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Single Surgical Procedures in Obstetrics and Gynaecology16

UTERUS DISPLACEMENTS
A Colour Atlas of Supravaginal Cervical Amputation (Nadkarni's)
Single Surgical Procedures in Obstetrics and Gynaecology16
UTERUS DISPLACEMENTS
A Colour Atlas of Supravaginal Cervical Amputation (Nadkarni's)
Series Editors
Arun Nagrath MS MAMS FICOG
Professor and Head
Department of Obstetrics and Gynaecology
Rural Institute of Medical Sciences and Research, Saifai, Etawah, Uttar Pradesh, India
Erstwhile
Professor and Head
Department of Obstetrics and Gynaecology
SN Medical College, Agra, Uttar Pradesh, India
Senior Clinical Training Consultant
Johns Hopkins Program for International Education in
Gynaecology and Obstetrics (JHPIEGO), Baltimore, USA

Narendra Malhotra MD FICOG FICMCH


President, FOGSI 2008
Dean, ICMU 2008-2009
Director, Ian Donald School of Ultrasound
Consultant and Director
Malhotra Nursing and Maternity Home (P) Ltd., Agra, Uttar Pradesh, India
Apollo Pankaj Hospital (P) Ltd., Agra, Uttar Pradesh, India

Associate Editor
Shikha Seth MD
Associate Professor
Department of Obstetrics and Gynaecology
Rural Institute of Medical Sciences and Research, Saifai, Etawah, Uttar Pradesh, India

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Single Surgical Procedures in Obstetrics and Gynaecology16: A Colour Atlas of Supravaginal Cervical Amputation (Nadkarni's)

First Edition: 2012


ISBN 978-93-5025-763-0
Printed at
Dedication

One of the legendry artists' surgeons of India who excelled and afforded respect
to a newly formed specialisation Gynaecological and Obstetrical Surgeries.

Famous in the 50s, 60s and 70s fondly called Teacher of Teachers.

Through this great master, I see a glimpse of his surgical mannerisms in my


work trying to achieve surgical perfection which came so naturally to him.

Lest he be forgotten in the footprints of time, a humble effort to propagate his


excellence through this organisation for posterity.

... lest the coming generations be starved of the magical art of gynaecological and
obstetrical surgery.
Arun Nagrath

... At the lotus feet of my master


Late Professor Nawal Kishore MS FICOG FACS
(Rockefeller Foundation Fellow)
Preface
Any thing that simplifies our medical education is always welcomed. This provided important notes in an effort to aid the surgeon in reducing blood
series, Single Surgical Procedures in Obstetrics and Gynaecology is organized loss, minimizing complication rates, and improving their surgical skills.
into multiple volumes on all gynaecological and obstetrical surgical All the commonly done obstetrical and gynaecological procedures are
procedures related to female reproductive organs. Special sections are illustrated. Nevertheless, some rarely done procedures required by very
dedicated to patient positioning, type of incision, their closures along with selected group of cases are also discussed in different volumes so that
proper use of drains, suture choices, etc. Special emphasis is placed on one can assist the experienced surgeon with this, serving as a source of
different aspects of surgical options for uterovaginal prolapse involving basic information illustrating the surgical technique.
the supravaginal amputation of cervix (especially Nadkarnis supravaginal We hope that the resident gynaecologic surgeon will find this series
amputation of cervix). of books on surgical procedures very useful as he or she prepares for a
We as editors of this Colour Atlas of Supravaginal Cervical Amputation career in this area of medicine and begins to perform these procedures.
(Nadkarni's) have set out to simplify surgery by creating a step-by-step We believe that the experienced gynecologic surgeon will also find this a
procedural process, illustrated to emphasize those surgical steps which useful reference with many new approaches and helpful notes for
are critical to the individual procedure under consideration. We have also commonly performed operations.

