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  IN THIS Article
 ::  Abstract
 ::  Introduction
 ::  Material and Methods
 ::  Results
 ::  Discussion
 ::  Acknowledgements
 ::  References
 ::  Article Tables

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ARTICLE
Year : 1978  |  Volume : 24  |  Issue : 4  |  Page : 221-225

Complications of vaginal hysterectomy - (Analysis of 1105 cases)


Department of Obstetrics & Gynaecology, K.E.M. Hospital, Parel, Bombay-400012, India

Correspondence Address:
Menna S Bhattacharya
Department of Obstetrics & Gynaecology, K.E.M. Hospital, Parel, Bombay-400012
India
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Source of Support: None, Conflict of Interest: None


PMID: 745151

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 :: Abstract 

Eleven hundred and five cases of vaginal hysterectomy are analysed and their complications discussed.
More than 90% of the patients were between the ages of 31 to 60 years. The common indications for hysterectomy were prolapse (51%) and dysfunctional uterine bleeding (34.9%). In four cases abdominal approach was necessary to complete the operation. The overall incidence of major complications was 4% and the corrected mortality rate was 0.18%. The complications of vaginal hysterec­tomy by other authors are discussed.



How to cite this article:
Bhattacharya MS, Shinde S D, Narwekar M R. Complications of vaginal hysterectomy - (Analysis of 1105 cases). J Postgrad Med 1978;24:221-5

How to cite this URL:
Bhattacharya MS, Shinde S D, Narwekar M R. Complications of vaginal hysterectomy - (Analysis of 1105 cases). J Postgrad Med [serial online] 1978 [cited 2019 Sep 22];24:221-5. Available from: http://www.jpgmonline.com/text.asp?1978/24/4/221/42651



 :: Introduction Top


Vaginal hysterectomy with or without repair of vagina and/or perineum is the commonest major gynaecological opera­tion performed in our institute. Besides the cases having utero-vaginal prolapse, we prefer vaginal route for hysterectomy for all other non-malignant conditions as far as possible. Abdominal approach is selected only when the size of the uterus is larger than 12 weeks' size of pregnancy, when the mobility of the uterus is very much restricted due to adhesions or in the presence of palpable adnexal patho­logy with restricted uterine mobility. History of previous operation either vaginal or abdominal of any kind is not considered as a contraindication.


 :: Material and Methods Top


A total of 1105 cases of vaginal hysterec­tomy with or without repair, done at K.E.M. Hospital, Bombay, for non­malignant conditions during January 1974 to March 1977, are analysed. Among these, plain vaginal hysterectomy was done in 615 cases while hysterectomy with repair of vagina and/or perineum was done in 490 cases.

[Table 1] shows the age distribution of patients. More than 90% o of the patients were between the age of 31 to 60 while 3.5% of them were less than 30 and 6.1% were above 60 years of age. The oldest patient was 82 years old. Majority of the patients were multiparous while only four were nulliparous and one of them required perineotomy due to nonavailabi­lity of space while performing the hysterectomy.

The choice of vaginal route for hysterectomy was not related to any systemic disease like hypertension or diabetes etc.

In 685 cases (62%), the hysterectomy was performed under general anaesthesia. Spinal anaesthesia was used in 388 cases whereas epidural route was utilized in 19 cases. In 13 cases hysterectomy was done under local anaesthesia.

Indications for hysterectomy are shown in [Table 2]. Prolapse was present in 51% of the cases while among the other indications, the major indication was dysfunctional uterine bleeding in 34.9% of the cases.

In all these cases the size of the uterus was less than 14 weeks of pregnancy. In most of these cases vaginal hysterectomy could be successfully performed, with bisection of the uterus in six and morcel­lation in two.

In 15 cases bilateral salpingo-oopherec­tomy had to be done as an additional measure because of the presence of un­diagnosed small tubo-ovarian masses or hydrosalpinx.

There was a history of previous opera­tion, either vaginal or abdominal, in 178 cases (15.2%). Only in one who had a previous caesarean section and sterilisa­tion, vaginal hysterectomy could not be done successfully and had to be compet­ed abdominally.


 :: Results Top


Out of these 1105 cases, only in four vaginal approach had to be abandoned, and the abdominal route was resorted to, to complete the operation. In one, vaginal hysterectomy could be carried out right upto the cornual structure but the uterus could not be delivered due to the presence of a thick fibrous band between the fundus of uterus and anterior abdominal wall, which was excised after opening the abdomen. In this case there was a history of previous caesarean section and abdo­minal sterilization.

