Abdominal Versus Vaginal Hystrectomy Biology Essay

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OBJECTIVE: The purpose of this study was to evaluate abdominal versus vaginal hysterectomy in relation to intra operative and postoperative complications.

DESIGN: descriptive observational study.

PLACE AND DURATION OF STUDY: This study was conducted in gyne ward of Liaquat University hospital Hyderabad Sindh Pakistan from 6th Feb 2000 up to 5th Jan 2001.

PATIENTS AND METHODS:

Total 225 patients were included in the study randomly. Out of these 225 patients, 127 patients had abdominal hysterectomy while 98 patients had vaginal hysterectomy. All patients in the study were selected from outpatient department after taking informed consent. Patients information regarding age, parity, menstrual history and presenting complaint and operative complications were noted on self administered proforma.

Antibiotic coverage was given to all patients. Surgical complications were categorized into intra operative and post operative complications. All data was analyzed by computer software programme of social sciences (SPSS version 11). Frequency & percentages were calculated to describe the results.

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RESULTS: Vaginal hysterectomy was more in the age group of 43-48 years i.e. 35(35.71%) while abdominal hysterectomy was more in age group of above 49 years i.e. 39 (30.70%). In vaginal hysterectomy the most common indication was uterovaginal prolapsed seen in 71( 72.44%) while in abdominal hysterectomy the most common indication was dysfunctional uterine bleeding which was seen in 68( 53.54%).

In vaginal hysterectomy, commonest intra operative complication was bleeding seen in 11(11.22%) patients. While in abdominal hysterectomy commonest complication was bleeding seen in 42(33%) followed by urinary bladder injury seen in 3(3%) patients.

CONCLUSION: Results of our study showed that vaginal hysrectomy is safer than abdominal hysterectomy with less morbidity.

Key words: abdominal hysterectomy, vaginal hysterectomy, morbidity, complications.

INTRODUCTION:

Hysterectomy is one of the most frequently performed surgical procedures among women of late reproductive age 1. The first total abdominal hysterectomy along with bilateral salpingoophorectomy was performed by Clay in 1844. Hysterectomy rate varies accordingly to geographic distribution, patient and physician related factors2. There have been no population based studies in Pakistan providing estimates of hysterectomy prevalence, although there has always been concern about the high rates of this procedure. Approximately 20% of women have had the procedure by the age of 60 years, about 40% of these for dysfunctional uterine bleeding (DUB) with no gynecological pathology3. Hysterectomy is still considered as the treatment of choice for benign lesions such as myomas, adenomyosis and pelvic inflammatory disease (PID). In Pakistan, the rate of hysterectomy is quite high because it is the only surgical option available if patient is not responding to medical treatment. However, hysterectomy is associated with high morbidity.

Al-Kadri H M et al4 reported complications of abdominal and vaginal hysterectomy. A total of 108 women who had hysterectomy were included. The principal indications for vaginal hysterectomy were uterine prolapsed and for abdominal hysterectomy, it was DUB & fibroid. The overall complication rates were less in vaginal hysterectomy as compared to abdominal hysterectomy.

The purpose of this study was to evaluate abdominal versus vaginal hysterectomy in relation to intra operative and postoperative complications.

MATERIAL & METHODS.

This descriptive study was conducted in gyne ward of Liaquat University hospital Hyderabad Sindh Pakistan from 6th Feb 2000 up to 5th Jan 2001. Total 225 patients were included in the study randomly. Out of these 225 patients, 127 patients had abdominal hysterectomy while 98 patients had vaginal hysterectomy. All patients in the study were selected from outpatient department after taking informed consent. Patients detail history regarding age, parity; menstrual history and presenting complaint were noted. Patients were examined thoroughly. Baseline investigations, included blood group, for Rh factor, hemoglobin estimation, midstream specimen for urinalysis, blood sugar, x-ray chest, and ECG and abdominopelvic ultrasound were done. Associated co morbidity was corrected before surgery.

Operative information included detail of operative procedure, operative findings and complications. Surgical complications were documented and majority of patients were discharged between 5th â€" 7th post operative days after receiving the histopathological report. Follow up was done after 6 weeks.

Patient’s information was collected on self administered proforma. Antibiotic coverage was given to all patients. Surgical complications were categorized into intra operative and post operative complications. All data was analyzed by computer software programme of social sciences (SPSS version 15). Frequency & percentages were calculated to describe the results.

