Volume 1 Issue 12, December 2014

Editorial
Chauhan AR

Vesicophobia During Vaginal Hysterectomy – Too Deep Dissection
Manjrekar VM, Parulekar SV

 Vesicophobia During Vaginal Hysterectomy – Too Superficial Dissection
Raut DP, Parulekar SV

 Vesicophobia During Vaginal Hysterectomy – Too Lateral Dissection
Parulekar SV

 Triplets with Acardiac and Anencephalic Fetuses
Bang N, Panchbudhe S, Satia MN.

 OHVIRA syndrome
Saxena N, Channawar S, Khadkikar R, Chauhan AR.

Uterine Artery Psuedoaneurysm
Ansari M, Samant PY, Parulekar SV. 

 Peritoneal Inclusion Cysts
Chawla T, Fernandes G, Parulekar SV.

Hazardous Outcome of a Wrong Incision in Shirodkar’s Sling Surgery

Pandey N, Gupta AS, Mirchandani A, Chauhan AR.

 Adenomyosis In Non-CommunicatingUterine Horn
Pawde A, Khadkikar R, Mayadeo NM, Chauhan AR.

Quiz December 2014

Editorial

Chauhan AR
Vaginal hysterectomy (VH) with or without vaginal wall and perineal repair, is the commonest type of hysterectomy in our institute; worldwide literature shows that it is the preferred route for benign disease of the uterus. Routine indications include uterine prolapse, abnormal uterine bleeding, adenomyosis, fibroids up to 12 weeks’ size and endometrial hyperplasia. The “difficult vaginal hysterectomy” is a well defined entity and in the hands of skilled vaginal surgeons, expanded indications for VH like non-descended vaginal hysterectomy (NDVH), uterus > 12 weeks’ size, multiple fibroids, concomitant oophorectomy or salpingo- oophorectomy, previous uterine or abdominal surgeries (previous LSCS, previous tubal ligation, myomectomy, sling surgery, adnexal surgery, bowel surgery), are possible. Probably the only contraindications for VH are previous vesicovaginal and rectovaginal fistula repair and previous Fothergill’s surgery. Anticipation and preparation are keys to success and most surgeons will be prepared for these difficult cases; however surgical difficulties may be encountered even in routine or relatively simple VH and this article addresses these issues.
The challenges in both routine and difficult cases are similar and include: adequate exposure and visualization, opening of anterior vesicouterine peritoneum (A pouch) and posterior cul-de-sac (P pouch), securing pedicles and achieving hemostasis in a narrow space, avoiding injury to bladder and rectum, and retrieving the uterus.
Preoperatively, two parameters which should be assessed are uterine mobility and size. In the absence of previous surgeries and adhesions, most uteri, even those of nulliparous women, will demonstrate physiologic descent. If the vagina is of adequate capacity so as to allow access to the uterosacral ligament complex, it will be possible to remove even an immobile non-descended uterus via the vaginal route once the ligaments are divided. More subjective is the judgment of uterine size, which we routinely express in weeks’ of gestation. This measure considers only the height of the uterine fundus and not the bulk; obviously the bulkier uteri are difficult to remove vaginally and if terminology and interpretation are not uniform, the surgeon may be stumped at surgery with a uterus broader than expected. Some authors have recommended preoperative uterine volume assessment by USG: a uterus of 8 – 10 weeks’ size is approximately 150–200 cm3 in volume and is easily removed vaginally, and may not require USG. On the other hand, if the uterus is > 10 -12 weeks’, the volume may be in excess of 250–300 cm3, warranting reassessment under anesthesia.
Examination under anesthesia (EUA) is a crucial step prior to VH as surprises like enlarged uterus or adnexal pathology may be encountered. Apart from examining descent and mobility, it is imperative to assess the upper vagina, which should not be narrow at the apex, and should allow at least 2 fingerbreadths. Sheth SS introduced the concept of “trial VH” akin to “trial forceps”, where facilities for rescue surgery via laparoscopy or laparotomy are kept ready.
Adequate visualization and exposure are achieved by small simple checks:
  • Lithotomy position with the patient’s buttocks at the edge of the table and stirrups high up with the legs slightly hyperflexed. This will improve the surgical field and prevent abutment of speculum against the table. 
  • The operating surgeon should adjust the height of the table so as to bring the patient’s pelvis at eye level; this will not only aid vision but will also decrease strain on the surgeon’s arms and shoulders
  • The assistants should stand within the stirrups 
  • The surgeon should do away with multiple retractors, especially right angle retractors which are space- occupying. Rather, the simple labial stitch or circular retractor systems with elastic stays and hooks should be employed
  • Structures deep in the vagina are better visualized with either a head lamp or pelvic illuminators. An easy modification is to mount the light source so that it is immobile and frees the assistants’ hand, or the assistant can hold the light source with a Babcock forceps
Opening of A pouch is the Achilles heel of many vaginal surgeons, especially during the learning curve, and is in fact seen as the limiting factor of VH.  The anterior incision at the very start of the VH is where most errors occur.
  • In bulky uteri the error is usually that the plane of cleavage is too deep and inadvertently the superficial layers of myometrium are incised. This can be rectified by applying Allis’ forceps to the upper cut edge and dissecting sharply just above it, to enter the A pouch
  • Another common error is to restrict the anterior incision to the midline. In case the incision is too superficial or the correct plane is not achieved, it is beneficial to carry the incision laterally and dissect the bladder pillars well away, and approach the A pouch from the lateral aspect. This helps for both large prolapsed uteri as well as cases with supravaginal elongation and is the preferred approach for scarred uteri
  • For postmenopausal women with atrophic narrow uteri but massive vaginal wall prolapse, it may be helpful to dissect the entire vagina and raise anterior and posterior flaps, elevate the dissected bladder with Babcock forceps, and then enter the A pouch below the instrument
The P pouch usually poses less difficulty than the A pouch but sometimes it may be high. The dictum while dissecting is to stay close to the uterus or approach the pouch from the lateral side; often the uterosacral ligaments and sometimes even the uterine arteries can be ligated extra-peritoneally until descent improves.
Securing pedicles and achieving hemostasis can be challenging; modifications which have been suggested are:
  • Avoidance of hand knots deep in the vagina
  • Use of long thin needle holders and clamps
  • Right angle forceps or bipolar forceps, which can control bleeding high up and on lateral pelvic wall
  • Vessel sealing devices are advantageous in tight spaces. Newer devices include a blade which cuts after the hemostatic seal is complete
Retrieving the enlarged uterus involves debulking or volume reducing steps like bisection, coring, morcellation, myomectomy or a combination, after securing the uterine arteries. This step may take some time and the surgeon should persist. Conversion to laparoscopy or laparotomy is rare but usually occurs at this point. Myoma screw may be used as it gives excellent traction or the cervix and lower part of uterus may be removed first, and traction applied on the remaining uterus, to facilitate its removal.
In conclusion, as the surgeon’s knowledge of anatomy, training and vaginal skills improve, difficulties can be easily overcome. Proponents of VH believe that “every hysterectomy should be planned primarily by the vaginal route and, unless contraindicated, be performed via the vaginal route. The December issue of our journal carries three articles on this subject which we hope will benefit the reader. 

