BICORNUATE UTERUS - DIFFICULTIES DURING HYSTERECTOMY скачать в хорошем качестве

BICORNUATE UTERUS - DIFFICULTIES DURING HYSTERECTOMY

BICORNUATE UTERUS - DIFFICULTIES DURING HYSTERECTOMY OVERCOMING THE SOME OF THE DIFFICULTIES DURING HYSTERECTOMIES DURING BICORNUAT UTERUS AND MINIWORKSHOPE OF ITS SIMPLE TECHNIQUE OF REPAIR BY GENERAL GYNAECOLOGIST AND YOUNG AND DYNAMIC CONSULTANTS TO HELP THE NEEDY EVE POPULATION AT LARGE. I was called to help in the middle of the abdominal hysterectomy( BICORNUATE UTERUS) after the first clamp and difficulty in entering and opening of the UV AND THE RV POUCH . There was a FIBROFATY TISSUE EXTENDING FROM THE ANTERIOR WALL OF THE RECTUM TO THE DOME OF THE BLADDER between the two horns . It is a rare coincidence one can come cross during the Hysterctomy of the bicornuate uterus. It is my first experience in the 40yrs my service and hardly any of our senior and junior colleagues have experienced. I remember it was mentioned in the text book of Operative Obstetrics by Munro Kerr ‘s in my PG period of 1983. It is very simple , cutting the band at level of the bridge without any hegitation one enter the UV and the RV pouch if their injury , can be easily repaired. Bladder was pushed inferiorly and laterally so that uraters goes away from the cervix 1) Here cervix is broader and the ureter maybe closer to it 2) MULLERIAN anamolies in 25-30% cases may be associated with renal abnormalities ie unilateral renal agenis, Horse shoe kidney , unasended kidney, double uretors and like so on.Here it was explored every thing normal. Cut section uterus shows fibroid in the left horn and a Sessil poly in the right horn. This patient was infertil and peri menopausal age and so many couples factors plays a role even though there was adequate size of both the hornes with good overian volume. Commonest MULLERIAN anamolies were being Arcuate uterus, Septate and subseptate uterus,Bicornuate uterus, unicornuate uterus and Rudimentary horn uterus ( communicating or Non communicating ). Incidence of BICORNUATE UTERUS may be 1 in 5000 to 1 in 10000. Majority cases my go unnoticed since spontaneous conception and delivery rate being high. Accidentally may be recognised during routine evaluation of infertile couples and RPL with HSG , USG, 3D USG, CT, MRI, During LSCS, During sterilisation ( LSS and Tubectomy) can suspected during ANS with Mal presentation ,Abnormal lie ,abnormal uterine contractions, prolonged labour , retained placenta and increased incidences of MRP and so on. In such case incidence may 1 in 500 to 1 in 2000. Routine surgery not required unless infertility is the troublesome with fibroid uterus,endometrial polyp,?RPL and unexplained infertility. In my series of about 15 cases successfull PREGNENCY was achieved in more than 80% with in a year after my reconstructive surgery but if they won’t conceived in spite of the induction of ovulation with the normal husbands seminal parameters, l consider reference to ART center. In spite of the difficult reconstruction few cases didn’t not turned up for the follow up. Finally I will demonstrate unification two horns of the uterus on the POST HYSTERECTOMY SPECIMEN . V shape incision was made along the medial aspect of the both horns without cutting the intervening cervial septum of the two cervical canal Intramural myoma was enucleated from the left horn. Bicornuate uterus. Making V cutt on the medial aspect of the uterine horn to open the cavity. Small endometrial polyp in the left horn and intramural fibroid on rt horn. Polypectomy with myomectomy specimen. Preparing for reconstruction. Preparing for the suturing the posterior wall in two layers from below up wards first endometrium and then the myometrium easy with the uterus in situ. Preparing and reconstruction the anterior wall utelizing the both anterior walls of both the horns. Finally the suturing of the 2 nd layer of the anterior wall. Re construction of the fundus. Final specimen of metroplasty. First layer is muscular-submucous to submucouso- muscular and second being sero-muscular to musculo-serosa by lumbert’s stich with the Chronic cat gut (preferred) since it does not cut through ,inciates better tissue reaction, cold case - sutures were hardly get loosened. Suturing may be invariably superior compared to Laparoscopic surgeon. All of we can’t become either laparoscopic or Hysteroscopic surgeon since it requires finance,training,Equipments,skilled assistants,trained man power,good set up building and so on but for traditional surgery can be done with the available instruments and large number of consultants can be trained with shorter learning curve to benefit the population at large.