13/1241,Ankur Hospital, Near Uttam-Prakash Theatres, ICHALKARANJI 416115.
Maharashtra State. INDIA.
Telephones -0091-230-421177 / 425002 Fax – 0091-230-424425
Email anjor@bom6.vsnl.net.in v_benadikar@hotmail.com
Purpose
Abdominal Total Pan-Hysterectomy is being done for decades for various indications . Conventionally a vertical or a transverse incision is taken in the lower abdomen . The length of the incision usually varies between 5 to 8 inches , depending on various factors . We all notice a significant difference between post-operative pain and morbidity of abdominal hysterectomy and abdominal tubectomy . I thought that one of the main factors responsible for this is the smaller length of tubectomy incision . Obviously the amount of tissue damage and post-operative edema is much less in tubectomy . My next thought was whether abdominal hysterectomy could be done through an incision as small as tubectomy . If this could be done , then we will be able to achieve -
A. reduced post-operative pain.
B. reduced tissue destruction and subsequent post-operative edema.
C. reduced post-operative morbidity and to improve early mobilization .
D. more cosmetic & small size scar than conventional incisions.
Method
I started doing abdominal total pan-hysterectomy through a considerably small –“ mini-pfannenstial ” incision . The modified incision measures between 1.5 to 2 inches . I have done more than 130 hysterectomies through this modified incision .
After taking this incision the main problem is that the self-retaining retractor cannot be put inside the abdominal cavity because of lack of space . With Babcocks forceps the left cornu if uterus is held. Then the uterine fundus is grabbed with volsellum and a tenaculum is applied to the remaining part of fundus. Now the uterus is pulled & delivered out obliquely turning it in about 45 degrees so that , the left cornu comes out first , followed by the fundus . Now the uterus is turned lateraly to left side & with further pull action the right cornu is delivered out. By turning the uterus to right side & with continuous pull action, remaining portion of left cornu is delivered out. This action of turning to left & right side may have to be repeated 2 to 3 times. During this maneuver of pulling the uterus out,, an assistant is pushing the abdominal wall down. Once the uterus is delivered out of abdominal wall , a small C - shaped retractor is put on the right side, in the peritoneal cavity . By retracting the abdominal wall to right side, the right round ligament and the right infundibulo-pelvic ligament is clamped , cut and ligated with no. 1 vicryl . The same step is repeated on left side .Rest of the procedure is the same as in a conventional abdominal hysterectomy, where in the uterus with cervix and both tubes & ovaries are removed .Vagina is closed with No.1 – 0 vicryl. Peritonization was done with No.1-0 vicryl . Abdominal wall was closed back in layers with 1-0 vicryl . Skin closure is done with Mono-filament Nylon – either as interrupted sutures or subcuticular sutures.
In all the cases, pre-operative estimation of uterine size was done by ultrasound and subsequently confirmed by measuring the specimen. Thus obviously large uterine fibroids or large adnexal masses were not included in this series. The largest removed uterus measured 3 inches in width, height and length are not a constraint.
Advantages
1. The small mini-Pfannenstial incision of 1.5 to 2 inches in length is subsequently hidden in the pubic hairline . So the cosmetic value of this is tremendous . The acceptance and appeal of surgery has tremendously increased.
2. Since the incision is very small , bleeding , tissue damage and subsequent edema is much less .
3. Post-operative pain is almost absent in this series . The minimal tissue damage because of small incision , coupled with epidural anaesthesia and epidural norphin , gives virtually pain-free status to the patient in first 24 to 48 hours . Third post-operative day onwards , only with oral analgesics , the patient is pain-free . In fact all my patients describe this procedure as PAINLESS HYSTERECTOMY .
4. No abdominal wall packing is done or required . So intestinal handling is absent . Good peristalsis are present within first 4-6 hours , and early oral fluids were started in all cases , lessening the need of IV fluids .
5. Patient can be discharged home earlier, lessening her hospital stay and expenditure.
6. As a routine, urinary catheter is removed immediately after the surgery. Because of this, patients are encouraged to go to the toilet – because these leads to early mobility, chances of DVT are reduced. Also the risk of urinary tract infection becomes less.
6. For any working woman anywhere in the world , resuming her daily work is important. Because of this modified mini-pfannenstial incision , women go back to their daily routine much faster than otherwise .
Disadvantages
1. Large fibroids , large ovarian tumors , malignancies , and grossly obese patients cannot be operated with this modified technique for obvious reasons . They require larger incisions . However ovarian cysts can be , first aspirated and then could be removed through the modified incision . I have done this in about 10 cases.
2. Delivering uterus, out of abdominal wall is not easy , because the length of the modified incision is much smaller than the breadth of the uterus . It requires skill , extra maneuverability and practice .
3. Because of the smallness of the incision , one has to work with restricted visibility .Rather than “seeing” the structures you need to “feel” them by your fingers.
4. If patient has previous multiple abdominal surgeries , she may need a slightly larger incision .
Complications
There were no complications in the series attributable to the modified technique . However , one case developed abdominal wall hematoma . The hematoma was evacuated successfully.
Results
The results achieved with Modified Mini-Pfannenstial technique were excellent . All the objectives mentioned earlier were satisfactorily achieved . The patients were extremely happy and comfortable because of the excellent results .
Comparison with LAVH -
This procedure seems to be far simpler than LAVH and has lot of advantages over it .
1. Modified Mini-Pfannenstial technique is inexpensive . It does not require costly instrumentation as required in LAVH .
2. Modified Mini-Pfannanstial technique does not require any special training .One , who is well versed with conventional abdominal hysterectomy , can easily get adjusted to the new modification.
3. Considerably smaller team is required to do Modified Mini-Pfannenstial Hysterectomy .
4. Pneumoperitoneum complications are absent in Modified Mini-Pfannenstial Hysterectomy . In fact there are no complications in my series attributable to Modified Mini-Pfannenstial Technique .
5. Post-operative pain is almost absent in my series . The same can not be said about LAVH .
6. Hospital stay in both modalities is comparable .
7. A small transverse incision completely hidden in pubic hairline , is any day better looking than multiple punctures in lower abdomen . Ask any lady undergoing hysterectomy , who likes to have a beachwear , which one she will prefer , Modified invisible Mini-Pfannenstial incision or multiple punctures in lower abdomen due to LAVH .
8. Chances of injury to other intra-abdominal structures are almost absent in Modified Mini-Pfannenstial technique .
Conclusion
Though there are a few disadvantages of Modified technique , the advantages are abundant , and they outweigh the disadvantages by a large margin . I sincerely believe , that , Modified Mini-Pfannenstial Pan-Hysterectomy is almost complication-less , convenient and comfortable procedure . The invisible pubic hairline incision is much more cosmetic than conventional hysterectomy incision or multiple punctures of LAVH . It is more appealing to the patient and the surgeon , both . Modified Mini-Pfannenstial Hysterectomy is a superior technique than conventional hysterectomy or LAVH . The future belongs to modified Mini-Pfannestial Hysterectomy . Women of the world , you deserve it .
