The International Journal Of Science & Technoledge (ISSN 2321 – 919X) www.theijst.

com

THE INTERNATIONAL JOURNAL OF

SCIENCE & TECHNOLEDGE
NDVH (Non Descent Vaginal Hysterectomy) without Any Suture Staples or
Clips Using Erbe Open Programmed Vessel Seal with Minimal Blood Loss:
An Alternative Consumer Friendly Innovative Cost Effective Technique!!

Dr. Rabindra Nath Behera

Professor & HOD, MIS & ART Unit, HITECH Medical College, BBSR, Odisha, India

Abstract:
Objective: To evaluate the feasibility and safety of Erbe open programmed vessel seal biclamp electro-cautery appliances in
non-descent vaginal hysterectomy (NDVH) even up to the size of twenty-two weeks of uterine mass with minimal blood loss
without the application of sutures, clips and staples for uterine attachments.
Study method:: In a prospective study vaginal hysterectomy was reviewed by consecutive 1628 women from December’2004
to sept’2014 for different benign uterine diseases without any uterine descent excluding cancers, known endometriosis,
previous lower abdominal scars, and uteri of more than 22 weeks size at Hitech medical college, Bbsr, Odisha, India &
Melaka General Teaching Hospital, Malaysia. Under combined spinal epidural anaesthesia and adopting hydro dissection for
bladder separation through vesicocervical fascia anteriorly and later entry into the pouch of Douglas, all lateral attachments
of the uterus and even the infundibulo-pelvic ligaments were secured using Erbe open programmed vessel seal without
applying any sutures, clips or staples. Vaginal vault was closed in one layer with bilateral postero- lateral fixation to
uterosacral stump.
The results: Vaginal hysterectomy was successful in all cases without any pre-operative complications. Weight of the patient
ranges from less than 60Kg – 396 cases (24.32%), 60-80 Kg-858cases (52.7%),80-100 Kg-286 cases(17.56%) and only 88 (
5.4% )patients weighing more than 100Kg (100-116Kg).The size of the uterine mass varies from less than 12 week-836
cases(51.35%), 12-16 week- 528 cases(32.43%),16-20 week-242 cases(14.86%), and 22 patients (1.35%) were ranging more
than 20 week size of uterus. The indications for NDVH were uterine Leomyomas in 539 patients (33.1%), Adenomyosis in 341
cases (20.94%), Mixed adenomyosis with fibroid in 352 cases (21.62%) and DUB (dysfunctional uterine bleeding) in 396
patients (24.32%).Bleeding was less than 20 milliliters in 968 cases (59.45%), 20-50 milliliters in 418 patients (39.18%) ,50-
100ml in 220 cases and 22cases (1.35%) with more than 100 milliliters (100-130 milliliters), without requiring any blood
transfusion. Mean operating time was less than 40 minutes in 1097 cases (67.38%), 40-60 minutes in 515 cases (31.62%) &
more than 60 minutes in 16 cases(1%) . 902patients (55.4%) were discharged within 48 hours of hospital stay while 649
(39.86%) cases stayed up to 48- 60 hours and only 77 (4.72%) patients were discharged after 60 hours (60-66hours) of stay.
One dose of Tramal injection or voltaren (diclofenac sodium) suppository was used as post operative analgesia No patient
needed relaparotomy or readmission. Histo-pathology revealed benignity in all cases. More than ninety percent (1608) cases
resume work within three week with excellent customer satisfaction.
Conclusion: Non-descent Vaginal hysterectomy using Erbe open programmed vessel seal electro-cautery method is feasible,
safe and an effective alternative innovative armamentarium with excellent consumer satisfaction even for large uteri up to
22weeks. However large series with meta-analysis need to be addressed.

1. Introduction & Background

NDVH (non descent vaginal hysterectomy) is not the usual prototypic hysterectomy through vagina for prolapsed uterus. This is
literally an innovative highly qualitative procedure where the uterine mass is exteriorized through the natural vaginal orifice
resulting in affording an invisible minimum scar. The basic rule is that the uterus is not anatomically distorted from its original
position without any descent or prolapse. The second exhilarating character of this operation is that all the pedicles of the uterus
are secured by radiofrequency electrosurgical instrument without utilizing any sutures, staples or clips, thus providing the relative
perioperative comfort and lessen postoperative morbidity.

