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References:

1. Purohit Ram Krishna. Purohit technique of vaginal hysterectomy: a new approach. BJOG 2003, 110(12):1115-1119
2. Purohit Ram K: Purohit technique of vaginal hysterectomy: a new approach performed in 214 patients; Gynaecological endoscopy 2002 Dec; 11(6); 423-430
3. Purohit Ram Krishna, Tripathy Prakash Narayan, Pattnaik Abhaya Kumar: Vaginal Hysterectomy Using Electrocautery and Purohit Approach to Uterine Artery; J Obstet Gynecol India Vol.53, No. 5: September / October 2003   Pg 475-478
4. Purohit R K;Purohit Technique of Vaginal Hysterectomy learn step by step:Asian Journal Of Obs & Gynae Practice: Vol.11,No.3.July-September 2007, Pg 12-18.

Principles:

1. Vaginal walls are incised by monopolar current (30-35watts).
2. Lateral attachments and adhesions are desiccated by bipolar current (45 watts) close to uterus and divided by scissors. Clamps are not used. Uterine arteries are secured extraperitoneally by newly designed Purohit approach to uterine artery.
3. Right angle forceps is used throughout to elevate, hook, spread and retract all the lateral attachments and vessels from their posterior aspects; tissues were desiccated and divided between the prongs of forceps.
4. Conventional volume reduction manoeuvres used to reduce the volume of a large uterus to create the parauterine space to approach the lateral attachments
5. Suture is only used to attach Mackenrodt’s ligament to vaginal vault and in vault closer.
6. 10mm telescope with light sources or a pelvic illuminator is used as a rigid torch if needed to illuminate the deeper and darker part of pelvis and during vaginal salpingo-oophorectomy.

Instrumentsrequired: a big size Sim’s speculum, Allis forceps, two Right angled vaginal wall retractors, a 20 ml syringe, one ampoule Inj.Adrenaline, Normal saline,monopolar and bipolar electrocautery, use monopolar pure cutting current (30-35watts),bipolar ( 45-50watts),one Right angle forceps(Lahey or Mixter),Bipolar forceps (8-9inches long)

( available at Galtron Electromedical Pvt. Ltd,G/I,Nahar & Seth Industrial Estate,Chakala road,Andheri east,Mumbai-400099,India.Phone 091-22-28345018,Visit www. galtronindia.com,Email galtron@rediffmail.com.)Scissors, Artery forceps, Suction cannula with suction machine, a telescope with light source or a specially made Dr R K Purohit pelvic illuminator

(Photograph no 1)

(available at kalelker Surgicals Pvt.Ltd, 7&8 rosary Building,MM Chotani road,Mahim (W),Mumbai 400016,India,phone 091-22-24441042 email-Chirkal@bom7.vsnl.net.in)

One vicryl no 1 suture, needle holder, Corrugated drain, catheter, ribben gauze.

Steps in the standard procedure: -

Vaginal hysterectomy is commenced in the standard manner. Insert a large Sims’s speculum. Each lip of cervix is grasped by Allis forceps. Traction is given on cervix. Vaginal walls are retracted by 2 lateral retractors(one anteriorly another laterally).3 drops of injection adrenaline (1 in 1000) strength is mixed in 30ml normal saline, fill a 20 ml syringe with the mixed solution, infiltrate around the cervix to cause sub mucosal oedema.

Incise the anterior vaginal wall at cervico vaginal junction by a semi lunar incision using pure cutting current (30-35watts). Assistant holds the anterior margin by Allis forceps and gives traction to expose supravaginal septum.Incise the lower part of supravaginal septum directing scissors against the cervix. Then separate bladder from the cervix by index finger. Do not incise anterior cul-de-sac peritoneum at this stage and keep it intact. Then pull the cervix anteriorly to stretch the posterior vaginal wall.