Arun Nagrath
Narendra Malhotra
Shikha Seth
Acknowledgements
I am grateful to Director, Brig T Prabhakar, who has a fixation for quality of frustration and its manifestations and constantly encouraging me to
and continued progress, dedicated to his institution. He has always cajoled 'keep up' my endeavours and see this work through completion.
his staff to move forward and do something that 'makes a difference'. The preparation of the book of this magnitude involves many
This series is an attempt in this direction. All through our hours of toil, he individuals who play a role in its creation. I am especially proud of the
always helped us in smoothening the rough edges and this work carries quality of the photographs and it would be in place to put on record the
the hallmark of his 'quality'. contribution of Mr Dharmendra, Photographer of Excellence, Department
I am thankful to all the staff of the Department of Obstetrics and of Social and Preventive Medicine, UP Rural Institute of Medical Sciences
Gynaecology of UP Rural Institute of Medical Sciences and Research, and Research, Saifai, Etawah, Uttar Pradesh, India, for his untiring
Saifai, Etawah, Uttar Pradesh, India, for their contribution in this project. assistance.
My better half, Dr (Mrs) Manju Nagrath, Department of Radio- To our patients who have very kindly consented to allow the use of
diagnosis, UP Rural Institute of Medical Sciences and Research, Saifai, their operative sequences for the purpose of advancement of medical
Etawah, Uttar Pradesh, India, who has stood by me, tolerating my hours education.

Arun Nagrath
All Volumes in the Series Single Surgical Procedures in
Obstetrics and Gynaecology
This book is one of the titles in the series of Single CERVIX C NDVH - Debulking by Coring
Surgical Procedures in Obstetrics and Gynaecology, a VOL-6 Biopsy of cervix NDVH - Debulking by spiral incision
series which will eventually have 36 volumes. Cervical conisation NDVH - Debulking by cervical amputation
If you wish to be kept informed of new additions Endocervical curettage at colposcopy NDVH - Debulking by cervical wedge
to the series and receive details of our other titles, Conisation of cervix by LEEP *VOL- 12 Ward Mayo's hysterectomy
please write to Jaypee Brothers Medical Publishers Electrocauterisation of cervix Modified Ward Mayo's hysterectomy
(P) Ltd at sujatha.jp@gmail.com. Cervical cryocauterisation Dr Nagrath's modification
VOL-7 Trachelorrhaphy Clampless vaginal hysterectomy
We list below a few of the other titles in print and in Abdominal excision of cervical stump
VOL-8 Correction of incompetent cervix by
UTERUS-D3
preparation in the Single Surgical Procedures series. VOL-13 Dilatation and curettage
Shirodkar's technique
Titles already published are marked (*); those titles Suction curettage for abortion
Correction of incompetent cervix by
to be published during the coming months are marked Dilatation and endometrial biopsy
McDonald's operation
(#). Fractional curettage
Correction of incompetent cervix by
Lash operation *VOL-14 Upper segment caesarean section
VULVA A Lower segment caesarean section
VOL-1 Bartholin's gland excision UTERUS: ABDOMINAL HYSTERECTOMY-D1
Marsupilisation of Bartholin cyst VOL-9 Total abdominal hysterectomy UTERUS: DISPLACEMENTS-D4
Release of labial fusion Total abdominal hysterectomy with #VOL-15 Cervicopexy (Purandare's)
VOL-2 Hymenectomy (Imperforate hymen) bilateral salpingo-oophorectomy #VOL-16 Supravaginal cervical amputation
Simple vulvectomy Nagrath's minilap hysterectomy (Nadkarni's)
VOL-10 Abdominal subtotal hysterectomy VOL-17 Manchester's operation
VAGINA B Obstetrical hysterectomy Fothergill's repair
VOL-3 Anterior colporrhaphy and Kelly's plication VOL-18 Shirodkar's anterior sling
Posterior colpoperineorrhaphy UTERUS: VAGINAL HYSTERECTOMY-D2 Shirodkar's posterior sling
Vaginal repair of enterocoel VOL-11 NDVH - Conventional approach VOL-19 LeFort's operation
Abdominal repair of enterocoel NDVH - With salpingo-oophorectomy Gilliam's operation
VOL-4 Complete perineal tear repair NDVH - Debulking by uterine bisection Modified Gilliam's operation
VOL-5 Fenton's operation NDVH - Debulking by wedge excision William Richardson's operation
Episiotomy NDVH - Debulking by myomectomy #VOL-20 Ventral suspension of vaginal vault
Schuchardt's operation NDVH - Debulking by morcellation Abdominal sacro-colpopexy
UTERUS: MYOMECTOMY-D5 FEMALE STERILISATION-E3 Marshall Marchetti Krantz operation
A Colour Atlas of Supravaginal Cervical Amputation (Nadkarnis)

