briskey retractor 1

Sim’s speculum

• Deaver retractor 1
• Suture -Proline no 1
• For patient with pelvic pain
• Post- hysterectomy check laparoscopy
• A set up for diagnostic laparoscopy and few accessory hand instruments for adhesiolysis
• For failed vaginal hysterectomy
• A set up for operative laparoscopy or laparotomy conversion is needed
• For video recording or photo click
• Good mobile phone (Samsung S9+)

2. laboratoty model training

Placenta model training

Requirements:

• Platform 1.
• A large size square tray is required. Place it on a table turning upside down.
• Put a towel on it.
• Place few cotton balls in a kidney trey. The cotton balls soaked in saline are used to clean placental surface, and to moist dry tissue of placenta, also, to clean carbon sticking on to the forceps tip.
• A Bowl filled with normal saline
• 6 Allis forceps to fix membrane
• 2 Artery forceps
• 2 PTVH Right-angle forceps.one for trainee and other for trainer
• 1 Placenta in a plastic pocket. Use the foetal surface for training. The placenta with membrane collected after delivery, placed in refrigerator to avoid smell and decay before use.
• 1 Electrocautery generator. Monopolar setting at 30-35-40watts, bipolar setting 40-45 watts
• 1 Monopolar pencil with cable -connect to machine
• 1 Bipolar forceps with cable-connect to machine
• 1 bipolar cutter (optional)
• 1 bi -clamp (optional)
• 1 Harmonic focus(optional)
• 1 Student
• 1 Mobile phone to record
• 1 LED light

Procedures

Place placenta on the platform. Stretch and spread the membranes on the platform. Fix it to the towel cloth by Allis forceps.

Monopolar pencil

Give square monopolar incision on the smooth fetal surface of placenta. Square incision represents that of the cervico-vaginal incision. Do not incise vessels. Repeat it in many sites.

Learn holding the right-angle forceps (PTVH forceps)

Hold by right hand, direct its tip forward, support ring of handle by index and ring finger lightly.

Applications(there are 4 applications)

Posterior application-Tip of the right-angle forceps applied from the posterior aspect of the target structure(figure)

Anterior application- Tip of the right-angle forceps applied from the anterior aspect of the target structure(figure)

Lateral applications- form Right side of patient - Tip of the right-angle forceps applied from the lateral right aspect of target structure (Figure). Hold the right-angle forceps by left hand.

Lateral application -from left side of patient- Tip of right-angle forceps applied from the lateral left aspect of target structure (Figure). Hold the right-angle forceps by right hand.

Posterior application close to uterus at placenta model- slide tip of right-angle forceps from the maternal surface of placental disc towards the membrane to find a knuckle between disc and membrane. That knuckle is the point where the prongs are opened and the coagulation and cut are done.

Open prongs of right-angle forceps, draw it down a little, stabilise, and then, coagulate between prongs of right-angle forceps and then, incise the coagulated place by scissors. Separate a portion of membrane from the disc repeating the coagulation and separation proceduresNow, rotate the placenta gradually to find intact membrane with disc, and repeat the coagulation- cut - separate procedure of membrane from the disc by posterior application. In case of hysterectomy operation, all horizontal anatomical structures like uterosacral cardinal, uterine arteries, broad ligament, upper pedicles to IP ligament separated using posterior application.

Anterior application placenta model -tip of forceps directed backward, apply it from the anterior aspect of membrane close to disc, press it downward and backward to create a fold. The fold is coagulated and incised above level of bend of forceps. In case of hysterectomy operation, uterovesical peritoneum is usually separated by anterior application, sometime uterine artery is hooked by anterior application.

Lateral application on placenta model-hold forceps by right hand for lateral application from left side of target tissue, direct tip of forceps to left side, take it to the square monopolar incision described above, insert to the left angle of incision to glide the tip between placenta and its amniotic covering. Open the prongs to stretch the membrane. Change hand and hold right -angle forceps by left hand. The membrane is then coagulated and incised by right hand. Similarly, the right-angle forceps is held by left hand for lateral application from right side of target tissue directing its tip to left side, and through left angle of the square incision, tip is glided, membrane is coagulated and incised. In case of hysterectomy operation, lateral application is used to dissect the supravaginal septum,UV scar, fundal adhesions of omentum to uterus, posterior adhesions to uterus, and adnexa adhesions.

Definition of close to uterus - when one side of the blade of bipolar forces touches the side or edge of the uterus or side of the organ you like to remove like ovary. This should be practiced in every step associated with the of separation uterus and organ like to remove such as adnexa (ovary and tube)

These four applications are sufficient for removal of uterus and adnexa.