(Photograph no 2)

The loose posterior fornix is grasped and stretched by one Allis forceps on left hand. Incise the posterior vaginal wall anterior to Allis forceps using cutting current by a light stroke. Stroke should be superficial only to cut the vaginal wall but not to incise the peritoneum. Hold the posterior margin by Allis forceps on left hand and separate the posterior cul-de-sac peritoneum from the vaginal wall by the index finger of right hand. Do not open pouch of Douglas at this stage. The speculum is moved further into the dissected space to stretch posterior vaginal wall. Now remove the Allis holding posterior incised margin. Insert retractor in to the vesicocervical space and stretch the anterior vaginal wall. Pull the cervix to right side of patient to stretch the cervicovaginal junction of left side. Retract the left lateral vaginal wall by another retractor. Incise the left side vaginal wall at cervicovaginal junction and join the anterior with the posterior semi lunar incision to expose the attachment site of ligaments extraperitoneally. Vaginal skin is not peeled up from the surface of ligaments. Suction cannula is used to aspirate the blood during operation.

Bring a right angle forceps (Laheys/Mixter)

Direct its tip anteriorly.Apply its tip into the notch between the posterior wall of cervix and lower ligaments extraperitoneally from posterior aspect (Photograph no 3)

Spread the prongs. Hold it by left hand and press gently on speculum. It will elevate the cervix and the ligaments from the posterior aspect by a lever action and brings them to surgeon’s view. It stabilizes and brings the ligaments easily to the surgeon’s view and to the mouth of bipolar forceps and scissors. This maneuver increases the accessibility and visibility of lower ligaments in cases with very poor access irrespective of nature of benign pathology. It makes the lateral vaginal wall incision prominent even in cases with poor access.

Use a straight bipolar forceps with fine tip. Length of the forceps preferable should be between 7-9 inches. Remove its insulation of about 1 cm from the tip to increase active surface area. Use bipolar current of 45-50watts. Insert the tip of bipolar forceps into the lateral incision directing tip of forceps towards cervix and activate. Take smaller bite at a time and go step by step. The attachment site of vesicocervical- cardinal- uterosacral ligaments with cervix is desiccated. Separate the ligaments from cervix by scissors. Only coagulated tissues are divided in every step of operation to avoid bleeding. The procedure is usually started from the vesicocervical ligament and carried out backwards and upwards to detach whole ligaments from the cervix. By a series of elevation by right angle forceps, coagulation and cut manoeuvres the whole thickness of ligament is separated from cervix. Each maneuver requires two steps (coagulation- and -cut), fewer instrument changes and less space for a thin bipolar forceps than techniques using ligatures for hemostasis that requires three steps (clamping, cutting and suture ligation), many instrument changes and a wide space for the movement of a curve needle on a holder. It is helpful in gaining access to para cervical attachments under direct vision. Smaller bleeding arterioles if any is coagulated. No clamp is used. No suture is used to ligate the ligament. Ligament stumps remain free and segregated during operation.

Photograph No.3

The right angle forceps creates a narrow working platform between its opened prongs sufficient for application of bipolar forceps and scissors. The opened prongs keep the neighboring tissues away. Its lateral prong prevents the lateral wall structures coming into working space between prongs. Its bend tip hooks structures and prevents slipping unlike an artery forceps. It is not used as a clamp in this procedure.

Push the divided ends of ligaments by index finger directing finger against the lateral uterine wall and in the direction of ascending branch of uterine artery. These maneuvers and the traction between the speculum posteriorly, retractors anteriorly and laterally cause a wide separation of the anterior and posterior leaves of lower broad ligament and create a wide para uterine working space extraperitoneally. It will expose the bulge of uterine artery.

(photograph no 4)
.

The visible bulge of artery of about 2-3cms is the tortuous part of the uterine artery before it becomes ascending branch.

If the bulge is not seen then seel that a part of ligaments or tissues is still covering the artery. They are dissected from the posterior aspect by right angle forceps and cauterized and incised to expose the bulge of artery.

Bring the right angle forceps, direct its tip forward. Tip of right angle forceps is brought in contact with the posterior aspect of the bulge of the artery, and then the tip of the right angle forceps is inserted between the bulge and uterine wall. Hook the skelitonised artery by its bend. Spread the mouth of right angle forceps, stretch and spread that portion of the artery between the prongs of forceps.