VOL- 21 Myomectomy for Fundal fibroid, Hood's VOL-26 Laparoscopic sterilisation by silastic bands Burch suspension operation
operation Sterilisation by minilaparotomy technique
Myomectomy for anterior wall fibroid Sterilisation by Pomeroy's operation CONGENITAL ANOMALIES-HI
Sterilisation by modified Pomeroy's VOL-30 Strassmenn's utriculoplasty
Myomectomy for isthmic fibroid
operation Jone's utriculoplasty
Myomectomy for anterior cervical fibroid
Sterilisation by Irving's method Tompkin's utriculoplasty
Myomectomy for posterior wall fibroid
Sterilisation by Uchida's method VOL-31 Excision of transverse vaginal septum
Myomectomy for intracavitary fibroid
Sterilisation by Madlener's method Excision of longitudinal vaginal septum
Myomectomy for fibroid polyp
Sterilisation by Parkland's method VOL-32 Mc Indoe's vaginoplasty
Myomectomy for broad ligament fibroid Modified McIndoe's vaginoplasty
Myomectomy for round ligament fibroid Sterilisation by Aldridge method
William's vulvo-vaginoplasty
Myomectomy for multiple fibroids Sterilisation by Kroener's method
VOL-33 Ileal neovagina
Sterilisation by Oxford's method
FALLOPIAN TUBES AND OVARIES-E1 Sterilisation by Shirodkar's method FISTULA OPERATIONS
VOL-22 Salpingo-oophorectomy Fimbriectomy VOL-34 Layer method of RVF
Wedge resection of ovary Sim's Moir saucerisation
ABDOMINAL WALL-F
Ovarian cystectomy Latzko's operation
*VOL-27 Infra-umbilical midline laparotomy
Ovariotomy VOL-35 Urethral reconstruction
Paramedian abdominal incision
VOL-23 Enucleation of broad ligament cyst Vesicovaginal fistula
Pfannenstiel's incision
Ectopic pregnancy Vesicocervical fistula
Kustner's incision
Ureterivaginal fistula
Maylard's incision
FALLOPIAN TUBE RECONSTRUCTION-E2
Cherney's incision MISCELLANEOUS OPERATIONS-J
VOL-24 Salpingolysis VOL-36 Intestinal loop urinary diversion
VOL-28 Abdominal closure
Fimbriolysis Urinary diversion cutaneous ureterostomy
Single layer abdominal closure
Salpingo-ovariolysis Skin closure methods Urinary diversion uretero-sigmodostomy
Salpingostomy Use of drains Ureterovesicle anastomosis (psoas hitch)
Salpingectomy Incisional hernia repair Posterior colpotomy
VOL-25 Cornual reimplantation Insertion of suprapubic catheter
Fimbrioplasty URINARY STRESS INCONTINENCE-G Demonstration of tubal patency via
TuboplastyMicroresection and VOL-29 Retropubic urethropexy laparoscopy
anastomosis Kelly's operation Demonstration of tubal patency by HSG

xii
Contents
1. Introduction ..................................................................................................................................................................... 1
Introduction 1
2. Principles of Nadkarnis Operation ............................................................................................................................ 2
3. Pre-operative Preparation ............................................................................................................................................. 3
4. Position and Anaesthesia .............................................................................................................................................. 5
Position 5
Anaesthesia 5
5. The Technique................................................................................................................................................................. 6
Nadkarnis OperationAmputation of the Supravaginal Part of the Cervix 6
6. Advantages and Disadvantages ................................................................................................................................. 87
Advantages 87
Disadvantages 87
7. Indications and Contraindication .............................................................................................................................. 88
Indications 88
Contraindications 88
8. Complications and Post-operative Care ................................................................................................................... 89
Complications 89
Post-operative Care 89