In another case there was difficulty in opening the pouch of Douglas and the uterine vessels slipped while ligating. An attempt made to clamp them from below failed and hence the abdomen was opened to clamp the uterine vessels. On opening the abdomen, bilateral chocolate cysts of ovaries were also detected.

In two more cases the presence of un­diagnosed tubo-ovarian masses made an abdominal approach mandatory.

Complications

The overall incidence of major complic­ations in these 1105 cases of vaginal hyste­rectomy was 4%.

Accidental opening of bladder occurred in 13 cases (in 8 cases while doing plain vaginal hysterectomy and in 5 cases of vaginal hysterectomy with repair). In all these cases there was no history of any previous vaginal or abdominal surgery. The bladder injuries were recognised during the procedure in all of them and were managed by suturing the bladder in two layers and an indwelling catheter for two weeks postoperatively. None of them developed fistulae.

In one case rectum was opened acci­dentally while opening the posterior pouch, which was sutured immediately and the patient went home without any further problems. Haemorrhage, primary in 9 and secondary in 5, formed another important group of complications.

Primary haemorrhage occurred in 4 cases of plain vaginal hysterectomy and in 5 cases of vaginal hysterectomy with repair. Four of these 9 cases of primary haemorrhage could be managed simply by suturing the bleeding edges of vagina and packing, whereas in one case a simple packing was unable to control the haemorrhage and required suturing and packing twice. In four cases exploratory laparotomy was performed because no obvious bleeder was seen from below. Only in two cases broad ligamentary haematoma was detected and evacuated, while in one of the cases no particular bleeder could be identified and ligated and thus bilateral internal iliac ligation had to be resorted to.

There were 5 cases of secondary haemorrhage-3 following a plain vaginal and 2 following vaginal hysterectomy with repair. All of them responded to packing, adequate blood transfusion and higher antibiotics.

Vault sepsis was one of the commonest problem encountered during post opera­tive period. There were 28 cases of vault sepsis which responded to systemic and local antibiotics and drainage.

Four had a pelvic abscess with perito­nitis. Two of them responded to drainage and intensive management but the other two succumbed.

Myocardial infarction occurred in 4 cases within 48 hours of the operation. These patients were between the age of 45 to 52 and none of them had any pre­operative cardiovascular problems. One of these patients died on the third day. Postmortem report confirmed the cause of the death as myocardial infarction.

The other interesting complications were deep vein thrombosis of leg veins in one and femoral artery embolism in another. The patient who had femoral artery embolism was a 50 year old obese hypertensive and diabetic woman. Ex­crutiating pain and absence of pulsations, on the 10th day drew our attention to the presence of femoral artery embolism. A 10 th long embolus was removed by the Vascular Surgeons.

One patient developed psychosis after two weeks of operation and was managed by major and massive doses of tranquili­zers.

Post operative paraparesis developed in 6 cases requiring prolonged physio­therapy.

One patient developed signs and symptoms of intestinal obstruction on the 6th postoperative day. Exploration showed loops of small bowel adherent to the vaginal vault causing subacute intestinal obstruction. Patient went home after 3 weeks.

There were four deaths in this series of 1105 cases of vaginal hysterectomy. The causes of death were myocardial infarc­tion in one, acute viral enteritis with paralytic ileus in another. These two were obviously not directly related to the sur­gery. Two cases developed severe perito­nitis on the 3rd and 6th day of the opera­tion and died due to terminal bronchop­neumonia and endotoxic shock respective­ly. Hence the corrected mortality rate is 0.018%.


 :: Discussion Top


Hysterectomy by the vaginal route has become increasingly popular. It is always preferable to perform a hysterectomy by the vaginal route whenever technically feasible. Advantages of vaginal route are too well known to be enumerated. How­ever a careful selection and a proper re­examination of the patient under anaes­thesia before starting the surgery is essen­tial to avoid complications.

Accidental injury to the bladder during hysterectomy has been a common occur­rence (1.17%) in our series. None of them had any history of previous vaginal surgery and none of them developed fistulae. Sheth and Ashar, [6] in their study from the same institute of 687 cases of vaginal hysterectomy, reported bladder injury in 6 cases with fistula developing in one. Tatra [7] from Austria in his massive series of 3482 cases of vaginal hysterec­tomy had only 13 (0.36%) cases of blad­der injury. However the incidence of urinary fistulae was 0.3% (12 cases) Seven of these were vesico-vaginal and 5 uretero-vaginal. Gray [1] reported an un­usually high incidence of uretero-vaginal fistulae in 7 out of 810 cases of vaginal hysterectomy with repair.