(Photograph No 5)

Then insert the bipolar forceps between the prongs of right angle forceps, cauterize the artery and then divide it by scissors between the prongs of right angle forceps. This approach is termed, as PUROHIT approach to uterine artery. It is the interesting step of operation. The right angle forceps helps in dissecting the tissue planes, elevating and stabilizing the target tissue from posterior aspect, isolating the artery, creating safe working space between its opened prongs for bipolar forceps and scissors and thus protects the neighboring ureter. We did not need to use clamps, needle holder and suture. Ordinary bipolar forceps was preferable for achieving better coaptation by manual compression of lumen between its prongs than the spring operated laparoscopic bipolar forceps. Two to three successive strokes of coagulation along the length of arterial wall are sufficient for achieving complete hemostasis. Bleeding end of artery if any was easily held by one artery forceps and its proximal part is cauterised to achieve complete hemostasis.

In this extraperitoneal technique after division the uterine artery stump protrudes itself ahead of the soft fascia between leaves of broad ligament, remains in its natural position and does not retract A bleeding uterine artery never retracts away from field of vision it can easily be caught by an artery forceps and cauterised

(Photograph no 6).

in contrast to the conventional intraperitoneal techniques that includes peritoneum in the suture ligation.Separation of artery with posterior peritoneum from lateral wall of uterus by scissors in the conventional intraperitoneal techniques immediately moves the stumps away from the field of vision and to the lateral pelvic wall. Peritoneum has the tendency to recoil to its natural position at lateral pelvic wall immediately after separation from lateral uterine wall as a result of release from the downwards traction on cervix.

The divided lower end of the ascending branch on the side wall of uterus is identified to confirm the division of the uterine artery. It is cauterised to prevent back flow bleeding. The above procedures are repeated on the other side to secure both uterine arteries extraperitoneally.

Then pull the cervix anteriorly to stretch the posterior cul-de- sac peritoneum. Grasp and stretch the peritoneum by an Allis forceps.

Then incise the posterior cul-de- sac peritoneum to proceed intraperitonally. Hold the posterior margin by Allis forceps. Insert speculum into cul-de- sac anterior to Allis forceps and then remove the Allis forceps. Bring the right angle forceps. Insert the tip of right angle forceps in to the cul-de-sac and move it to the notch between the posterior uterine wall and posterior leaf of broad ligament. Elevate and hook the loose posterior leaf of broad ligament and remaining few fibers of the cardinal-uterosacral ligament from posterior aspect, spread between prongs (Photograph No 7) and coagulate them close to uterine wall and divide between the prongs of forceps.

Photograph no. 7

It requires 2-3 successive applications to reach a level above the stump of uterine artery along the lateral wall of uterus. The above procedures are repeated on the opposite side.

This maneuver enhances the descent of the uterus and brings down the anterior cul-de-sac to surgeon’s view and makes the lower half of the uterus bare and free of broad ligament. Then the anterior cul-de- sac is incised. Retractor is inserted in to ant cul- de -sac.Vesicouterine peritoneum on either side coagulated and separated from uterus. Again take the right angle forceps, from the posterior aspect of uterus bring its tip to the notch between posterior wall of uterus and posterior leaf of broad ligament, round ligament, tube, ovarian ligament elevate and hook them, spread them between prongs of forceps

Photograph no 8

Step by step coagulate –cut from below upwards to separate the upper pedicles from uterus. Hold the last part by an Allis forceps before finally separated from uterine cornue.The manoeuvres is repeated on the opposite side to separate uterus completely from the body. No ligation or stay suture is used up to that stage. Uterus is removed. Right angle forceps is used to hook them usually from posterior aspects and occasionally from the anterior aspect.

Photograph No 9

We do not use clamps. Occasionally tip of the right angle forceps is used to push the wider cornual part to the opposite side to get space for bipolar forceps and scissors. Now pull the Allis forceps holding the upper pedicles medially downwards to expose the round ligament. By another Allis forceps hold the round ligament stump, pull it medially downwards to visualize the tubal and ovarian ligament stumps.The stumps are examined and if needed coagulated again to achieve complete hemostasis.The stumps are then dropped.It is repeated on the opposite side.

To check effective hemostasis of lateral wall.

Posterior cul-de-sac peritoneum margin is held by an Allis forceps. Speculum is removed and again reinserted anterior to Allis forceps to stretch the cul-de-sac peritoneum and the posterior margin of vault.Catheterise the bladder to increase pelvic space anteriorly.