Index ......................................................................................................................................................................................... 91
1 Introudction

Introduction friction against the thighs while the patient is walking. All these result in

Uterovaginal prolapse is a very frequent presentation in gynaecological cervical hypertrophy, formation of decubitus ulcer and mucosal

practice. The surgical treatment outlined for congenital prolapse and hyperkeratinization. The aetiology of changes in the supravaginal portion

postmenopausal prolapse is fairly clearly defined. Prolapse in the child of the cervix are not related to pelvic congestion but rather due to a constant
bearing age, especially when the reproductive requirements of the patients downwards drag on the cervix caused by the descent of the sagging
are yet not fulfilled poses a dilemma in the mind of the operating ligaments.
gynaecologist, not being able to design his surgery to suit the requirements Also of concern is the fact that the portio vaginalis has a specific role
of the patient. to play in the process of sperm pickup and destruction of the portio
Prolapse in the reproductive age is usually the result of insult to the vaginalis and formation of a neocervix (as in a Fothergills repair) may
ligamentary and fascial supports of the uterus. This results in laxicity of hamper the process of sperm pickup. It is therefore logical to accept the
the supports and changes in the cervix. The deviations in the cervix as a importance of the portio vaginalis and its retention to physiologically
result of prolapse are different in the lower and upper cervix. The lower preserve the reproductive functions of the patient. Therefore, if the
part of the cervix is also referred to as the portio vaginalis or the vaginal anatomical alterations in the cervix are to be corrected and a normal anatomy
portion of the cervix and the supravaginal vaginal part of the cervix which restored, the elongated portion of the cervix (the supravaginal portion of
lies above the level of the vaginal insertion and bears on its periphery the the cervix) should be removed rather than a cervical reconstruction following
related ligaments anteriorly, posteriorly and laterally. partial amputation of the vaginal portion of the cervix.
The cervical changes in its lower part are a result of vascular changes The above observations led to the development of the correction of
resulting from venous obstruction of the blood vessels traversing the prolapse through sacrifice of the supravaginal portion of the cervix and
cardinal ligaments and also due to dryness of the cervical and vaginal anastomosis of the portio vaginalis with the uterine stump. This operation
mucosa as a result of lying outside the introitus, combined with constant is named after Dr Nadkarni and is being demonstrated in following chapters.
3 Pre
re--operative PPreparation
reparation

Woman should be thoroughly worked up prior to this surgery locally, Vagina is a pool of micro-organisms that can be problematic during
as well as systematically and her fitness for anaesthesia is taken prior. post-operative wound healing, therefore vagina should be cleaned
The reason for the early reproductive age prolapse should be properly by the nurse using savlon and povidine iodine at least twice
identified from the list of predisposing factors by personal history, prior to surgery.
habits, obstetrical history, family history and dietary history, etc. Woman should be kept nil orally after 10 pm in the night before
All the other concomitant compartment weakness be identified prior surgery.
to plan the surgery, so that they can be tackled in the same sitting Soap water or proctoclysis enema should be given in the previous
and chances of recurrence be reduced. evening and in early morning of surgery to clear the rectum and
There should be no decubitus ulcer over the cervix, if present it thus avoiding the chances of faecal soilage at the surgical area during
should be tackled with acriflavine-glycerine temponing twice daily. and in post-operative phase.
Acriflavine is a dye which works as bactericidal and glycerine is a Local and antibiotic sensitivity should be done in the ward on the
hygroscopic agent that removes the oedema of the dependent part. previous day as sometimes unexpected sensitivities can pose a grave
In cases of excessive oedema of the cervical lips woman should be problem during and after surgery.
nursed in trendelenberg position. Woman and attendants should be cleared about the problems,
Packing the cervix inside the vagina with tempon is of utmost weakness in the pelvic floor musculature and connective tissue as it
importance as it reverts most of the changes mentioned above. can continue to pose problem again later in life even after the surgery.
As with the other vaginal surgeries these woman should be given She should be advised about the life style modifications which
vaginal antibiotic pessaries to remove the local infections daily at are important to prevent the recurrence of the problem later in
least three days prior to the surgery. the life.
A Colour Atlas of Supravaginal Cervical Amputation (Nadkarnis)