Coagulation and incision-

• learn coagulation
• cut only coagulated tissue.
• For cardinal uterosacral ligament -coagulate and cut directly
• For uterine artery-skeletonised artery is coagulated at 3 places along is exposed length close to uterus and then, cut.
• For broad ligament -coagulated and cut directly.
• For upper pedicles -coagulate 2 -3 time and then cut.
• For IP ligament -coagulate 2-3 times along expose length similar to uterine artery and then cut.
• Fimbria ovarica-coagulate properly and cut

Morcellation and wedge rection-

Can be practiced on the disc of placenta removing wedges of placental disc. Myomectomy can be practiced on uterus specimen.

Tracing or walking on the margin of posterior lip of broad ligament to find upper pedicles in placenta model

Stretch and fix the incised margin of the amniotic membrane on the platform. The margin is then climbed up by 2 Allis forceps step -by-step to bring down the high-placed disc. It is repeatedly practiced. This is used to trace incised margin of posterior leaf of broad ligament. After hysterectomy operation, hold the posterior cul-de-sac peritoneum with posterior vaginal incision by Allis forceps. Put the Sim’s speculum anterior to the Allis forceps. It stretches the posterior pouch peritoneum. Then by 2 Alli’s forceps, walk step -by- step along the incised margin of posterior lip of broad ligament. After uterosacral ligament uterine artery is seen. Then, ovarian ligament stump will be seen. Pull the ovarian ligament stump in downward and backward direction by Allis forceps. It visualises the tubal stump. Pull the tubal stump gently in downward and backward direction to find the round ligament stump. Hold the round ligament stump, and give the forceps to the assistant. Then, hold the ovarian stump. Check haemostasis and coagulate the raw places if needed to achieve complete haemostasis.

Upper pedicle haemostasis -achieve complete haemostasis before dropping all stumps.

Vault closure-placenta model - to find the supravaginal septum after hysterectomy.

Hold a selected disc margin by Allis forceps one on each side. Slide the horizontally held tip of the right-angle forceps from above downwards using the maternal side of placenta. Find the notch, Turn the tip forward, Open the prongs. And then insert the needle between tips of right-angle forceps. Then, try a purse string suture using the membrane. Ryle’s tube insertion to right side. Then tie knot.

Then. second layer membrane closure was done using hanging membrane below first layer.

Post operative lavage using the IV set and saline is done till the return fluid is clear.

Web training protocol

1.Practical anatomy in VH

• Vaginal vault
• Supravaginal septum
• Uterosacral-cardinal complex
• Uterine arteries
• U-V fold
• Cornual pedicles
• I P ligament
• In-pelvic anatomy
• High-up pelvic anatomy

2.Practical electrosurgery in VH

• Monopolar setting, needle tip width

3.Practical bipolar forceps in VH

• Bipolar setting, length & width of active surface of the forceps

4.Basic of PTVH

• Technical aspect of PTVH,
• Principle

5.Practical application of PTVH forces

• Practical application of PTVH forceps in placenta model

6.PTVH in standard size uterus

• Standard PTVH in adhesions free uterus up to 10 weeks size

7.PTVH in previous CS

• In cases with U-V adhesions
• Posteroanterior approach

8.PTVH in Obliterated posterior cul-de-sac

• In cases with obliterated posterior cul-de-sac
• Anteroposterior approach

9.Transvaginal adnexa mobilisation

• Manual adnexa mobilisation

10.Vaginal adnexectomy during VH

• Technique
• Cystectomy

11.Opportunistic salpingectomy

• Bilateral opportunistic salpingectomy

12.post-hysterectomy check laparoscopy (Indications)

• After vaginal hysterectomy

13.post-hysterectomy check laparoscopy(procedure)

• Technique
• Transvaginal endoscopic guided primary trocar insertion

14.LAVH in ventrofixed uterus

• LAVH only indication

15.Vaginolaparoscopic hysterectomy of very large uterus above 16 weeks size

• Technique

16.How to deal with lateral wall bleeding during and after VH

• Technique

17.Tracing of missed upper stumps

• Technique

18.vaginal Adhesiolysis

• Technique

19.vault closure

• Technique

20.Post operative Ryle’s tube lavage

• Technique

21.Post operative complications after PTVH

• Early
• Late

22.PTVH in endometriosis

Demonstration of operations

1.PTVH in standard size uterus

• Standard PTVH in adhesions-free uterus up to 10 weeks size

2.PTVH in previous CS

• In cases with U-V adhesions
  Posteroanterior approach

3.PTVH in Obliterated posterior cul-de-sac

• In cases with obliterated posterior cul-de-sac
  Anteroposterior approach

5.Transvaginal adnexa mobilisation

• Manual adnexa mobilisation

6.Vaginal adnexectomy during VH

• Technique
• Cystectomy

7.Opportunistic salpingectomy

• Bilateral opportunistic salpingectomy

8.post-hysterectomy check laparoscopy (Indications)

• After vaginal hysterectomy

9.post-hysterectomy check laparoscopy(procedure)

• Technique
  Transvaginal endoscopic guided primary trocar insertion

Note-case demonstration as per avaibility