Suction cannula is used to aspirate the collected blood and clots from the pelvic cavity and from lateral side.

Then the incised edge of posterior leaf of broad ligament on one side is walked over by two successive Allis forceps step by step to trace the edge up to the utero-ovarian ligament. Suction cannula is used to keep the bowels away from the incised edge. Tiny bleeder if any is cauterized.

As a result of tracing the ovary is visualized. It is gently pulled to expose the ovarian ligament. Grasp it by Allis forceps. Medially downwards pull exposes the round ligament stump. Give traction on round ligament stump to expose all three upper stumps. Cauterize them adequately to achieve complete hemostasis.

By this tracing maneuver all pedicles starting from lower ligaments to the upper pedicles including uterine artery stumps are distinctly visualized along the lateral wall between the splitted edges of the broad ligament. Tiny bleeder if any was traced and coagulated. Fine tip bipolar forceps precisely and accurately cauterizes a tiny bleeding point with out involving bunch of tissues. Tracing is done routinely to avoid postoperative vault hematoma. Tracing can be done in almost all cases including very obese women. Occasionally telescope with light source or a pelvic illuminator is used to increase visibility. It is difficult to trace in case of conventional technique that includes peritoneum in the bunch suture ligation of stumps. Lavage of the pouch of Douglas is done by normal saline. After satisfactory hemostasis vault is closed with vicryl no 1 by our special vault closer technique as described below.

Vault Closure TECHNIQUE

It is completed in three steps.

1) Lateral angle fixation

Vault margins are stretched by retractors and speculum. On one side lateral margin is pulled by an Allis forceps (AF1) to expose ligament stumps.

Photograph No 10

The stump near the vault margin is gently grasped by another Allis forceps (AF2) and pulled medially downward. Then the incised edge of posterior peritoneum covering uterosacral ligament stump is pulled by a third Allis forceps (AF3). A suture is passed through lateral vaginal wall anterior to first Allis forceps then through vesicocervical -cardinal –uterosacral ligament antero posteriorly and then through peritoneum with uterosacral ligament stump. It then loops back and comes out through lateral vaginal wall posterior to first Allis forceps .Both ends are tied to make a knot. The site of needle piercing through the cardinal –uterosacral ligament must be at a spot just beyond the tip of Allis forceps holding the stump to avoid needle injury to the lower end of ureter.The procedure is repeated on the opposite side.

2) Vault plication suture:

Vault margins are stretched by retractors and speculum. Anterior margin is stretched by two Allis forceps one on either side of midline to visualize the lower end of bladder attachment. The tip of the right angle forceps is swept above downward from posterior bladder wall to the vault margin. It enters to a notch between posterior wall of bladder and supravaginal ligament. The tip of right angle forceps is spread. A suture is passed through the anterior wall just below the notch and between prongs of right angle forceps.(Photo no 11)

Photo No 11

It passes through supravaginal septum, then through left side ligament stump (needle is inserted antero posteriorly), (Photo No 12)

Photo No 12

then through peritoneum of posterior cul-de-sac that comes out through posterior vaginal wall far behind the incised margin. Again it is passed through posterior vaginal wall from out side to inside on the right side, then through peritoneum of posterior cul-de-sac, then through the ligament stump (needle pierces postero anteriorly) (Photo No 13)

Photo No 13

And finally comes out from inside to out side through the anterior vaginal wall with supravaginal septum. (Photo no 14)

Photo No 14

A corrugated drain is kept in situ and is removed after 12 hours. Both ends are tied to make a knot. (Photo No 15)

Photo No 15

3) Then the redundant margins below the knot are closed from one end to other. (Photo no 16)

Photo No 16

Advantages-

It closes the dead dissected space between the vaginal wall and posterior peritoneum and avoids vault hematoma.

In cases of postoperative bleeding the purse string can be cut and vault can be opened with out disturbing the lateral angle fixation sutures.

Post operative features after one month follow up-It pulls the anterior vaginal wall upwards, both angles upwards and outwards, posterior fornix upwards and backwards and maintains the depth and width of apex of vagina.It reduces the sagging of the upper part of anterior and posterior vaginal wall after hysterectomy. It creates a strong vaginal vault.