Written informed consent should be taken from them explaining to curb the pre-operative anxiety and good night sleep prior to
the procedure, its benefits, advantages over other surgical options operation.
available and complications. Proper scrub bath should be given early in the morning of surgery
As the woman is kept empty stomach antacids or H2 blockers as and patient is given sterile gown to wear.
ranitidine should be given in night before surgery. One shot of intravenous antibiotic should be given at least one hour
An anxiolytic (0.25 mg of alprazolam) can be given to the night before prior to start of surgery to create the adequate level in the sera.

4
4 Position and Anaesthesia

Position instrument trolley in front. Two assistants stand on the sides of the surgeon
Lithotomy position is best suited for the Nadkarni's operation as with between the abducted legs of the patient.
any other vaginal surgery, in which patient is laid down on her back with
the buttocks at the edge of gynaecological operation table. Both the legs Anaesthesia
are flexed and abducted and put on stirrups or leggings for their Regional anaesthesia in the form of spinal or epidural is best suited for
support. Surgeon sits in centre facing the perineum with small Mayos any vaginal surgery is fit for Nadkarni's operation also.
6 Advantages and Disadvantages

Advantages Chances of cervical incompetence are less compared to Fothergill's


The portio vaginalis, is retained as such in Nadkarnis operation operation where greater initial dilatation of cervix is required
compared to the other uterine conservative prolapse surgeries like Vaginal flaps used for making the cervical lips decreases the diameter
Fothergill's/Manchester operation of cervical os and increases the incidence of cervical stenosis in
The cervical configuration is maintained Forthergill's operation, which is not there in Nadkarni's supra-
Direction of the original cervix is maintained vaginal cervical amputation.
Parent transitional zone is maintained
Technically not very difficult to perform
Disadvantages
The process of sperm pickup is not affected as after a conventional Since the elongated supravaginal portion of the cervix is excised, there
Fothergill's repair is a likelihood that in subsequent labours a cicatrisation ring may
Does not require a laparotomy like in other surgeries for nulliparous produce dystocia, and the patient may require a caesarean section.
prolapse, thus avoids the complication of wound infection, In extreme cases of obstruction, bucket handle tears of the cervix or even
dehiscence and ventral hernia later on a complete annular detachment of the cervix is a theoretical possibility.
There is no peritoneal entry. Neither the posterior or the anterior In the opinion of the author (of his own experience and on personal
peritoneal pouch is opened during surgery. It prevents any intra- communication with the designer of this surgery), vaginal deliveries
abdominal chances of infection following this surgery have been reported.
7 Indications and Contraindications

Indications Contraindications
Nulliparous prolapse in which the supravaginal portion of the cervix Pregnancy
is elongated. In a long standing prolapse with cervical hypertrophy, decubitus
Third or second degree prolapse with no or minimal cystocoele and/ ulcer (healed or healing and bilateral cervical tears which require a
or rectocoele and mainly supravaginal elongation of the cervix, the portio concurrent trachelorrhaphy
vaginalis looks healthy and the woman desires to continue childbearing Suspected malignancy of lower genital tract.
function.
8 Complications and PPost
ost
ost--operative Care