RESULTS.

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A total of 225 patients were included in the study. Out of these, 98 patients had vaginal hysterectomy while 127 patients underwent abdominal hysterectomy.

Table 1 shows age wise distribution of patients having hysterectomy. Vaginal hysterectomy wad more in the age group of 43-48 years i.e. 35(35.71%) while abdominal hysterectomy was more in age group of above 49 years i.e. 39 (30.70%).

Table 2 describes the indications of hysterectomy. In vaginal hysterectomy the most common indication was uterovaginal prolapsed seen in 71( 72.44%) while in abdominal hysterectomy the most common indication was dysfunctional uterine bleeding which was seen in 68( 53.54%).

Table 3 describes the complications of patients undergoing hysterectomy. In vaginal hysterectomy, commonest intra operative complication was bleeding seen in 11(11.22%) patients. While in abdominal hysterectomy commonest complication was bleeding seen in 42(33%) followed by urinary bladder injury seen in 3(3%) patients.

In vaginal hysterectomy, commonest postoperative complication was urinary retention seen in 13(13.26%) while 11 (11.22%) patients required blood transfusion due to bleeding.

In abdominal hysterectomy 11 (8.66 %) patients had pyrexia and 7 (5.51%) patients developed paralytic ileus.

DISCUSSION.

Hysterectomy is the common major gynecological surgery performed all over the world after cesarean section. 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 re examination of the patient under anesthesia before starting the surgery is essential to avoid complications.

According to systematic evidence review by Johnson N women who had vaginal hysterectomy had fewer infections after surgery compared to those who had abdominal hysterectomies. Dicker and his associates in their study found that total abdominal hysterectomy has 1.7 times more risk of complications than vaginal hysterectomy 5 .

In our study, wound infection was major cause of febrile morbidity in TAH group. This finding is consistent with the study done by Dicker and his associates 5.

Dysfunctional uterine bleeding affects 20-30 % of women, accounts for 12% of gynecological referral6,7 and within 5 years of referral, 60% of women will have to undergo hysterectomy 8 making it the commonest major gynecological problem. Same is reported in another study conducted by Bashir R 9.

In our study, among abdominal hysterectomies, DUB was the commonest indication for abdominal hysterectomy (53.54%), while study conducted by Khaskheli M 10, showed 35.53% of hysterectomies are because of DUB. The high rate of hysterectomies due to DUB in our setup could be because of non compliance with medical therapy and majority of patients in his study were more than 35 years of age, had completed family and preferred this operation due to their long lasting symptoms and poverty.

In our study, uterovaginal prolapse was the commonest reason for vaginal hysterectomy (72.44%).

Vaginal hysterectomy was generally safer than abdominal hysterectomy and causes low morbidity 11. In our study, patients with vaginal hysterectomy have less complication as compared to those who had abdominal hysterectomy.

In our study, postoperative pain was less in patients with vaginal hysterectomy. Similar is reported in study conducted by Garry R 12 .vaginal hysterectomy is associated with less pain, quick recovery and better short term quality of life. There are certain conditions where vaginal route is not considered safe and should be avoided. These are patients with adnexal pathology, restricted uterine mobility, limited vaginal space, previous vesicovaginal repair and ca cervix 13.

Intra operative hemorrhage is still of major concern to the gynecologist. In our study, bleeding was 33% seen in abdominal hysterectomy group. Same is reported in another study conducted by Papaloucas et al14.

Accidental injury to the bladder and ureter has been noticed in 2.36% and 0.78% of patients with abdominal hysterectomy respectively. Sheth and Ashar 15, in their study on 687 cases of abdominal hysterectomy, reported bladder injury in 9 cases and ureter injury in 11 cases.

The operation of vaginal hysterectomy left no abdominal scar and involved little risk of later complication such as adhesions and intestinal obstructions16. There were no complications of wound dehiscence or wound abscess incase of vaginal hysterectomy group. In our study it is noted that morbidity after abdominal hysterectomy was greater than vaginal hysterectomy 17,18.

CONCLUSION

Results of our study showed that patients who underwent vaginal hysterectomy had few complications than patients who had abdominal hysterectomy. vaginal hysrectomy is safer than abdominal hysterectomy with less morbidity.

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