Vault sepsis has been the commonest complication (2.7%;) of our series. But this is a relatively minor complication in the sense that mere digital separation of vaginal edges followed by vaginal pessa­ries could control the infection in majo­rity of the cases. Lash [3] in his series of 2007 cases reported a 35% incidence of post-operative low-grade infection of the vault which was brought down to 7-10% by the use of vaginal suppositories. du Toit [8] from S. Africa has reported an 11% incidence of vault sepsis in a study of 367 cases. Four out of these developed pelvic peritonitis. Incidence of vault sepsis can be minimised by keeping the vault open.

Immediate and late haemorrhage is still of major concern to the gynaecologist. Our incidence of primary haemorrhage was 0.81% and that of secondary haemor­rhage was 0.45%. Papaloucas et al [5] in their series of 360 cases had 4 cases of haemorrhage Secondary haemor­rhage was reported in 26 cases out of 3482 cases of Tatra. [7] Gray [1] reported an overall incidence of 2.4% of postopera­tive haemorrhage. Lash [3] advocates imme­diate exploratory laparotomy with liga­tion of uterine or ovarian vessels for primary haemorrhage and internal iliac ligation in presence of broad ligament haematomas. Secondary haemorrhage can be tackled by vessel ligation and vaginal packing.

Deep vein thrombosis and pulmonary emboli are reported more frequently in the western literature. We had only one case of deep vein thrombosis. Walsh [9] et al in their study of 100 vaginal hysterecto­mies showed a 7% incidence of deep vein thrombosis. These were, however, detect­ed by using labelled fibrinogen phlebo­graphy.

Mortality rate following vaginal hyste­rectomy varies from 0.03% (Lewis [4] ) to 0.38% (Lash [3] ). No mortality has been reported by Sheth and Ashar [6] in their series of 687 cases. Hawksworth [2] himself has performed 1000 cases of vaginal hysterectomy without a single death.

Hence there is a tremendous scope for improvement by careful pre-operative assessment, meticulous surgical techni­ques and proper post-operative care in order to reduce the complication rate further.


 :: Acknowledgements Top


We take this opportunity to thank Dr. C. K. Deshpande, Dean, K.E.M. Hospital & Seth G.S. Medical College and Dr. V. N. Purandare, Hon. Prof. & Head, Depart­ment of Obstetrics and Gynaecology, for allowing us to publish the hospital data.

 
 :: References Top

1.Gray, L. A.: Views and reviews-Indica­tions, techniques and complications in vaginal hysterectomy. Obst. and Gynace., 28: 714-722, 1966.  Back to cited text no. 1    
2.Hawksworth: As quoted in "The Year Book of Obstetrics and Gynaecology." (Editor-J. P. Greenhill). Year Book Medical Publishers, 35, East Wacker Drive, Chicago, 1871, p. 330.  Back to cited text no. 2    
3.Lash, A. F.: Vaginal surgery for non­malignant gynaecological conditions. Illinois Med. J., 137: 490-504, 1970.  Back to cited text no. 3    
4.Lewis, T. L.: "The William Hawksworth Memorial Lecture-1970." Australian & New Zealand J. Obstet and Gynaec., 11: 1-6, 1971. Quoted in "The Year Book of Obstetrics and Gynaecology" (Editor­J. P. Greenhill). Year Book Medical Publishers, Chicago, 1971, p. 330.  Back to cited text no. 4    
5.Papaloucus, A.. Mantis, C. and Zervos, A.: Management of vaginal vault after vaginal hysterectomy-Problem of recurrent rectocele. Int. Surg., 54: 458-461, 1970.  Back to cited text no. 5    
6.Sheth, S. S. and Ashar, L. I.: Clinical evaluation of vaginal hysterectomy. J. Obst. and Gynaec. India, 16: 534-539, 1966.  Back to cited text no. 6    
7.Tatra, G.: Indications and complications of vaginal hysterectomy. Geburtshife Frauen­heilkd., 33: 904-909, 1973.  Back to cited text no. 7    
8.Toit, P. F. M. du: Prevention of com• plications in vaginal hysterectomy. South African Med. J., 45: 99-100. 1971.  Back to cited text no. 8    
9.Walsh, J. J., Bonnar, J. and Wright, F. W.: Study of pulmonary embolism and deep vein thrombosis after major gynae­cological surgery using lebelled fibrinogen phlebography and lung scanning. South African Med. J., 48: 111-116, 1974.  Back to cited text no. 9    



 
 
    Tables

  [Table 1], [Table 2]



 

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© 2004 - Journal of Postgraduate Medicine
Official Publication of the Staff Society of the Seth GS Medical College and KEM Hospital, Mumbai, India
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