Vesicophobia During Vaginal Hysterectomy – Too Deep Dissection

Author Information

Manjrekar VM*, Parulekar SV**.
(* First Year Resident, ** Professor and Head, Department of Obstetrics and Gynecology, Seth G.S. Medical College and K.E.M Hospital, Mumbai, India.)

Abstract

Vaginal hysterectomy is a lot more difficult to perform than an abdominal hysterectomy. Unless the gynecologist is well trained in vaginal surgery, there can be serious complications during the performance of the operation, including injury to the urinary bladder. A fear of injuring the bladder can lead to dissection in a wrong plane. Dissection into the front of the supravaginal cervix is a common error. We present such a case because the management of this error has not been documented well in the literature.

Introduction

The space available for operating is limited during performance of a vaginal hysterectomy.[1] The anatomy is also a little difficult to understand, because conventional education of human pelvic anatomy is through cadaveric dissection, which is done by the abdominal route. Without adequate training and clinical experience, the operating surgeon can experience difficulty in finding correct tissue planes and performing the correct steps.[1] Finding the uterovesical fold of peritoneum  and opening it is an important step, of which many untrained surgeons are afraid out of fear of injuring the bladder. This may result in dissection in a plane that is too deep, passing into the supravaginal cervix. We present such a case and discuss methods of diagnosing the condition and managing it.

Case Report

A 45 year old woman, married for 28 years, multipara, presented to the outpatient department with complaints of menorrhagia for 2 years. There was soakage of 3-4 pads per day and passage of clots. She also complained of something coming out per vaginum for 2 years, which was aggravated by straining and required digital manipulation for reposition. She had 3 normal deliveries and 1 intrauterine fetal demise. She had a history of lifting heavy objects at home on a regular basis. There was no other significant contributory factor like history of chronic cough, constipation, urinary retention or medical or surgical illness. On examination her vital parameters were stable. A speculum examination revealed hypertrophied cervix, a second degree uterovesical descent, moderate cystocoele and rectocoele. The vagina was healthy. On per vaginal examination the uterus was normal sized, retroverted, firm and mobile. Her PAP smear showed severe inflammatory cell changes and endometrial aspirate showed no malignant cells. Her investigations for fitness for anesthesia showed normal values.
She was posted for Vaginal hysterectomy with anterior colporrhaphy and posterior colpoperineorrhaphy. The operating surgeon was a resident doctor being assisted by a junior consultant. The patient was put in lithothotomy position under spinal anaesthesia. Anterior pouch dissection was started after making infiltration of normal saline under the anterior vaginal mucosa and incision into the vaginal mucosa just above the portio vaginalis. Dissection was attempted between the cervix and the bladder, but the correct plane could not be found. We were called at that stage.
Figure 1. The cut edges of the supravaginal cervix (yellow arrows) are held with two Allis’ forceps.


Figure 2. The black arrow indicates the place where the supravaginal cervix had been cut into. The green arrow indicates the beginning of the plane between the supravaginal cervix and the urinary bladder.


Figure 3. The plane is being dissected by placing closed blades of a curved hemostat at the lower end of the plane and opening the blades widely.


Figure 4. The blue arrow indicates the uterovesical fold of peritoneum.

It was found that the incision had passed into the supravaginal cervix. The upper cut edge of the cervix was identified on the bladder wall. It was held with two Allis’ forceps and drawn down. The pubovesicocervical fascia was cut between the cervical edge and the bladder, and the correct plane was indentified between the bladder and the cervix. The plane was developed further by putting closed blades of a curved hemostat there and opening the blades in the transverse plane. The bladder was retracted with Landon’s retractor. The uterovesical fold of peritoneum was identified deep inside this plane. It was held with two hemostats and cut. Subsequent hysterectomy was carried out by the conventional technique. The patient made an uneventful recovery and was discharged after 5days.