1.1. Are We Vagina Friendly?

This interrogation invariably peeps from the eminent gem in the field of clamp less NDVH (Non descent vaginal hysterectomy) in
almost all Gynecological gatherings—He is ‘Dr Shirish Sheth’-the ex FIGO president and coauthor of the text book on ‘vaginal
hysterectomy’.(Ref 1)

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1.2. But To What Extent We Are Indeed Vagina Friendly!!

In 2003, 602,457 hysterectomies were performed, for a rate of 5.38 per 1,000 women-years in the United States of America and an
estimated 20 million U.S. women have had a hysterectomy. Of the 538,722 hysterectomies for benign disease (rate 4.81 per 1,000
women-years), the abdominal route was selected in the most common (66.1%) cases, followed by vaginal (21.8%) and
laparoscopic (11.8%) routes only (Ref 2). And in other parts of the world vaginal hysterectomy was performed in UK about -27%,
FRANCE <30% and MALAYSIA-<10%... In fact the true incidence of NDVH is still awaiting .The major indications of
hysterectomy were Fibroids-40.7%, followed by endometriosis-17.7% and prolapsed uterus about 14.5%.

1.3. What We Gynecologist Fears!!

Fear of the internal organs injury during the procedure and especially the injury to ureters are the principal worries of the
operating Gynaec surgeon .In spite of the fact that internal organs injury (Tab 1),
Especially the ureters is the least in vaginal approach (1/1000 VH), NDVH (Non descent vaginal hysterectomy) is performed only
by about less than 10 % globally (Ref 3).

2. History
Though vaginal hysterectomy for prolapsed, gangrenous uterus dates back to ‘Soranus of Ephesus’ (2ND century AD) ,first
planned, successful vaginal hysterectomy was performed in 1813 by “Conrad Langenbeck’ for a 50 year female with, ulcerated,
possibly cancerous cervix procedure without anesthesia or assistance. He did not report the case until 1817. In 1824 ‘Recamier’
(1774-1852) performed and published the first successful vaginal hysterectomy for cancer of the cervix. (Ref 4)
With the advent of modern anesthesia and safe biomedical equipments, lot of modifications was in scripted and ornamented in the
era of hysterectomy and selectively for NDVH (non descent vaginal hysterectomy).
International consensus reveals vaginal hysterectomy is to be preferred for benign uterine conditions. Vaginal hysterectomy
indeed is the safest and most cost-effective method to remove the uterus for noncancerous reasons, according to a new Committee
Opinion released by The American College of Obstetricians and Gynecologists (ACOG) and published in the November issue of
Obstetrics & Gynecology. In general, based on the medical evidence, vaginal hysterectomy is associated with better outcomes and
fewer complications than either laparoscopic or abdominal hysterectomy .SPRS practice guidelines ‘2009 comply with
recommendations of the ACOG. (Ref5, 6, 7)
In the wards of Albert Einstein ‘Learn from yesterday, live for today, hope for tomorrow. The important thing is not to stop
questioning." –

2.1. So Why NDVH Is Less Popular?

May be because the trainers for this qualitative technique are relatively less in numbers and the existing trainers have less time to
spare for training and on the contrary, the resident trainees’ training schedule is most probably not properly organized, timely
audited, duly edited and optimally utilized with the end result of an instantaneous unnoticed vicious cycle of incompetency of a
marvelous qualitative surgical technique is sprouting and revolving.
No one likes any scar, neither nobody wants to stay in the hospital more days with pain. Everyone prefers to join with the near and
dear at an early date. Who doesn’t want to resume back duty early for bread and butter! And most important is the cost factor—
how much the operation is cost effective! What we prefer—we need an operation which should be simple, straightforward,
qualitative, and cost effective and most importantly consumer friendly. And that is the surgery for NDVH.

