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\title{Removing Ovarian Tumours Vaginally: The Odyssey of a Gynaecologist}
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             \author[1]{Dr. Gunjan  Bahuguna}

             \author[2]{Dr. Ashok. R.  Anand}

             \author[3]{Dr. Shraddha  Rathod}

             \author[4]{Dr. Mridula  Raghav}

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\date{\small \em Received: 6 December 2018 Accepted: 1 January 2019 Published: 15 January 2019}

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\begin{abstract}
        


Ovarian enlargement can be due to non-neoplastic conditionsor neoplastic condition. The most common functional cyst is the follicular cyst, which rarely is larger than 8 cm .Most ovarian tumours (80 to 85%) are benign and two thirds of these occur in women between 20 and 44 years. The chance that a primary ovarian tumor in a patient younger than 45 years of age is less than 1 in 15. In postmenopausal women the incidence of malignant ovarian tumours increases to about 30 %.Most benign ovarian tumours are cystic and presence of solid component makes it more likely to be malignant.In my study 18 womenunderwent vaginal hystere-ctomy with ovarian cystectomy with bilateral salphingectomy. Investigations (usg pelvis, CT/MRI, Tumour markers) were done to rule out ovarian malignancy. After vaginal hysterectomy, veress needle was used to pucture the cyst vaginally, aspirate it and deliver it out. Histopathology proved the benign nature of the cysts. This study illustrates vaginal removal of benign ovarian cysts as large as 30wks size successfully. After all vaginal route is the prerogative of a gynaecologist.

\end{abstract}


\keywords{benign ovarian tumours, vaginal hystere- ctomy, vaginal removal of benign ovarian tumours, veress needle.}