Discussion

Abdominal hysterectomy permits visualization of the pelvic structures clearly prior to making any cuts or performing any dissection of tissues. The uterus, the urinary bladder, and the uterovesical fold are clearly identifiable unless the anatomy has been distorted by pelvic adhesions or tumors. It is easy to hold the uterovesical fold of peritoneum, confirm that it is indeed the uterovesical fold by its looseness over the supravaginal cervix and isthmus, and cut it with scissors. The situation is quite different in a vaginal hysterectomy.[1] After cutting the anterior vagina near the portio vaginalis, the pubovesicocevical fascia has to be dissected in the correct plane that can be identified only with experience, and then the peritoneal fold can be reached. [2,3,4,5,6,7] An experienced surgeon identifies the fascial fibers which stand out as the divided vaginal edge is elevated held by two Allis’ forceps. After cutting these, the peritoneal fold can be reached. It is confirmed to be the fold by putting a finger over it and rolling it from side to side. It rolls very easily. On catching with two hemostats, it stands out as a thin translucent fold. In case of any doubt, the urinary bladder and the bladder neck can be identified by palpation of the inflated balloon of the Foley’s catheter in the bladder.[2,8] In case it does not help, the catheter can be substituted for with a bladder sound. The tip of the sound is directed backwards. It defines the lower limits of the bladder wall, so that dissection can be carried out away from it.[2,8] If the peritoneal fold is high in situation and cannot be reached, the uterosacral ligaments can be clamped, cut and ligated first. The uterus then descends and the peritoneal fold becomes accessible. It can be opened then.[2] In case all of these methods fail, the posterior peritoneal pouch can be opened first.[2,8] Then a finger can be passed behind and then over the top of the uterus to reach the uterovesical fold of peritoneum from above. Then it can be opened over the finger seen through it.

Conclusion

A resident doctor or a consultant not trained in vaginal surgery may experience difficulty while opening the uterovesical fold of peritoneum, and being afraid of injuring the urinary bladder, may go in a wrong plane. Adequate training, experience, and adopting the techniques described in this article should help overcome this difficulty and fear.

References

1.      Colaco J, Campos AP, Nunes F, et al. Route of hysterectomy: vaginal versus abdominal. J Pelvic Med Surg 2003;9(22):69.
2.      Parulekar SV. Vaginal Hysterectomy. In Practical Gynecology and Obstetrics. 5th ed. Mumbai: Vora Medical Publications; 2011. pp. 350-253
3.      Kovac SR. Vaginal Hysterectomy. In Rock JA, Jones HW III, editors. Te Linde’s Operative Gynecology. 10th ed. New Delhi: Wolters Kluwer Health – Lippincott Williams & Wilkins 2008; pp. 744-762.
4.      Monaghan JM, Lopes A, Naik R. Vaginal hysterectomy and radical vaginal hysterectomy (Schauta and Coelio-Schauta procedures). In Bonney’s Gynaecological Surgery. 10th ed. Malden, USA.Blackwell Science. 2004. pp 95-109.
5.      Duhan N. Techniques of Hysterectomy. In Hysterectomy.  Al-Hendy A, Sabry M. editors. 1st ed. Rijeka: InTech 2012. pp. 3-22.
6.      M.Cosson Vaginal hysterectomy. In Vaginal Surgery. Cosson M, Querleu D, Dargent D. editors. 1st ed. Boca raton. Taylor & Francis. 2005. pp 29-55.
7.      L. Hoffman B. Schorge J, Schaffer JI, Halvorson L, Bradshaw KD, Cunningham FG.Vaginal Hysterectomy. In Williams Gynecology. 2nd ed. New York: McGraw Hill. 2012. pp 1051-1054.
8.      Kovac SR. A technique for reducing the risk of intentional cystotomy during vaginal hysterectomy. J Pelvic Surg 1999;5:32.

Citation

Manjrekar VM, Parulekar SV. Vesicophobia During Vaginal Hysterectomy – Too Deep Dissection. JPGO 2014. Vol 1 No. 12: Available from: http://www.jpgo.org/2014/12/vesicophobia-during-vaginal_30.html

Vesicophobia During Vaginal Hysterectomy – Too Superficial Dissection

Author Information

Raut DP *, Parulekar SV**.
(* First Year Resident, ** Professor and Head, Department of Obstetrics and Gynecology, Seth G.S. Medical College and K.E.M Hospital, Mumbai, India.)

Abstract

Vaginal hysterectomy is much more difficult to perform than an abdominal hysterectomy. The surgeon has to be well trained in vaginal surgery, or there can be serious complications during the performance of the operation, including injury to the urinary bladder. Lack of expertise and a fear of injuring the bladder can lead to dissection in a wrong plane. Dissection into the fascia over the detrussor and the detrussor itself is a not uncommon error. We present such a case becuse the management of this error has not been documented well in the literature.

Introduction

The space available for operating is limited while performing a vaginal hysterectomy.[1] The anatomy is also a little difficult to understand, as conventional education of human pelvic anatomy is through cadeveric dissection, which is done by the abdominal route. Without adequate training and operative experience, the operating surgeon can experience difficulty in finding correct tissue planes and performing the correct steps.[1] Finding the uterovesical fold of peritoneum  and opening it is an important step, which may be associated with a fear of injuring the bladder. This may result in dissection in a plane that is too superficial, passing into the fascia over the detrussor and the detrussor itself. We present such a case and discuss methods of diagnosing the condition and managing it.

Case Report

A 40 year old woman, married for 20 years, multipara, presented to the outpatient department with complaints of menorrhagia for 2 years.  She has soakage of 3-4 pads per day and passage of clots for 8 days, without any dysmenorrhea. She had come with similar complaints 5 days back to the emergency section and was started on norethisterone and tranexemic acid to stop the bleeding. However this treatment failed to control the bleeding. She had undergone a rapid cervical dilatation and endometrial curettage 1 month back for abnormal uterine bleeding. The histopathology report was suggestive of bleeding endometrium. The patient was operated for anal hemorrhoids 22 years ago and tubal ligation was done 6 years ago. There was no other significant medical or surgical history. On examination her vital parameters were stable. Speculum examination showed a hypertrophied cervix. Bimanual pelvic examination showed bulky, retroverted, midposed uterus and free and nontender fornices. Ultrasound examination of the pelvis showed a bulky uterus measuring 9.4 x 4.0 x 6.6 cm and endometrial thickness of 12 mm. Malignancy was screened for by Pap smear which showed severe inflammatory cell changes and endometrial aspiratyub xytology which showed no malignant cells.
The patient was posted for a vaginal hysterectomy. She was being operated on by a resident doctor, assisted by a junior consultant. She was put in lithothotomy position under spinal anaesthesia. After making an incision into the anterior vagina near the portio vaginalis, anterior pouch dissection was started. Blunt dissection  was done to open the plane between the supravaginal cervix and the bladder. There was a significant amount of bleeding. The uterovesical fold could not be identified. At this stage we were called for help.
The findings are shown in figure 1. The detrussor was torn in the midline and the bladder mucosa was seen pouting throgh it. The plane between the bladder and the supravaginal cervix was identified after dividing the fibers of pubovesicocervical fascia between the two. It was a smooth, white surface which had no bleeding from its surface. The bladder was retracted with Landon’s retractor.Dissection was continued upward in this plane until the uterovesical fold of peritoneum was reached. It was held with two hemostats and cut. Subsequent hysterectomy was carried out by the conventional technique. The detrussor injury was repaired with a continuous suture of No. 3-0 polyglactin. The patient made an uneventful recovery and was discharged after 5 days.