2.2. Why Vaginal Route Is Preferred?

 No Visible Scar: Any operation- either total abdominal or laparoscopic hysterectomy procedure -needs to remove
uterus ends up in a scar and its complications relatively more in open abdominal route. NDVH delivers uterine mass
through a natural passage just like delivering a baby and incidentally caters no visible scar.
 Less Anesthetic Complications: since NDVH operation usually carried out employing CSE (combined spinal epidural)
anesthesia, preoperative prototypic general anesthetic precautions like bowel preparation, Ryle’s tube insertion etc are
unnecessary and accordingly complications of general anesthesia are relatively less encountered.(Ref 8)
 Video Watch: Sometimes few patients opt to observe the procedure directly on video recording and also to listen the soft
music to smoothen the anxiety and tension. This satisfies lot to the consumer with instantaneous evidences.
 Easy To Dissect: Instituting hydro dissection. After infiltrating saline or diluted vasopressin it is relatively easy and
smooth to dissect and separate the bladder anteriorly through the vesico-cervical fascia and posteriorly access direct entry
into the pouch of Douglas in-between the uterosacral-ligaments. (Ref 9)
 Less Internal Organ Injury: By dissecting bladder through vesicocervical fascia and drawing bladder upwards the
ureters are automatically displaced from the operating sites with the end result of easy application of the Erbe vessel seal
without any damage at all to the bladder or the ureters. Likewise intestinal injury at the posterolatera aspects can be
avoided by the insertion of soaked long ribbon gauze in to the pouch of Douglas which caters the function of an
abdominal pack.
 Easy To Secure The Pedicles: Adopting traction by assistant and counter traction by the operating surgeon , packing
pouch of Douglas with a long soaked ribbon gauze all the pedicles including infundibulopelvic ligaments can be well
secured without the apprehension and fear of ureteric injury.
 Minimal Blood Loss: All the feeding vessels are sealed under direct vision using vessel seal. Blood loss is minimal
about less than 50 cc.No blood transfusion and accordingly no blood transfusion complications are to be encountered.

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 Less Post Operative Morbidity: Post operative analgesia is less needed either with one dose of dynastat or tramal
injection or voltaren suppository since the nerve endings are abruptly sealed off by the radio frequency electrosurgical
vessel seal forceps.
 Early To Resume Work: usually patients can join back work within two to three week which consequently improves the
financial aspect of the family.
 NO Sutures, No Staples Or No Clips: In our series we usually avoid any suture materials, staples or clips. All pedicles
were grasped and secured by the Erbe open vessel seal electrosurgical instruments. At present the following
electrosurgical vessel sealing instruments are available

3. Vessel-Sealing Devices Available

 LigaSure V (Valleylab)
 PK Gyrus system
 Harmonic Scalpel
 Erbe system
 Ligamax 5 Endoscopic Multiple Clip Applier
 Martin vessel seal.

Figure 1: Radio Frequency Equipments Available

Evidence review suggests that Electrosurgical vessel sealing in vaginal hysterectomy is beneficial in reducing the operation time,
perfect vessel sealing device leading to less blood loss, operate within relatively less available space, no subsequent tissue
necrosis resulting in relatively very less pain, no reaction to foreign materials like sutures, clips ,staples and especially averting
needle prick injury.(Ref10 )
The possible explanations documented for above advantages are: Radio frequency waves destroy the affected nerve endings s
immediately, preventing the propagation of painful sensations through the lateral spino-thalamic tract to the hypothalamus while
Suturing tends to strangulate and slowly necroses nerves endings (Figure 2). This application reduces the risk of adverse reactions
to foreign materials and finally, the reduction in needle use reduces the potential risk for needle prick injury during vessel ligation.
(Ref 11)

Figure 2: Relative Comparison between Suturing and Erbe Vessel Seal on Securing Pedicles

3.1. Is Erbe Open Vessel Seal Beneficial And Worthy?

The ERBE VIO Electrosurgical System is preprogrammed and automatically provides the appropriate waveform and voltage for
thermo fusion with optimal hemostasis. In our series we prefer to utilize the Erbe open programmed vessel seal forceps because of
its reusability, so cost effective, perfect vessel sealing quality up to the extent of securing about 7millimeter vessel thickness,
offering an absolute dry operating scenario, good visibility since retrograde bleeding from the uterine mass is avoided, rapid
convalescence and requires almost no ligatures-hence no subsequent tissue necrosis therefore relatively less pain experienced.
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Figure 3: Erbe Programmed Monitor and Open Vessel Seal

3.2. No Problem For Securing Infundibulopelvic Ligament

The obstacle of identification, approach, clamp, transfixation and ligation of the infundibulopelvic ligaments to remove the
ovaries is well ameliorated by the application of Erbe open vessel seal. Hence no worry for ovaries exteriorization!