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\let\tabcellsep& 	 	 		 
\section[{Introduction a) Aims and Objectives}]{Introduction a) Aims and Objectives}\par
Removing ovarian tumours vaginally. 
\section[{b) Selection Criteria}]{b) Selection Criteria}\par
Patients with more than 35 years of age and have completed their family and wanted hysterectomy along with cystectomy.\par
Patients who have an ovarian mass with investigations suggestive of benign etiology.\par
Author ? ?: Grant Government Medical College and JJ Group of hospitals, Mumbai-08. e-mail: drgunjanjjh@gmail.com c) Exclusion Criteria Pts with ovarian mass suggestive of neoplastic etiology.\par
Pts less than 35 years of age and want further child bearing. 
\section[{II.}]{II.} 
\section[{Materials and Methods}]{Materials and Methods}\par
Study period: April 2014 to april 2018. Place: JJ Hospital, Mumbai. 18 women presented with pelvic mass. History and clinical examination was done.\par
Trans vaginal ultrasound was done to know the nature of the cyst, excluding the malignant ones; multilocular appearance, irregular border, intracystic papillary projection or the presence of as cites. Color doppler to rule our the increased blood flow in malignancy. (Picture1)\par
CT/MRI was done to confirm the benign nature in doubtful cases. (Picture 2) Tumour markers s/o benign etiology.\par
Preoperatively, the patients were counseled and written consent was obtained for the surgery to be performed vaginally. In 10 women (55.6\%) vaginal hysterectomy was performed for heavy menstrual bleeding. As these women came from remote areas where follow up was difficult, they wished for a hysterectomy. All the women consented to possible laparotomy, oophorectomy and hysterectomy.\par
Pre anesthesia fitness obtained .After careful clinical examination, mobility of the uterus and the cyst was checked for adhesions. This was further as curtained and reassessed under anesthesia. (Picure 3, 4)\par
Vaginal hysterectomy/non descent vaginal hysterectomy done. Endometriomas required adhesiolysis which was done digitally along with fine dissection. The cyst was gently pulled down with the help of a allis forceps or babcocks and the cyst fixed abdominally. The head end was raised (Reversed Trendlenberg position) to assist gravitational forces in bringing the cyst down in the pouch of douglas.\par
For cystic masses a veress needle was used for cyst aspiration vaginally, the veress needle was attached to a tubing leading to a suction apparatus. The cyst would come down to the pouch of douglas after volume reduction; there after cystectomy was done. Using the veress needle for aspiration reduces Removing Ovarian Tumours Vaginally:\par
The Odyssey of a Gynaecologist ost ovarian tumours (80 to 85\%) are benign and two thirds of these occur in women between 20 and 44 years. Normal functioning ovary produces cysts 4-5 times every year. In most cases, these functional masses are self limiting and will resolve within 2-3 cycles. Sometimes, they persist longer or become larger than 5 cm size and transforms into pathological condition. The chance of a primary ovarian tumor in a patient younger than 45 years of age is less than 1 in 15. \hyperref[b0]{1} In postmenopausal women the incidence of malignant ovarian tumours increases to about 30 \%. \hyperref[b1]{2} M the chances of spillage of the cyst contents in the peritoneal cavity. Image (Image 5, 6, 7)\par
Cystic wall was sent for frozen analysis in doubtful cases Image (Image 8). All frozen analysis were s/o benign etiology.\par
Prophylactic bilateral salphingectomy was done on all. In postmenopausal women, prophylactic b/l salpingo-oophorectomy was done .\par
Extra-peritonization of pedicles done. Vault closure done.\par
Histopathological examination of the excised specimen was done by the pathology department of the hospital.\par
Average blood loss was 150 ml to 200 ml. Average time taken for surgery was 1.5 to 2 hrs. (Image 9) Patients were discharged day 5 post operatively.\par
Image Pre-operative assessment in ot reveals a III. 
\section[{Results}]{Results}\par
Table \hyperref[tab_0]{1} shows the age distribution .Maximum women belonged to the age group of 46 to 55 years who underwent vaginal hysterectomy with removal of benign ovarian cyst vaginally. They compromised about 44.5 \% and least were in the age group of 66 to 75 years.    {\ref 1} show the parity distribution. Maximum women were multiparous, 50 \% had 3 to 4 live issues.  
\section[{Figure 1}]{Figure 1}\par
Table \hyperref[tab_6]{3} shows the association with previous surgeries. 5 women had tubal ligation done and 3 had a previous LSCS. Table \hyperref[tab_4]{4} and figure  {\ref 2} depicts that maximum women had pelvic mass upto 14 weeks size. Though there were 2 women with 30 weeks size pelvic mass. 
\begin{quote}
Figure 2\end{quote}
\par
Table \hyperref[tab_5]{5} and figure \hyperref[fig_0]{3} illustrates that most of the ovarian cysts were simple cysts and serous cystadenoma 55.6\%. Mucinous cystadenoma fall the next with 22.2\% and then endometriotic cyst 11\%. There was 1 corpus luteal cyst and 1 cystic teratoma. Endometriomas 11\% required adhesiolysis to access the peritoneal cavity. It was done digitally and with sharp dissection.  
\begin{quote}
Figure 3\end{quote}
\par
Table \hyperref[tab_7]{6} shows that 4 ovarian cysts had undergone torsion. There were no intraoperative complications including rectal / bladder injury.\par
Average blood loss was 150 ml, no patient required blood. 
\section[{IV.}]{IV.} 
\section[{Discussion}]{Discussion}\par
Robert Glassgow is credited for the first cystectomy in 1701 AD. Since then cystectomies have been performed either via the vaginal route or abdominal route.\par
Earlier ovarian cyst aspiration was done by vaginal ultrasonography 3 ultrasound-guided culdotomy using a renal balloon dilator catheter for transvaginal ovarian cystectomies 4 has been done .Here in this study veress needle is used after vaginal hysterectomy to aspirate the contents of the cyst and extract it vaginally. Intraperitoneal spillage of cyst contents is minimized because of direct puncture of the ovarian cyst wall.\par
Though maximum number of women were multiparous, there was 1 nullipaous patient. Nulliparity and even virginity should not themselves be considered as contraindications to VH or as an indication for the abdominal route or laparoscopic assistance. \hyperref[b4]{5} 16.7\% of women had previous LSCS. It was possible to perform vaginal hysterectomy safely in patients with previous cesarean sections. \hyperref[b5]{6} Vaginal hysterectomy is not contraindicated per se after previous abdominal pelvic operations. \hyperref[b6]{7} There have been studies, where women with dermoid cysts were operated on vaginally via the posterior cul-de-sac without laparoscopic assistance. \hyperref[b7]{8} They had concluded that the vaginal route offers an excellent alternative to laparoscopic surgery and eliminates, in most cases, the need for invasive laparotomy. We had 1 case of a teratoma (5.6\%), where cystectomy along wiith vaginal hysterectomy was done successfully.\par
4 Ovarian cysts that were removed had undergone torsion.\par
In postmenopausal women, prophylactic salpingo-oophorectomy on the opposite side should be performed \hyperref[b8]{9} .\par
Vaginal ovarian cystectomy is the only cystectomy procedure that leaves no surgical scars on the abdomen.\par
If vagina is the gateway to the abdomen a big fibroid uterus, large ovarian cysts can be easily removed vaginally. Every hysterectomy unless absolutely contraindicated should begin by vaginal route. \hyperref[b4]{5} . A uterus with a volume up to 300 cm 3 or uterine size up to 12 weeks should be dealt vaginally, and as surgeons become more experienced larger uteri and also the adnexa can be approached in the same manner, at least as trial vaginal hysterectomy. \hyperref[b9]{10} Proponents and practitioners of vaginal hysterectomy have widened their indications and decreased the contraindications through liberal usage of debulking, performing oophorectomy, laparoscopic evaluation and trial vaginal hysterectomy. \hyperref[b10]{11} VH with better outcomes and fewer comlications than laparascoic/TAH. \hyperref[b11]{12} Cochrane Review concluded VH is far superior to other technique and has the best outcomes. \hyperref[b12]{13} V. 
\section[{Conclusions}]{Conclusions}\par
Cystectomies through the vaginal route paves the way for a scarless surgical technique. It offers less blood loss, with less operative time.\par
With minimum intraoperative complications, minimum hospital stay and a swift recovery.\par
There were no ureteric or bladder /bowel injuries. From pelvic masses of 14 wks to 30 wks size pelvic masses can be removed vaginally .irrespective of size of tumour. After all surgery through the vaginal route is the prerogative of a gynaecologist.\begin{figure}[htbp]
\noindent\textbf{3}\includegraphics[]{image-2.png}
\caption{\label{fig_0}Image 3 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{1} \par 
\begin{longtable}{P{0.5335106382978723\textwidth}P{0.08138297872340425\textwidth}P{0.2351063829787234\textwidth}}
Age\tabcellsep Frequency\tabcellsep Percentage\\
35 to 45 Years\tabcellsep \tabcellsep 22.2\\
46 to 55 Years\tabcellsep \tabcellsep 44.5\\
56 to 65 Years\tabcellsep \tabcellsep 22.2\\
66 to 75 Years\tabcellsep \tabcellsep 11.1\end{longtable} \par
 
