Purohit Technique of vaginal hysterectomy

This technique increases the lateral accessibility and visibility. This technique is safe and effective in conducting vaginal hysterectomy and salpingo-oophorectomy in almost all cases of benign disease with a uterus up to 20 weeks of gestation and without prolapse irrespective of most pre-existing conditions regarded as relative contraindications to vaginal hysterectomy.

It increases accessibility and visibility to narrow working spaces between uterus and the pelvic sidewall. This newer technique has almost eliminated the traditional difficulties in completion of vaginal hysterectomy. Vaginal hysterectomy has been made easy, accessible and visible. However, many gynecologic surgeons traditionally do not believe the security of the uterine artery after bipolar cauterization and division. It is indeed reliable similar to that of laparoscopic hysterectomy.

How this technique increases lateral accessibility.
Vaginal walls are incised by monopolar current (30-35 watts). A right angle forceps in stead of index finger is used throughout to elevate, hook, stretch, spread and retract all the lateral attachments of uterus and vessels from their posterior aspects; tissues were desiccated by bipolar current (45 watts) and divided between the prongs of forceps. Uterine arteries are secured extraperitoneally by Purohit approach to uterine artery. In Purohit technique of vaginal hysterectomy the main player is a right angle forceps, it eases vaginal hysterectomy. An ordinary long thin bipolar forceps is used. Liga Sure and Harmonic or any other energy may be used in place of bipolar current. We do not use thick clamps, needle, and suture as used in conventional methods. Suture is only used for vault anchoring and vault closure.

How this technique increases lateral visibility.
Use of a thin rigid long torch like 10 mm telescope with light source or pelvic illuminator to transmit light to the deeper and darker operation sites increases visibility. It further makes the operation easier. Conventional volume reduction maneuvers were used as associated procedures in cases of large uteri to create the parauterine space for bipolar forceps and scissors. Thus, our technique overcomes the problems due to narrow lateral space and poor visibility in vaginal hysterectomy.

Frequency of need of Morcellation
Only 13.55% cases required morcellation of uterus to reduce volume. Because of increased lateral accessibility and visibility, uterus of 280 grams seldom need morcellation. They are removed intact. Using this technique we have removed uteri of 400 and 430 grms intact (specimen photograph & photograph in last part of video) with out the need of morcellation.

Salpingo-oophorectomy during vaginal hysterectomy
We have conducted salpingo-oophorectomy during vaginal hysterectomy in all indicated cases including a case of benign unilocular simple ovarian cyst of 20 weeks size (photograph of which is shown in the last part of video no 1), the cyst was aspirated before it was excised. Hydrosalpinx, benign adnexal cysts, Adnexal mass, (last part of video no 1) could be safely removed by this technique.

Adhesiolysis during vaginal hysterectomy
Adhesions could be easily dissected by right angle forceps, coagulated by bipolar forceps close to uterine wall, and divided by scissors to release uterus and ovaries. History of previous pelvic operation has not been always a contraindication to our technique.

Advantages
This newer technique promises advantages of a high success rate, almost no need of conversion, low frequency of requirement of volume reduction maneuvers, less intraoperative and postoperative bleeding, mild postoperative pain, early discharge from hospital and early resumption of routine work. Thus, it will reduce cost and complications. Surgeon who is in favour of vaginal hysterectomy will inflate his limit; Surgeon who is not in favour of vaginal hysterectomy will think to go for the technical vaginal hysterectomy to provide maximum comfort (no scar no pain) of the removal of uterus to a loyal customer. Women will not be afraid of undergoing removal of uterus through this technique. Number of fancy laparoscopic hysterectomies will be brought down. Learning is easy.

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References.