Figure 1. Cut edges of detrussor are shown by arrows.


Figure 2. The cut edges of the supravaginal cervix (yellow arrows) are held with two Allis’ forceps. The correct plane of dissection is shown by white arrow.

Discussion

Abdominal hysterectomy permits visualization of the pelvic structures clearly prior to performing any pelvic surgery, unless the anatomy has been distorted by pelvic adhesions or tumors. The uterovesical fold of peritoneum can be held easily, confirmed to be the uterovesical fold by its looseness over the supravaginal cervix and isthmus, and then cut with scissors. It is quite different in a vaginal hysterectomy.[1] After making an incision in the anterior vagina near the portio vaginalis, the pubovesicocevical fascia has to be dissected in the correct plane that can be identified only with experience, and then the peritoneal fold can be reached. [2,3,4,5,6,7] The fascial fibers which stand out as the divided vaginal edge is elevated held by two Allis’ forceps have to be identified. The peritoneal fold can be reached after cutting these. It is confirmed to be the fold by putting a finger over it and rolling it from side to side. It rolls very easily over the smooth anterior surface of the corpus. When caught with two hemostats, it stands out as a thin translucent fold. If the dissection is carried out more superficially, it passes into the fascia over the bladder and then the bladder wall. Injury to the detrussor is suspected when there is significant bleeding during the sharp dissection. Detrussor injury is more likely to occur when the dissection is done bluntly, with finger pressure. Injury to the bladder wall is suspected when there is leak of watery fluid into the operative field, hematuria, visualization of the catheter through the dissected area, and leak of methylene blue solution into the operative field when it is instilled into the urinary bladder through Foley’s catheter.[2,8] The correct plane has to be found posterior to the dissected area. The correct plane has a number of diagnostic features. The smooth, white surface of the supravaginal cervix is seen posterior to the plane. When in doubt, a bladder sound can be passed into the bladder to define the limits of the bladder, so that dissection can be done beyond the bladder wall. In case all of these methods fail, the posterior peritoneal pouch can be opened first.[2,8] Then a finger can be passed behind and then over the top of the uterus to reach the uterovesical fold of peritoneum from above. Then it can be opened over the finger seen through it. But this is not possible if the uterus is large. Passing more superficially and hence into the bladder wall is much more serious than passing too deep into the cervical tissue. However both of these situations must be avoided by following meticulous technique, so that morbidity is kept low.

Conclusion

A resident doctor or a consultant not trained in vaginal surgery may experience difficulty while opening the uterovesical fold of peritoneum, and being afraid of injuring the urinary bladder, may go in a wrong plane. Adequate training, experience, and adopting the techniques described in this article should help overcome this difficulty and fear.

References

1.      Colaco J, Campos AP, Nunes F, et al. Route of hysterectomy: vaginal versus abdominal. J Pelvic Med Surg 2003;9(22):69.
2.      Parulekar SV. Vaginal Hysterectomy. In Practical Gynecology and Obstetrics. 5th ed. Mumbai: Vora Medical Publications; 2011. pp. 350-253
3.      Kovac SR. Vaginal Hysterectomy. In Rock JA, Jones HW III, editors. Te Linde’s Operative Gynecology. 10th ed. New Delhi: Wolters Kluwer Health – Lippincott Williams & Wilkins 2008; pp. 744-762.
4.      Monaghan JM, Lopes A, Naik R. Vaginal hysterectomy and radical vaginal hysterectomy (Schauta and Coelio-Schauta procedures). In Bonney’s Gynaecological Surgery. 10th ed. Malden, USA.Blackwell Science. 2004. pp 95-109.
5.      Duhan N. Techniques of Hysterectomy. In Hysterectomy.  Al-Hendy A, Sabry M. editors. 1st ed. Rijeka: InTech 2012. pp. 3-22.
6.      M.Cosson Vaginal hysterectomy. In Vaginal Surgery. Cosson M, Querleu D, Dargent D. editors. 1st ed. Boca raton. Taylor & Francis. 2005. pp 29-55.
7.      L. Hoffman B. Schorge J, Schaffer JI, Halvorson L, Bradshaw KD, Cunningham FG.Vaginal Hysterectomy. In Williams Gynecology. 2nd ed. New York: McGraw Hill. 2012. pp 1051-1054.
8.      Kovac SR. A technique for reducing the risk of intentional cystotomy during vaginal hysterectomy. J Pelvic Surg 1999;5:32.

Citation

Raut DP, Parulekar SV. Vesicophobia During Vaginal Hysterectomy – Too Superficial Dissection. JPGO 2014 Volume 1 Number 12 Available from:  http://www.jpgo.org/2014/12/vesicophobia-during-vaginal_1.html

Vesicophobia During Vaginal Hysterectomy – Too Lateral Dissection

Author Information

Parulekar SV
Professor and Head, Department of Obstetrics and Gynecology, Seth G.S. Medical College and K.E.M Hospital, Mumbai, India.)

