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Re: Ligating without clamping first vag hyst pediclesFrom: Dr Mangeshikar (tilprash@giasbm01.vsnl.net.in)Thu Apr 30 10:37:56 1998
>From: "Dr. Premanand B Pai Dhungat" <prempai@bom3.vsnl.net.in> >To: "Dr Mangeshikar" <tilprash@giasbm01.vsnl.net.in> >Subject: Re: Ligating without clamping first vag hyst pedicles >Date: Wed, 29 Apr 1998 09:53:42 +0530 >X-MSMail-Priority: Normal >X-Mailer: Microsoft Internet Mail 4.70.1155 > >Dear Gail, >I was fascinated by the interest shown in the clampless technique of vag >hyst. I am of the strong opinion that if this technique is widely practiced >and taught the l.a.v.h. will become reduntant.Without trying to be boastful >we had to resort to laparotomy only in 7 cases out of total of 9982 vag >hyst done at bombay hospital upto dec.97. >It was nice to know that the same or similar procedure was practiced in >florida, johns hopkins, lyons and some other places. In india it was >practiced by late prof. dr.b.n.purandare and as it is only practiced in >bombay and that also in some places it is called bombay method. >I will send you the video-casette of the procedure but as all the other >methods have described some kind of clamps or and needle holders i will >briefly tell you how to tie the ligaments with simple everyday instuments. >The basics is; 1) retraction of post.vag wall with Auvard's.2) Jayle's >retractor for lateral vaginal wall retraction.3)having considered that you >have opened both the uterovesical pouch and the p.o.d the bladder wall >retractor is put in the u.v.pouch and held against the pubic symphisis by >the assistant.4)the assistant who holds the cervix with the traction >stitches pulls it to the right side and the surgeon puts the middle finger >of the left hand through p.o.d. to put the left utero-sacral under >tension, with the finger still in ;about 1/2 + 1 c.m. strip of vaginal >mucosa is excised. this serves 3 purposes :demacates the uterosacral >clearely, allows the ties securely and avoids overlapping at the end stage >of the operation.now with the regular needle holder 1 vicryl on the regular >needle is passed from anteriorly to posteriorly with your midle finger of >the left hand which is acting as a guide so that the needle comes on the >palmar surface of the middle finger. it is important that the assistant who >is holding the cervix traction stitch gradually lifts his traction >anteriorly. This is tied securely laterally. and with the middle finger >still keeping the tension the uterosacral is cut close to the uterus.5)the >middle finger now keeps the transverse cervical ligament under tension and >the 1 vicryl stitch is put ;again the needle traversing from anterior to >posteriorly on the palmar surface of the middle finger.This is tied >laterally to the first suture so that the uterosacral gets double tied.. >The assistant now pulls the cervix tension stitch to the right side and >the surgeon cuts the transverse ligament close to the uterus.6)the exact >procedure is repeated on the right side of the patient by taking mirror >image steps.7)Now comes the most important step.It is based on the simple >anatomical principle that all the blood supply of the uterus comes through >broad ligament, with the edges of the two leaves of the broad ligament >being visible anteriorly below the level of the bladder wall reractor and >the poseriorly near the edge of the cut transverse lagament the stitch is >taken of no.1 vicryl with the middle finger as the guide from edge of the >anterior peritoneum to the edge of the posterior peritoneum and this is >tied securely, to avoid any mishap no cutting is done but an additional >stitch is taken 1/2 cms. ant.; again going from anteriorly to posteriorly >and this is tied and then again taking help of the middle finger of the >left hand which keeps the ligament tense the vessels are cut close to the >uterus. to use the adjective of the master ,"you shave the uterus " >I hope this might give you some incentive in watching the videocassette i >will send to you in next few days >with regards >premanand, f.r.c.o.g. > >---------- >> From: Dr Mangeshikar <tilprash@giasbm01.vsnl.net.in> >> To: prempai@bom3.vsnl.net.in >> Subject: Ligating without clamping first vag hyst pedicles >> Date: Tuesday, April 28, 1998 9:18 AM >> >> >Date: Fri, 24 Apr 1998 05:19:54 -0500 >> >Reply-To: ob-gyn-l@obgyn.net >> >Originator: ob-gyn-l >> >Sender: ob-gyn-l@obgyn.net >> >From: "Gail Waldby, MD" <gwaldby@main.basec.net> >> >To: Multiple recipients of list <ob-gyn-l@talk.obgyn.net> >> >Subject: Ligating without clamping first vag hyst pedicles >> >X-Comment: list for discussion of obstetrics and gynecology >> > >> >Please explain how you ligate the cardinal and uterosacral ligaments and >> >ascending uterine vessels without first clamping them during vaginal >> >hysterectomy. I keep thinking this is a good idea and keep vowing to >> >try it, but when the time comes during a vaginal hysterectomy, the >> >pedicles never look right to me for this approach. How do you ligate >> >them securely before you divide them? >> >Gail Waldby, MD >> >Huron Clinic SD >> > >> Dr Tilottama Mangeshikar >> Consultant Anaesthetist & Intensivist >> Bombay Hospital Institute of Medical Sciences >> >> Mailing Address: >> Madhav Niwas >> 8 Laburnum Rd >> Gamdevi Mumbai 400007 >> India >> >> Tel 91 22 3805768 >> Fax 91 22 3804639 >> Mobile 98210 93832 > Dr Tilottama Mangeshikar Consultant Anaesthetist & Intensivist Bombay Hospital Institute of Medical Sciences Mailing Address: Madhav Niwas 8 Laburnum Rd Gamdevi Mumbai 400007 India Tel 91 22 3805768 Fax 91 22 3804639 Mobile 98210 93832
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