Hysterectomy history, types and advances

1. Sandesh Kamdi
M.Pharm (Pharmacology)

2.  Vaginal
 Abdominal
 Laparoscopic
 Robotic

3.  Vaginal
hysterectomy (VH)

VH was performed by Themison of Athens in 50 BC by
removing an inverted uterus that had become
gangrenous.1

The first authenticated VH was performed by the Italian
anatomist Berengario da Carpi of Bologna in 1507.
1. J Minim Invasive Gynecol 2010; 17(4):421-35. 2. Best Pract Res Clin Obstet Gynaecol 2005; 19:295-305.

4.  Self
performed VH !!

In the early 17th century a 46-year-old peasant named
Faith Haworth was carrying a heavy load when her uterus
prolapsed completely.

Frustrated by this frequent occurrence, she grabbed her
uterus, pulled as hard as possible, and cut the whole lot
of it with a short knife.

The bleeding soon stopped and she lived on for many
years, with a persistent vesico-vaginal fistula
Clin Obstet Gynaecol 1997; 11:1-22.

5. One of the strongest
proponents of vaginal
hysterectomy
 In
1934 he reported
a series of 627 VH
performed for
benign pelvic
disease, resulting in
death in only three
cases.
Noble Sproat Heaney - Chicago
Best Pract Res Clin Obstet Gynaecol 2005;19:295-305.

6. In the first part of 20th century,
Before the development of gynaecology as
separate speciality,
many hysterectomies were done by
general surgeons who, has not being
familiar with vaginal surgery, favoured the
abdominal route.

7. 
Abdominal Hysterectomy
The pathway to abdominal
hysterectomy was laid down with
the first laparotomy in the 19th
century.
 The human abdomen was
deliberately surgically opened for
the first time by Ephraim
McDowell (Kentucky)
 He successfully removed a 10.2
kg ovarian tumor without
anaesthesia in 18095.

Ephraim McDowell (Kentucky)
Baillieres Clin Obstet Gynaecol 1997; 11:1-22.

8. 
Abdominal Hysterectomy
He successfully removed a 10.2
kg ovarian tumor without
anaesthesia in 18095.
 McDowell operated on the
kitchen table, performing an
ovariotomy.
 The operation lasted only 25
minutes, but was carefully
planned.
 After a rapid recovery, the
patient lived for more than 30
years6.

Ephraim McDowell (Kentucky)
Baillieres Clin Obstet Gynaecol 1997; 11:1-22.

9.  Radical
Hysterectomy

Radical hysterectomy was
initially developed as a
surgical treatment for cervical
cancer due to the absence of
other modalities of treatment.

John Clark performed the first
radical hysterectomy at Johns
Hopkins Hospital, in 1895.
Best Pract Res Clin Obstet Gynaecol 2005;19:387-401.

10.  Laparoscopic


Hysterectomy
The first human laparoscopy was performed
by Hans Christian Jacobaeus of Stockholm
in 1911, by using pneumoperitoneum and
the Nitze cystoscope.
It was Raoul Palmer of France who
popularised gynaecological laparoscopy in
the 1940’s and who is considered to be the
father of modern gynaecological
laparoscopy
doctoral thesis. Helsinki: Medical Faculty University of Helsinki;1999.
Hans Christian
Jacobaeus
(Stockholm)
Raoul Palmer (France)

11.  Robotic
Laparoscopic
Hysterectomy
The first successful surgery using
the da Vinci surgical system was
performed in Belgium in 1997.
 da Vinci S and da Vinci SI is
equiped with double optic which
gives the operator threedimensional view of the operative
field, and with adjustable
magnification, enabling much
improved vision of the pelvis.

da Vinci surgical system

12. Fertility and Sterility 2005;84:1-11.

13. 
Robotic Laparoscopic Hysterectomy

Radical hysterectomy performed using
robotic techniques was comparable
with laparotomy, with equal lymph
node harvest, shorter operating time,
and reduced blood loss and the length
of hospital stay.
da Vinci surgical system
J Minim Invasive Gynecol 2010; 17(4):421-35.