Abstract

Vaginal hysterectomy is more difficult to perform than an abdominal hysterectomy, even if there are no complicating factors like uterine enlargement or distortion. The surgeon has to be well trained in vaginal surgery, or there can be serious complications during the performance of the operation. A fear of injuring the bladder can lead to dissection in a wrong direction. Dissection into the broad ligament lateral to the uterus is an error that has not been reported so far in world literature. Such a case is presented here, along with discussion on its prevention and management.

Introduction

The space available for operating is much less during a vaginal hysterectomy as compared to an abdominal hysterectomy.[1] The anatomy is also difficult to understand, as conventional teaching of human pelvic anatomy is through cadaveric dissection done by the abdominal route. Without adequate training and clinical experience, the operating surgeon can experience difficulty in finding correct tissue planes and performing the correct steps.[1] Finding the uterovesical fold of peritoneum  and opening it are steps which are felt to be quite challenging by many untrained surgeons, out of fear of injuring the bladder. The usual error is passing too deep into the cervix or too superficially into the bladder. The case presented here is the first case in the world literature, in which the dissection was done on one side and the broad ligament was opened instead of the uterovesical peritoneal fold.

Case Report

The patient was a 60 year old woman, third para, postmenopausal for fifteen years. She had a third degree uterine prolapse, moderate cystocele, moderate rectocele, lax perineum, and an atrophic uterus. Vaginal hysterectomy, anterior colporrhaphy, vault suspension, and posterior colpoperineorrhaphy were being done under spinal anesthesia. The operating surgeon was a junior consultant. The anterior vagina was cut transversely just above the portio vaginalis. The vaginal edges were held up with two Allis’ forceps. Sharp and blunt dissection was done to separate the urinary bladder from the front of the supravaginal cervix. Landon’s retractor was used to retract the urinary bladder during the dissection. Some bleeding was encountered, but it was not alarming. The uterovesical fold of peritoneum could not be identified. I was called for help at that stage.

The anterior surface of the supravaginal cervix was found to be irregularly dissected, but not bleeding significantly. The anterior and posterior leaves of the left broad ligament were torn, but the uterine artery and vein were not injured (figure 1). The ureter was not seen in the vicinity of the opening. The location of the otherwise unidentifiable uterus was demonstrated by passing a uterine sound into the uterocervical canal and palpating over it from the outside.



Figure 1. The cut edges of the anterior vagina are held with two Allis’ forceps (black arrows). The medial edge of the opening in the left broad ligament is held with two hemostats (blue arrows). A gloved finger (green arrow) is seen through the window in the left broad ligament, passed from behind the uterus and the ligament. The uterus (U) is on the right side of the opening. The cervix is seen below (C).

The posterior peritoneal pouch was opened first by the conventional method. An index finger was passed behind the uterus and was brought forward over the fundus of the uterus. The uterovesical fold was identified over the finger passed into it from above. It was held with two hemostats and cut open. Subsequent hysterectomy was done by the conventional method, followed by anterior colporrhaphy, vault suspension, and posterior colpoperineorrhaphy. An excretory urography done postoperatively did not reveal any injury to the left ureter. The patient made an uneventful recovery.

Discussion

Visualization of the pelvic structures clearly prior to making any cuts or performing any dissection of tissues is possible while performing an abdominal hysterectomy. The uterovesical fold is clearly identifiable unless the anatomy has been distorted by pelvic adhesions or tumors. It is easily confirmed that it is indeed the uterovesical fold by its looseness over the supravaginal cervix and isthmus. Then it is cut with scissors. The situation is quite different in a vaginal hysterectomy.[1] After cutting the anterior vagina near the portio vaginalis, the pubovesicocevical fascia has to be dissected in the correct plane that can be identified only with experience, and then the peritoneal fold can be reached.[2,3,4,5,6,7] The uterus is usually identifiable by its bulk. But in case of a postmenopausal woman with uterine atrophy, the uterus is very small in size and thin anteroposteriorly. It may not be easily identifiable. That adds to the difficulty of identifying the uterovesical fold. In order to avoid an injury to the urinary bladder, the surgeon may try to catch any thin fold of tissue and cut it. In the case described, the broad ligament peritoneum lateral to the uterus was caught and dissected believing it to be the uterovesical fold. Passage of a sound into the uterocervical canal helped identify the position of the uterus. The method of opening the posterior peritoneal pouch and passing a finger from there to the uterovesical fold is shown in figure 2.


Figure 2. Method of opening the uterovesical pouch by opening the posterior peritoneal pouch first and passing a finger from there to the uterovesical pouch over the uterus. B: urinary bladder; U: uterus; V. vagina; R: rectum. The course of the finger is shown by the black arrow.

Opening the broad ligament prior to clamping and dividing the uterosacral ligaments is associated with the risk of injury to the ureter. That is so because the ureters are related to the upper surface of the uterosacral ligaments and when the ligaments are divided, the ureters fall away and are less likely to get injured during performance of the remaining steps of the hysterectomy.[3] Opening the broad ligament in this manner is also associated with the risk of hemorrhage from injury to the uterine vessels. A blind attempt at stopping this bleeding by application of hemostats and ligatures or electrocautery may further increase the risk of ureteric injury.

Conclusion

Blind dissection to open the uterovesical fold of peritoneum without first identifying it is risky. If the broad ligament gets opened during such a procedure, there is risk of injury to the ureter and the uterine vessels.