\caption{\label{tab_0}Table 1 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{2figure} \par 
\begin{longtable}{}
\end{longtable} \par
 
\caption{\label{tab_1}Table 2 and figure}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{2} \par 
\begin{longtable}{P{0.413302752293578\textwidth}P{0.14036697247706423\textwidth}P{0.2963302752293578\textwidth}}
\tabcellsep \tabcellsep D D D D ) E\\
\tabcellsep \tabcellsep (\\
\tabcellsep 4\tabcellsep \\
\tabcellsep 8\tabcellsep \\
\tabcellsep 4\tabcellsep \\
\tabcellsep 2\tabcellsep \\
Parity\tabcellsep Frequency\tabcellsep Percentage\\
Nulliparous\tabcellsep 1\tabcellsep 5.6\\
P1L1-P2L2\tabcellsep 5\tabcellsep 27.7\\
P3L3-P4L4\tabcellsep 9\tabcellsep 50\\
P5L5-P6L6\tabcellsep 1\tabcellsep 5.6\\
P7L7-P9L9\tabcellsep 2\tabcellsep 11.1\end{longtable} \par
 
\caption{\label{tab_2}Table 2}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{4} \par 
\begin{longtable}{P{0.4868932038834951\textwidth}P{0.11553398058252426\textwidth}P{0.24757281553398056\textwidth}}
\tabcellsep Frequency\tabcellsep Percentage\\
Upto 14 wks\tabcellsep 6\tabcellsep 33.3\\
14 to 18 wks\tabcellsep 3\tabcellsep 16.7\\
18 to 22 wks\tabcellsep 3\tabcellsep 16.7\\
22 to 26 wks\tabcellsep 4\tabcellsep 22.2\\
26 to 30 wks\tabcellsep 2\tabcellsep 11.1\end{longtable} \par
 
\caption{\label{tab_4}Table 4}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{5} \par 
\begin{longtable}{P{0.595\textwidth}P{0.085\textwidth}P{0.17\textwidth}}
Types\tabcellsep Frequency\tabcellsep Percentage\\
Simple cyst\tabcellsep 5\tabcellsep 27.8\\
Serous cystadenoma\tabcellsep 5\tabcellsep 27.8\\
Mucinous cystadenoma\tabcellsep 4\tabcellsep 22.2\\
Corpus luteal cyst\tabcellsep 1\tabcellsep 5.6\\
Cystic teratoma\tabcellsep 1\tabcellsep 5.6\\
Endometriotic cyst\tabcellsep 2\tabcellsep 11\end{longtable} \par
  {\small\itshape [Note: E© 2019 Global Journals]} 
\caption{\label{tab_5}Table 5}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{3} \par 
\begin{longtable}{P{0.85\textwidth}}
Volume XIX Issue II Version I\\
D D D D ) E\\
(\\
Research\\
Medical\\
Global Journal of\end{longtable} \par
 
\caption{\label{tab_6}Table 3}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{6} \par 
\begin{longtable}{P{0.37280701754385964\textwidth}P{0.1789473684210526\textwidth}P{0.2982456140350877\textwidth}}
\tabcellsep Frequency\tabcellsep Percentage\\
Serous\tabcellsep 1\tabcellsep 5.6\\
Mucinous\tabcellsep 1\tabcellsep 5.6\\
Simple cyst\tabcellsep 2\tabcellsep 11.1\end{longtable} \par
 
\caption{\label{tab_7}Table 6}\end{figure}
 			\footnote{Removing Ovarian Tumours Vaginally: The Odyssey of a Gynaecologist} 			\footnote{© 2019 Global Journals} 		 		\backmatter  			  				\begin{bibitemlist}{1}
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\end{document}