Complications tightly. Excessive pressure on the sutures has two disadvantages,

Injury to the descending cervical vessels and formation of a one, the suture area tends to become more avascular with increasing
fibrosis and secondly the cervical sutures may tend to 'cut through'.
haematoma. This is recognisable at the time of surgery and
identification and ligation/cauterisation of the offending vessel is
Post-operative Care
done. In rare cases in which the blood vessel may tend to retract
It is as for any post-vaginal surgery. The cervix may be inspected on day
from the operation view a U shaped suture taken through the
three to look for evidence of any swelling as a result of a local haematoma
substance of the cervix including the blood vessel is sufficient to
formation. The dependent stitch on the cervix is removed and the
procure complete haemostasis.
haematoma allowed to drain.
Possibility of remote cicatrisation of the anastomotic site can be
The local use of antibiotic vaginal tablets assists in healing by primary
minimised by not tying the anastomotic sutures on the cervix too
intention.
Index
Page numbers followed by f refer to figure

A D I Needle
inserted endocervical canal 50f
Allis tissue 35f Direction of original cervix 87 Infiltration of tumescent fluid 8f
retrieved cervical stitch 53
Amputation Injury to descending cervical vessels 89
Normal saline used for infiltration 8
completed on posterior half 40 E Insertion of needle at 3 oclock position 54
of cervix in progress 39f
Elongated supravaginal part of cervix 39f
Anterior lip upper part of cervix 32 K O
Emerging needle being pulled out of
Application of anastomotic sutures 46f
endocervic 52 Knot Obstetrical history 3
Endocervical canal visualised 31f for accurate anastomosis of cervix 67f
C Entry of needle upper part of vaginal incision stabilised with mosquito forceps 74f
P
Cause prolonged vasoconstriction leading to 83f
necrosis 10f Extension of hydrodissection 8f, 9f L Paracervical
Cervical attachments of ligaments 28
Lithotomy position 5
configuration 87 dissection 35f
F Local and antibiotic sensitivity 3
lips decreases diameter of cervical os 87f Parent transitional zone 87
Fluid in filtrated all around cervix 9f Long over artery forceps 59f
tissue in non-pregnant state 45f Portiovaginalis 87
Foleys catheter 86f Lower
Cervix stump 57f
Fothergills operation 87 amputation incision 29f
covered with vaginal flap by simple Position in posteriorly cut cervix 35f
Fothergills/Manchester operation 87 cervical incision 33f
running sutures 79f Post-operative wound healing 3
French Foleys catheter 38f, 64f incision over cervix completed 32f
closed with simple running sutures 79, Post-vaginal surgery 89
80f M Pregnancy 88
Childbearing function 88 G Principle of Nadkarnis operation 2
Circumferential incision Mayos instrument trolley 5
Gynaecological practice 1 Pulled out from portiovaginalis stump 61f
extended over 15 Metal dilator passed through portiovaginal
planned 15f 42
Commence surgery and moderate traction 7f
H Minimal cystocoele 88 R
Complications and post-operative care 89 Haemostasis Mosquito forceps second knot tied 70f Reaction of local tissues to suture material
Conventional Fothergills repair 87 and approximation over cervix 77f 79
Curved over cervix ensured 77f N Remaining strands of paracervical tissue 25f
and stout artery forceps 25f Hangs freely with loose strands of tissue 40f Nadkarnis operation 5, 6, 87 Result of local haematoma formation 89
artery forceps 24f Higher concentration of adrenaline 10f amputation of supravaginal portion 6f Right side of supra-vaginal part 27
A Colour Atlas of Supravaginal Cervical Amputation (Nadkarnis)
S of cervix dilated using 38 U V
Sims retractor 20f short of internal os 28f U shaped suture 89 Vaginal
Suturing cervix requires stout, strong, edges approximated properly 84f
Soap water or proctoclysisenema 3 Upper
taper 45 flap
Starting overanterior surface of cervix 15f incision planned oversupravaginal
closure 81f
Strands of loose fascial tissue 17 segment 39f
suturing in progress from right to left
Supravaginal margin of vaginal incision 17f, 18f 81f
part planned to amputated 23 T part of cervical stump 34f portion of cervix 1
portion Use of antibiotic vaginal tablets assists in intact 29f
Tightening additional suture 73f
down and upper incision 39f healing 89 surgery 5
Trendelenberg position 3
of cervix 1, 2 Uterovaginal descent 2 suturing in progress 83f

92

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