References
  1. Colaco J, Campos AP, Nunes F, et al. Route of hysterectomy: vaginal versus abdominal. J Pelvic Med Surg 2003;9(22):69.
  2. Parulekar SV. Vaginal Hysterectomy. In Practical Gynecology and Obstetrics. 5th ed. Mumbai: Vora Medical Publications; 2011. pp. 350-253
  3. Kovac SR. Vaginal Hysterectomy. In Rock JA, Jones HW III, editors. Te Linde’s Operative Gynecology. 10th ed. New Delhi: Wolters Kluwer Health – Lippincott Williams & Wilkins 2008; pp. 744-762.
  4. Monaghan JM, Lopes A, Naik R. Vaginal hysterectomy and radical vaginal hysterectomy (Schauta and Coelio-Schauta procedures). In Bonney’s Gynaecological Surgery. 10th ed. Malden, USA.Blackwell Science. 2004. pp 95-109.
  5. Duhan N. Techniques of Hysterectomy. In Hysterectomy.  Al-Hendy A, Sabry M. editors. 1st ed. Rijeka: InTech 2012. pp. 3-22.
  6. M.Cosson Vaginal hysterectomy. In Vaginal Surgery. Cosson M, Querleu D, Dargent D. editors. 1st ed. Boca raton. Taylor & Francis. 2005. pp 29-55.
  7. L. Hoffman B. Schorge J, Schaffer JI, Halvorson L, Bradshaw KD, Cunningham FG.Vaginal Hysterectomy. In Williams Gynecology. 2nd ed. New York: McGraw Hill. 2012. pp 1051-1054.
Citation

Parulekar SV. Vesicophobia During Vaginal Hysterectomy – Too Lateral Dissection. JPGO 2014. Volume 1 Number 12. Available from: http://www.jpgo.org/2014/12/vesicophobia-during-vaginal.html

Triplets with Acardiac and Anencephalic Fetuses

Author Information

Bang N*, Panchbudhe S**, Satia MN***.
(* Third Year Resident, ** Assistant Professor, *** Professor. Department of Obstetrics and Gynecology, Seth GS Medical College & KEM Hospital, Mumbai, India)

Abstract

These pregnancies are seen more frequently than in the previous decades due to fertility enhancing technologies. These have lead to a marked increase in twins and triplets. 77% of triplets are due to fertility treatment and also as more women are waiting later in life to attempt pregnancy. Older women have higher chance of multiple gestation than younger women due to increased level of follicle stimulating hormone.[1]  In this era of advanced medical technology, although multiple births have improved outcome, they are still associated with complications. We hereby report a case of spontaneously conceived monochorionic triamniotic triplet gestation with two out of three fetuses having multiple abnormalities and poor fetal outcome. The patient was booked at 17 weeks of gestation with triplet pregnancy with fetus A anencephalic, fetus B normal and fetus C acardic fetus. This patient was managed in the antenatal ward, but spontaneously aborted at 23 weeks of gestation.

Introduction

Multifetal gestation includes twins, triplets, quadruplets and higher multiples. Spontaneously conceived triplet gestation is seen in 1 in 8000 pregnancies.[2] The incidence of multiple births is rising over the last two decades in contrast to Hellin’s rule which previously existed in nature. The fate of multiple pregnancy largely depends upon the chorionicity or the type of placentation whether it is monochorionic, dichorionic or so on. Monochorionic twins are at additional risk for complications due to placental angioarchitecture such as severe discordant malformations, twin reversed arterial perfusion sequence (TRAP), selective intrauterine growth retardation or twin-to-twin transfusion syndrome. The management is further complicated by presence of abnormal fetuses. Selective reduction of multifetal pregnancy can be done by radiofrequency ablation and other modalities. The decision is taken by comparing the medical risks of multifetal pregnancy, the possible benefits of multifetal pregnancy reduction and the complex ethical issues regarding multifetal pregnancy reduction.

Case Report

A 37 year old woman, married for 9 years, third gravida with previous one full term  normal delivery and one abortion presented at 17 weeks of gestation with monochorionic   triamniotic triplet gestation. Her general condition and systemic examination revealed no abnormality. On per abdominal examination the uterus was 24 weeks in size with multiple fetal parts felt and there was no uterine activity. Per vaginal examination revealed that the cervix was closed and uneffaced. A second trimester ultrasonography (USG) performed was suggestive of single anterior placenta with fetus A showing absent calvarium and poorly formed brain tissue above the orbits suggestive of anencephaly of 18 weeks. Fetus B was also of 18 weeks gestation and appeared normal with no obvious malformation. Fetus C was of 16 weeks with well developed lower thoracic and lumbar spine with well developed lower extremities with umbilical artery flow and with absent heart, upper extremity and skull suggestive of acardiac fetus. She had come for selective reduction of abnormal fetuses. Fetal Medicine expert’s opinion was taken in view of above USG findings and she was given the option of radiofrequency ablation for better survival and prognosis of Twin B. The patient and relatives were counseled about the advantages, complications and cost factor of radiofrequency ablation. In view of high cost associated with the procedure they decided for continuation of the pregnancy. The patient was advised to follow up regularly  in antenatal clinic and was advised to take hematinics and calcium.


Figure 1. USG picture showing acardiac fetus.


Figure 2. USG picture showing anencephalic fetus.


Figure 3. Umbilical artery flow on Doppler study in acardiac fetus.


Figure 4. USG picture showing normal fetus with acardiac fetus.


Figure 5. Placental vascular anastomoses on Doppler flow study.

The patient came in active labor at 23 weeks of gestation. On examination her general condition was fair, temperature was normal, pulse was 88 per minute and blood pressure 110/70 mm Hg. An abdominal examination showed a uterus of 28 weeks’ size with multiple fetal parts felt. There was good uterine activity. Per vaginal examination revealed that the cervix was 4 cm dilated, 60 percent effaced with first fetus in complete breech presentation at station zero.  Fetus A with anencephaly aborted spontaneously. It weighed 275 g. Artificial rupture of membranes of the second sac was done and Fetus B aborted. It weighed 395 g and had no obvious congenital malformations on external examination. Fetus C got expelled en sac along with the placenta. It was an acardiac triplet with well developed lower extremities and thorax and absent skull, heart and upper extremities. Its weight was 190 g.  The placenta was single with three cords.