3.3. Step Wise Surgical Techniques

Exclusion criteria: Uterine prolapse, Malignancy, Previous abdominal surgeries, recurrent endometriosis

4. Procedure

Figure 4: Anesthesia-Combined Spinal Epidural (CSE)

Figure 5: POSITION –Lithotomy, Bladder Catheterized

 Vagina exposed by retracting posteriorly by Sims vaginal speculum, anterioly by Landon’s vaginal retractor:

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Figure 6: Large Fibroid Polyp Grasped By Tenaculum Forceps And Avulsed

Figure 7: Avulsed Fibroid Polyp Figure 8:Hydro Dissection

 About 150 to 200 cc of normal saline or in suitable cases diluted vasopressin (One cc in 1oocc of saline) using 20 gauze
needle infiltrated all around the cervix taking precaution that anteriorly bladder and posteriorly pod contents are not
traumatized-

Figure 9: Infiltrating Saline Through Vesicocervical Space In Anterior Vagina

Figure 10: Posterior Saline Instillation

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Figure 11: Instilled Posterior Vaginal Fornix

Figure 12: Bladder Separation: Anteriorly Through Vesico Cervical Fascia

Figure 13: Antero-Lateral Incision By Monopolar Diathermy

 A Semi Lunar Incision Is Made Using 40 Watt Monopolar Cautery At Antero-Lateral Aspects Of The Cervix To Reach
The Vesico Cervical Space—A Whitish Glistening Fascia Separating The Bladder From The Cervix
 Bladder dissection through vesico-cervical fascia: The bladder is carefully dissected through the vesico-cervical fascia
taking advantage of hydro dissection.

Figure 14: Securing The Bladder Pillars

 The bladder pillars are cauterized and transected allowing the progressive gradual upward retraction easier

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Figure 15: Dissected Bladder Retracted Upwards

The dissected bladder is retracted upwards by the assistant. Hence the ureters are automatically displaced upwards and are kept
out of any possible injury during the later application of radiofrequency electrosurgical instruments to secure the uterine vessels.

Figure 16: Grasping Posterior Vagina By Littlewoods Forceps

 Posterioly The Infiltrated Vagina Was Grasped And Pulled Downwards With Littlewoods Forceps

Figure 17: Vagina Incised Transversely to Open Directly into the Pouch of Douglas

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Figure 18: Insertion of Long Ribbon Gauze Through Pod As Such Acting As Pod Pack

Long soaked ribbon gauze was inserted in to the pouch of Douglas. This helps in three ways: a. pushes up the pod contents
upwards allowing an optimum safe space for the introduction and the application of vessel seal forceps, b-absorbs the peri pasu
oozing and make operating field dry, c-averts the lateral dissipation of thermal injury during the radio frequency forceps use in
securing the pedicles.

Figure 19: Securing Lower Uterine Pedicles

 The uterosacral and cardinal ligaments of both sides were secured by applying Erbe vessel seal open programmed forceps
without utilizing any sutures, staples or clips

Figure 20: Approximation of Uterosacral to Posterolateral Vagina

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 The uterosacral stumps were approximated to the respective sides with 1/0 safil suture so as to reduce the chance of later
vault prolapse.

Figure 21: Uterine Vessels Secured

 Both sides’ uterine vessels were grasped and biclamped with same vessel seal forceps and later transected allowing easy
upward ascent in a dry operating field.

Figure 22: Grasping Upper Uterine Pedicles

 After uterine vessel were secured the uterine mass was pulled to one side so as to navigate the opposite upper uterine
pedicles like round ligaments, ovarian ligaments , infundibulopelvic ligaments ( if ovaries to be removed) and fallopian
tubes and were sealed one after another and cut. In cases of relatively large uterine mass uterus was incised in ‘S’ shaped
manner to access to the upper appendages.