Uterosacral ligaments—peritoneal and fibro muscular tissue bands extending from the vaginal apex to the sacrum—being the principal support for the vaginal apex are restored in this technique.

In a case of uterine prolapse: vaginal hysterectomy is done by the technique described above. Before beginning repair pull ligament stumps on each side by Allis forceps(AF2) and suture them in the middle by a figure of eight suture which is at last fixed to vault. Then carry out the repair procedures conventionally.

Salpingo-oophorectomy: Speculum is reinserted, cul-de-sac peritoneum margin is held by an Allis forceps. Speculum is removed and again reinserted anterior to Allis forceps to stretch the cul-de-sac peritoneum and the posterior margin of vault. Bladder is catheterized to increase the room in pelvis. Suction cannula is used to suck the collected blood and clots from the pelvic cavity and from lateral side.

Visible ovarian ligament is held by Allis forceps.Invisible ovarian ligament is traced by the tracing technique described above. As a result of tracing the ovary is visualized. It is gently pulled to expose the ovarian ligament. Hold the ovarian ligament by Allis forceps. Medially downward pull of ovarian ligament exposes the round ligament stump. Round ligament stump is then grasped by Allis forceps and pulled medially downward to expose all three upper stumps. Stumps are cauterized adequately if needed to achieve complete hemostasis.

Head low position was made to keep bowels away from field. Wet ribbon gauze packing was done adequately to push bowels away.

The round ligament stump is pulled medially forward and held by the assistant surgeon. Operating surgeon holds the ovarian ligament. Tissues between the round ligament stump and ovarian ligament stump is cauterized and is incised to make a split.

The split is deepened and the round ligament stump is separated from tube with ovarian ligament. Round ligament stump is released. It goes to lateral pelvic wall. Tiny bleeder if any is cauterized. Then the ovarian ligament with tube is pulled medially downward by Allis forceps. Apply the tip of the right angle forceps from the posterior aspect just lateral to the ovary and spread the prongs, coagulate and incise the mesosalpinx between prongs of forceps step by step and reach to a level above the upper pole of ovary. Tissues are dissected close to the ovary. The space between prongs of right angle forceps creates a safe working platform for bipolar and scissors away from lateral wall structures. This maneuver thus dissects and separates the infundibulopelvic ligament from the lateral wall vessels, ureter.It prepares for a long stump of infundibulopelvic ligament. Again apply the right angle forceps to the infundibulopelvic ligament from posterior aspect, hook it by its bend, spread the prongs and cauterize it by bipolar current close to ovary and then divide by scissors. By successive smaller bites (coagulate and cut maneuver) and step by step to achieve complete hemostasis the infundibulopelvic ligament is separated. The stump of the infundibulopelvic ligament is visualized and adequately cauterized to achieve complete hemostasis. Right angle forceps elevates the infundibulopelvic ligament from posterior aspect, brings target tissues to the operator’s view and away from intestine, its bend prevents bowels coming into the working space between its prongs. Its prongs prevent lateral structures coming into the working space. That is how the coagulation and incision between the prongs of right angle forceps is safe. Ovary with tube is removed. In cases with poor visibility up to the upper pole of ovary due to obesity, short infundibulopelvic ligament, cyst, adhesion a rigid and thin torch like 10mm telescope with light source or a pelvic illuminator is used to illuminate the pelvic structures.

CASE SELECTION

This technique is for vaginal hysterectomy for benign disease of uterus. We have an experience of 680 cases of different varieties. We do not take up a patient with uterus above 20 weeks size. Also we do not take up patient with severe endometriosis for purely vaginal hysterectomy. These cases need laparoscopic or minilaparotomy back up facility if we like to complete by minimally invasive procedures. We take up cases irrespective of parity, obesity, parametrial scarring, configuration of uterus, history of previous abdominal and vaginal operations, need of removal of movable adnexal cyst (5-7cm) or prophylactic oophorectomy.Our operation theatre is equipped with operative laparoscopy facilities. A beginner should start on a patient of uterine bleeding with uterus below 8 weeks size. Experience can buy uterine sizes. We believe the techniques described above and comments given below can increase the confidence of the readers.

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