14.  DaVinci
System
1999: Introduced for surgical use
 2000: Approved by FDA for
performance of procedures in
the abdomen and pelvis
 2003, 2004: Approved by FDA for
cardiac surgery, specifically
MVR, Coronary Artery Bypass
 2005: Approval by FDA for
Robotic Hysterectomy

da Vinci surgical system

15.  Benefits








of robotics
3-Dimensional viewing
Tremor filtration
Intuitive movements
7 degree instrument movement
90 degree articulation
Comfortable seated position for the
surgeon
Minimizes the number of needed
assistants
Telesurgery/telementoring

16.  Surgical
dexterity and the
robot

8-12% surgeons report pain
or numbness after
performing LSC

The robot allows for 7
degrees of motion versus the
limited 4 degrees of motion
in laparoscopy

Tremor is removed

17.  Trocar
Placement
Laparoscopic
Robotic

19. 
Vaginal hysterectomy is associated
with better outcomes and fewer
complications than laparoscopic or
abdominal hysterectomy1.

A Cochrane Review of 34 RCTs:
vaginal hysterectomy has the best
outcomes over laparoscopic and
abdominal hysterectomy2
1. Obstet Gynecol 2009;114:1156–1158. 2. Cochrane Database Syst Rev 2009; 3. CD003677.

20.  Limitation:
 Laparoscopic
vaginal hysterectomy is usually
associated with higher cost and longer duration
of operation and involves large number of
specially trained personnel.

22.  60%
of the patients without descent underwent
successful removal of uterus.
 Up to 16 weeks pregnancy size uterus were removed.
 There were minimal surgical complications, blood loss,
operative time or hospital stay.

23.  100
cases were taken for NDVH & 100 for
AH.
 Cases
of Dysfunctional DUB, Uterine
fibroid of less than 12wks, adenomyosis
and cervical polyp, Previous LSCS with
mobile uterus were included in the study
Free communication (oral) presentations / International
Journal of Gynecology & Obstetrics 119S3 (2012) S261–S530

24. Time (minutes)
Duration of surgery
70
60
50
40
30
20
10
0
61
38
NDVH
AH
Free communication (oral) presentations / International
Journal of Gynecology & Obstetrics 119S3 (2012) S261–S530

25. Post operative cathetarization
100%
100
80
%
60
40
21%
20
0
NDVH
AH
Free communication (oral) presentations / International
Journal of Gynecology & Obstetrics 119S3 (2012) S261–S530

26. NDVH
AH
Early ambulation
6-14 hours
24-48 hours
Regular diet
Earlier
Late
Post Operative stay
2-3 days
5-7 days
Complications rate
Lower
Higher
Free communication (oral) presentations / International
Journal of Gynecology & Obstetrics 119S3 (2012) S261–S530

27.  NDVH
is least invasive route
with least morbidity, least
expensive technique & with
most rapid postoperative
recovery.
 The
absence of an abdominal
incision leads to lower
morbidity, less hospital stay,
more rapid convalescence and
patient compliance.
Free communication (oral) presentations / International
Journal of Gynecology & Obstetrics 119S3 (2012) S261–S530

28.  100
patients with uterine size 8-10
weeks gestation
 Age: 35.2±5.2 years
 Mean parity: 4.17±1.5
Free communication (oral) presentations /
International Journal of Gynecology & Obstetrics
107S2 (2009) S93–S396

29. NDVH
Duration of surgery
35.5 mins
Mean hosp stay
3.5 days
Blood loss
100-300 ml
Free communication (oral) presentations /
International Journal of Gynecology & Obstetrics
107S2 (2009) S93–S396

30.  The
new technique of aqua
dissection in NDVH is
easy, fast, safe and relatively
less bleeding in modern
gynecology
Free communication (oral) presentations /
International Journal of Gynecology & Obstetrics
107S2 (2009) S93–S396

31.  74
patients with uterine size 8-10
weeks gestation
 Age: 35-55 years
 Volume of uterus: 80-500 cm3

32. NDVH
Duration of surgery
46 mins
Mean hosp stay
48 hours
Avg Blood loss
50 ml

33. • No abdominal wound
• No significant destruction of intestine
• Less post operative discomfort
• Easier mobilization
• Earlier discharge from hospital