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Figure 23: Exteriorising The Uterine Mass Through Vagina

 The whole uterine mass with ovaries and tubes were pulled downwards, forwards and exteriorized like delivering a baby
during parturition.

Figure 24: Large Uterine Mass Exteriorized

Figure 25: Approximation of Vaginal Lips with 1/0 Safil Suture

 Later anterior and posterior vaginal lips were approximated using 1/0 safil suture and vagina is packed with acriflavine
vaginal pack.

Figure 26: NDVH Postoperative Image of Vagina

Figure 27: Large Uterine Mass with Intramural Fibroid and Fibroid Polyp-- Cut Section

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 In our series: To evaluate the feasibility and safety of Erbe open programmed vessel seal biclamp electro-cautery
appliances in non-descent vaginal hysterectomy (NDVH) even up to the size of twenty-two weeks of uterine mass with
minimal blood loss without the application of sutures, clips and staples for uterine attachments.

5. Study Method
In a prospective study vaginal hysterectomy was reviewed on consecutive 1628 women from December’2004 to sept’2014 for
different benign uterine diseases without any uterine descent excluding cancers, known endometriosis, previous lower abdominal
scars, and uteri of more than 22 weeks size at Hitech medical college,Bbsr,Odisha ,India & Melaka General Teaching Hospital,
Malaysia. Under combined spinal epidural anesthesia and adopting hydro dissection for bladder separation through vesicocervical
fascia anteriorly and later entry into the pouch of Douglas, all lateral attachments of uterus and even the infundibulo-pelvic
ligaments were secured using Erbe open programmed vessel seal without applying any sutures, clips or staplers. Vaginal vault was
closed in one layer with bilateral postero- lateral fixation to uterosacral stump.
Results: Vaginal hysterectomy was successful in all cases without any peri-operative complications. Weight of the patient ranges
from less than 60Kg – 396 cases (24.32%), 60-80 Kg-858cases (52.7%),80-100 Kg-286 cases(17.56%) and only 88 ( 5.4%
)patients weighing more than 100Kg (100-116Kg).The size of the uterine mass varies from less than 12 week-836 cases(51.35%),
12-16 week- 528 cases(32.43%),16-20 week-242 cases(14.86%), and 22 patients (1.35%) were ranging more than 20 week size of
uterus. The indications for NDVH were uterine Leomyomas in 539 patients (33.1%), Adenomyosis in 341 cases (20.94%), Mixed
adenomyosis with fibroid in 352 cases (21.62%) and DUB (dysfunctional uterine bleeding) in 396 patients (24.32%).Bleeding was
less than 20 milliliters in 968 cases (59.45%), 20-50 milliliters in 418 patients (39.18%) ,50-100ml in 220 cases and 22cases
(1.35%) with more than 100 milliliters (100-130 milliliters), without requiring any blood transfusion. Mean operating time was
less than 40 minutes in 1097 cases (67.38%), 40-60 minutes in 515 cases (31.62%) & more than 60 minutes in 16 cases(1%) .
902patients (55.4%) were discharged within 48 hours of hospital stay while 649 (39.86%) cases stayed up to 48- 60 hours and
only 77 (4.72%) patients were discharged after 60 hours (60-66hours) of stay. One dose of Tramal injection or voltaren
(diclofenac sodium) suppository was used as post operative analgesia No patient needed relaparotomy or readmission. Histo-
pathology revealed benignity in all cases. More than ninety percent (1608) cases resume work within three week with excellent
customer satisfaction.
Conclusion: Non-descent Vaginal hysterectomy using Erbe open programmed vessel seal electro-cautery method is feasible, safe
and an effective alternative innovative armamentarium with excellent consumer satisfaction even for large uteri up to 22weeks.
However large series with meta-analysis need to be addressed.