Figure 6.  Anencephalic fetus.

Figure 7.  Acardiac fetus.

Figure 8.  Normal fetus.

Discussion

The type of placentation in multifetal gestation is predictive of many complications and pregnancy outcome.  It depends upon the type of placentation whether the triplet pregnancy is trichorionic, dichorionic or monochorionic. Trichorionic triplets have three foetuses with separate placentas and amniotic cavities. Dichorionic triplets have a singleton pregnancy with its own placenta along with monochorionic twins. Monochorionic triplets have three foetuses with one common placenta and three separate amniotic cavities as was seen in our case. Multiple pregnancy is associated with higher risks and complications for both mother and babies as compared to singleton pregnancies. Over 60 percent of twins and almost all higher order multiples are premature. The expected average duration of pregnancy decreases with increasing number of foetuses. The average duration of pregnancy is 35 weeks for twins, 32 weeks for triplets and 30 weeks for quadruplet. The risk of spontaneous loss of entire pregnancy is 8% for twins, 15% for triplets and 25% for quadruplets.[3] There is additional risk of complications due to vascular anastomoses such as  twin to twin transfusion syndrome and twin reversed arterial perfusion syndrome, conjoint twins and discordant growth in monochorionic triplets.   The relative risk of cerebral palsy in triplets is 12.7.[4]  The risk of death by the age of one year is seven times higher in twins and twenty times higher in triplets as compared to singleton pregnancy.[5] TRAP sequence occurs in 1% of monochorionic pregnancies and 1 in 35000 pregnancies overall. It has a normally developing pump twin which supplies blood to the acardiac fetus which lacks functioning cardiac system. The pump twin is at a very high risk of cardiac failure due to excessive demand and if not treated, it will die in 50-75% cases. The acardiac one is a parasitic twin that fails to develop a heart, arms and head and receives blood supply from the host by means of umbilical cord. Its much like a fetus –in- fetus, except that the acardiac twin is outside the hosts body. Acardiac fetus can be of three types depending upon the growth of head and other identifiable structures. Acardiac acephalus, as was seen in our case shows failure of head growth.  The other two types are acardiac myelacephalus with partially developed head and identifiable limbs and acardiac amorphous with no recognizable structure. The use of radio-ablation needle to coagulate the blood in the acardiac twins umbilical cord greatly increases the chances of survival of the pump twin to about 80%. However there are no definitive guidelines in the management of monochorionic higher order multiple pregnancies. It depends upon many factors such as available facilities and equipments, financial resources, potential litigations and patients influence which determines the management protocol.

References
  1. Lambalk CB, De Koning CH, Braat DD. The endocrinology of dizygotic twinning in the human. Mol Cell Endocrinol 1998; 145(1-2):97-102. 
  2. Benirschke K, Kim CK. Multiple pregnancy. N Engl J Med. 1973; 288(24):1276-84.
  3. Pharoah PO. Risk of cerebral palsy in multiple pregnancies. Clin Perinatol 2006; 33:301–13.
  4. Evans MI, Britt DW. Multifetal pregnancy reduction: evolution of the ethical arguments. Semin Reprod Med 2010;28:295–302. 
  5. Multiple gestation: complicated twin, triplet, and high-order multifetal pregnancy. ACOG Practice Bulletin No. 56. American College of Obstetricians and Gynecologists. Obstet Gynecol 2004;104:869–83.
Citation

Bang N, Panchbudhe S, Satia MN. Higher Order Births with Acardiac and Anencephalic Fetuses with Poor Fetal Outcome. JPGO 2014 Volume 1 Number 12 Available from: http://www.jpgo.org/2014/12/triplets-with-acardiac-and-anencephalic.html

OHVIRA Syndrome

Author Information

Saxena N*, Channawar S**, Khadkikar R**,  Chauhan AR***.
(* Third Year Resident, ** Assistant Professor, *** Additional Professor. Department of Obstetrics and Gynecology, Seth GS Medical college and KEM Hospital, Mumbai, India)

Abstract

A rare congenital mullerian anomaly which includes uterus didelphys, obstructed hemivagina and ipsilateral renal anomaly is a well recognized entity described as OHVIRA syndrome or Herlyn- Werner-Wunderlich (HWW) syndrome. It is a challenging diagnosis as patient may have normal menses. We report the management of a 14 year old girl presenting with pain in abdomen and dysmenorrhea diagnosed as OHVIRA syndrome.

Introduction

Gynecologists are often fascinated by cases of mullerian anomalies. These include a spectrum of developmental defects ranging from uterine and vaginal agenesis to duplication of the uterus and vagina to minor uterine cavity abnormalities. Mullerian anomalies are frequently associated with renal anomalies. The incidence rate ranges from 0.2 to 7.4%. [1] Didelphic uterus is a rare mullerian anomaly composed of two separate normal sized uteri and endocervical canals with cervices that are fused at the lower uterine segment. Rarer still is the association of didelphic uterus with obstruction of unilateral vagina; it is frequently associated with ipsilateral renal agenesis. This is known as OHVIRA (Obstructed Hemivagina with Ipsilateral Renal Anomaly) syndrome or Herlyn -Werner-Wunderlich syndrome, first reported by Wilson in 1925. [1]