6. Abbreviations
 NDVH-non descent vaginal hysterectomy
 TAH-total abdominal hysterectomy
 TLH-total laparoscopic hysterectomy
 RF-radio frequency
 CSE-combined spinal epidural
 Kg- kilogram
 Mins- minutes
 Dub-dysfunctional uterine bleeding

7. Tables

Types of injury TAH TLH NDVH

Bladder 5/1000 7/1000 1/1000
Ureter 5/1000 10/1000 1/1000
Intestinal nil 4/1000 nil
Table 1: Internal Organ Injury in Hysterectomy

Ref 3: Statistical analysis of injury in different types of Hysterectomy,www.parkermd.com/about-hysterectomy.htm, 13thoct’2009

Indications Patient numbers Percentage

Leomyoma 49 33.1
Adenomyosis 31 20.94
Mixed adenomyosis&fibroid 32 21.62
DUB 36 24.32
Table 2: NDVH-Major indications

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Patient’s weight in Kg Number of patients Percentage

Less than 60 36 24.32
60-80 78 52.7
80-100 26 17.56
More than 100 8 5.4
Table 3: NDVH Patients Weight Variables

Uterine size in weeks of pregnancy Patient’s Number Percentage

Up to 12wk 76 51.35
12-16wk 48 32.43
16-20wk 22 14.86
More than 20wk 2 1.35
Table 4: NDVH Uterine Size Variables

Amount Numbers of patient percentage

Less than 50cc 88 59.45
50-100c 58 39.18
100-150c 2 1.35
Table 5: NDVH Intra Operative Bleeding Pattern

Total Hours Number of Patients Percentage

Within 48 hrs 82 55.4
48-60 hrs 59 39.86
60-66hrs 7 4.72
Table 6: NDVH Hospital Stay

8. References
1. Vaginal Hysterectomy Author: Shirish S. Sheth, John Studd, Shirish S. Sheth ...
www.flipkart.com/vaginal-hysterectomy-shirish-sheth.../1901865436-r1x3ftn9db - India
2. Wu JM, Wechter ME, Geller EJ, Nguyen TV, Visco AG, Dept of Obst, University of North Carolina, USA
Hysterectomy rates in the United States, 2003. Obstet Gynecol 2007; Nov; 110(5):1091-5
3. Statistical analysis of injury in different types of Hysterectomy www.parkermd.com/about-hysterectomy.htm,
13thoct’2009
4. P.F.Vietz, M.D. Westminster, MD 21157 (USA), Hysterectomy –
A historical perspective,www.qis.net/~pvietz/history.htm. September 1997.
5. American College of Obstetricians and Gynecologists (ACOG), Choosing the Route of Hysterectomy for Benign
Disease," WOMENS HEALTH/GYNECOLOGY, November 2009 issue of Obstetrics & Gynecology.
www.medicalnewstoday.com/articles/168278.php -
6. Johnson, N, Barlow, D, Lethaby, A, et al. Surgical approach to hysterectomy for benign gynecological disease. Cochrane
Database System Rev 2006:CD003677
7. Santiago Domingo; Antonio Pellicer: Laurie Barclay: Charles P. Vega, Overview of Current Trends in Hysterectomy
Expert Rev of Obstet Gynecol. 11/25/2009; 2009; 4(6):673-685 WebMD
8. Neerja Goel (Author), Shalini Rajaram (Author), Surveen(Author), M.D.
Ghumman , University College of Medical Sciences, Delhi, India =Anesthetic considerations for Non-Descent Vaginal
Hysterectomy (NDVHStep by Step Non-Descent Vaginal Hysterectomy (Paperback) ISBN-10: 1905740808
ISBN-13: 978-1905740802, Anshan Publishers; 1 edition (December 15, 2007 www.amazon.comSpecialties › Obstetrics
& Gynecology )
9. Dr. MohammadAbdulQuayyu, FCPS, ChiefConsultantGynaeFeniprivate hospital, Bangladesh
Aqua Dissection -Ndvh - Figoo-2009www.scribd.com/doc/27966250/Aqua-Dissection-Ndvh-Figoo-2009
10. NHS Purchasing and supply agency, Evidence review Electro surgical vessel sealing in vaginal hysterectomy, CEP
November’ 2009
11. Dr. Kirwin, Dowden Health Media, UPDATE ON TECHNOLOGY, VESSEL SEALING DEVICES, Review.OBG
Mana @2009 September, 2009.Vol.21, No.09

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