Case Report

A 14 year old girl presented with complaints of irregular menses, pain in abdomen and dysmenorrhoea since last 3 months. Patient had attained menarche 9 months ago, and had regular menses for first 6 months. However since the past 3 months, bleeding occurred irregularly with increasing dysmenorrhea and lower abdominal pain even in between the menstrual cycle. She was referred with an ultrasonography suggestive of bicornuate uterus with hematocolpos of approximately 8.6 x 4.6 x 3.6 cm, with absence of right kidney in right renal fossa, probably renal agenesis. On examination, patient was thin built with normal height for her age. Her general condition was fair, mild pallor was present, systemic examination was normal; abdomen was soft with no tenderness and no palpable lump. Her secondary sexual characters were developed as per age (Tanner stage 2-3). Local examination was normal; detailed internal examination was deferred at this time.
A repeat ultrasonography showed bicornuate uterus with both cornua of approximately equal size, both endometrial cavities normal with endometrial thickness of 5.5 mm, and no fluid collection in the endometrium. There was evidence of a well defined elongated cystic lesion of size 7.3 x 5.3 x 4.2 cm with echoes within it seen below the level of uterus in the pelvis in continuity with uterine cavity on the right side. Another well defined small slightly echogenic soft tissue seen adjacent to the cystic structure appeared to communicate with uterine cavity on the right side. Magnetic resonance imaging (MRI) was done which confirmed didelphic uterus with hematocolpos of right side and absent right kidney. Hence a final diagnosis of OHVIRA syndrome was made based on the above clinical picture and findings.


Figure 1: MRI showing hematocolpos

Examination under anesthesia with drainage of hematocolpos was planned. Speculum examination revealed non- intact hymen, roomy vagina of adequate length and caliber, with a normal cervix seen on left side. High up in the vagina on the right side, a small dimple was seen over a prominent bulge. On per vaginal examination, a tense collection of approximately 4 x 5 cm was felt on anterior and right side. A transverse incision of 1- 1.5 cm was taken over the right sided bulging area and approximately 50 ml of chocolate colored fluid was drained suggestive of hematocolpos. After complete drainage, a small normal cervix was visualized inside the vaginal opening. The vaginal edges were underrun with simple sutures of polyglactin No 2 -0 and the right vaginal opening was kept patent by placing a No. 14 Foley catheter with the bulb inflated with 25 ml normal saline.
A week later, the Foley catheter was removed under anesthesia and the patient was re-examined. The right hemivagina was patent and the right normal cervix was seen. Excision of the edges of the redundant right hemivagina was done with suturing of edges to the right cervix, to restore the normal anatomy and to preserve the normal outflow tract. Patient withstood the surgical procedures well, was discharged on day 4 of second surgery with advice to follow up.


Figure 2: Left -sided normal cervix


Figure 3: Intraoperative image - hematocolpos


Figure 4: Two cervices and patent hemivagina

Discussion

The HWW or OHVIRA syndrome includes didelphic uterus which is characterized by complete or partial duplication of the vagina, cervix, and uterus and is included in class III of American Fertility Society (AFS) classification. The reported incidence in various case series is 0.1-3.8%. [2, 3] This syndrome is usually diagnosed at or after puberty with cases presenting as abdominal pain or dysmenorrhea, due to the associated hematocolpos or hematometra, due to obstruction to flow of menstrual products which collect in blind hemivagina. Because of regular menstruation in these patients, diagnosis is often delayed. Patients can present with complications like endometriosis, hydrosalpinx, secondary infection, pelvic adhesions causing chronic pelvic pain. Thus if not diagnosed and treated in time can lead to long term problems like infertility. The diagnostic modalities which are commonly used include ultrasonography and MRI. USG can diagnose the collection inside uterus or vagina but cannot identify the type of mullerian anomaly while MRI has multiplaner and tissue characterization ability giving  precise information  about uterine morphology, the continuity with each vaginal (obstructed and non-obstructed) lumen. MRI has more sensitivity in detecting the uterine contour, the shape of cavity, presence of the septum, as well as presence of the associated pathology such as endometriosis, pelvic inflammation, and adhesions. [4, 5] Thus MRI is the gold standard method for accurate diagnosis and allows the most appropriate treatment option to be used.

Laparoscopy should be reserved when the diagnosis is not confirmed after imaging or when MRI is not available. Surgical treatment includes excision of vaginal septum.[6, 7] Hysteroscopic resection of the septum can be carried out under transabdominal USG guidance, to preserve hymenal integrity, especially in young females.[8] It is a feasible, convenient, and effective tool in the management of such cases.

References:

1.    Candiani GB, Fedele L, Candiani M. Double uterus, blind hemivagina and ipsilateral renal agenesis: 36 cases and long term follow-up. Obstet Gynecol. 1997; 90:26-32.
2.   Smith NA, Laufer MR. Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA syndrome): management and follow-up. Fertil Steril. 2007; 87:918
3.      Zurawin RK, Dietrich JE, Heard MJ, et al: Didelphic uterus and obstructed hemivagina          with renal agenesis: case report and review of the literature. J Pediatr Adolesc Gynecol. 2004; 17:137
4.      Tanaka YO, Kurosaki Y, Kobayashi T, Equchi N, Mori K, Satah Y, et al. Uterus didelphys associated with obstructed hemivagina and ipsilateral renal agenesis: MR findings in seven cases. Abdom Imaging 1998; 23:437-41.
5.   Sen KK, Balasubramaniam D, Kanagaraj V. Magnetic resonance imaging in obstructive Müllerian anomalies. J Hum Reprod Sci 2013; 6:162-4.
6.      Alborzi S, Tavana Z, Amini M. Hysteroscopic Resection of Vaginal Septum in Didylphys Uterus with Hemiobstructed Vagina. J Minim Invasive Surg Sci. 2014 May; 3(1): e13573.
7.     Kim TE, Lee GH, Choi YM, Jee BC, Ku SY, Suh CS, et al. Hysteroscopic Resection of the Vaginal Septum in Uterus Didelphys with Obstructed Hemivagina: A Case Report. J Korean Med Sci. Aug 2007; 22(4): 766–769.
8.   Burgis J. Obstructive Mullerian anomalies: case report, diagnosis, and management. Am J Obstet Gynecol. 2001; 185:338–344.

Citation

Saxena N, Channawar S, Khadkikar R, Chauhan AR. OHVIRA syndrome. JPGO 2014. Volume 1 Issue 12. Available from: http://www.jpgo.org/2014/12/ohvira-syndrome_1.html