00 : 00 / 05: 00 (Preview)

This discussion has ended. Watch the recording on Medflix app,

Vaginal Vault Prolapse

Sep 08 | 1:30 PM

Vaginal wall prolapse occurs due to many pathological conditions and can be associate with prolapse of other pelvic structures. Let's look at the structural problems, their causes, and potential therapy options.

[Music] hi dr welcome you all uh to this amazing session on vaginal wall prolapse uh today we have dr vanitar out with us uh she's a considerate of obstetrician and gynecologist practicing at lhirananda hospital mumbai uh she's one of the most experienced gynecologist in the country she has like uh 40 plus years of work expectancy so uh welcome ma'am and thank you for getting uh to take this session on vaginal prolapse thanks a lot what prolapse after the hysterectomy though not very common is a very challenging clinical scenario and let's see about it today it's a descent of the vault into the vagina the incidence really varies but roughly the incidence is about 18.2 percent it's most commonly after a previous hystectomy that results in the damage of the pelvic floor support before we go to the normal uh to the wall prolapse we have to know what are the normal supports of the vagina and the uterus delancy has described it at three levels the uppermost that is level one is the cardinal and the uterosacral ligaments the middle level consists of pivo cervical fascia in anteriorly rectal vaginal fascia posteriorly and levator ni muscles through the arcus tendinous facial pelvis whereas the lowermost level of support is formed by the perineum and the urogenital diaphragm patient may come with a symptoms like a mass protruding from the vagina pelvic pressure they can be dysperonia or even aperonia urinary symptoms like difficulty in voiding or difficulty in incompletely welding and because the urine is staying behind they can be recurrent utis they can be even associated conditions like cystoseal enterocill or retrosyl the risk factors along with this are one is aging as a woman advances in age the supports of the vagina and the uterus start becoming weak and more so after the menopause because of the estrogen deprivation each vaginal birth does cause a lot of trauma to the pelvic floor and that if it is a multiparity especially before the time is given to recover the tone of the tissues if it's in a rapid succession that can be one of the risk factors occupational like laborers who are holding a very very heavy work or a heavy sort of uh carrying the uh load on their head it can be because of the persistent intra-abdominal pressure when there is chronic cough aeroponic constipation a few cases there may be a genetic predisposition where there is a congenital weakness of the supporting tissue obviously everything starts with prevention and one has to prevent the enterocill which can occur because of the separation of the superior portion of the recto vaginal fascia and that's why at hysterectomy it is important to reattach the recto vaginal fascia to the pivo cervical fascia provide a good support to the vaginal apex by reattaching the vaginal cuff to the uterosacral and the cardinal ligament complex let's see how it can be done the most commonly done are the macall's caldognasty is a surgical correction of the interoseal at the time of vaginal hysterectomy there are two types of macule sutures one is the internal sutures and the external sutures the internal macular sutures there are several non-absorbable sutures which are used to obliterate the enterocell by approximating both uterosacral ligament and several bytes of the posterior peritoneum together whereas the external macall sutures is taken by delayed absorbable sutures which are inserted through the full thickness of the posterior vagina just lateral to the midline and then pass through the each utero sacral ligament and back on the posterior wall the internal sutures are tied first followed by closure of the wall and then lastly tying the external sutures uh there is no cursor but i suppose you can see that the transverse sutures which you can see are the internal macall sutures going from one utero sacral then few bytes on the posterior wall of the interoseal which is actually the anterior wall of the rectum and then going on the other side of the uterus whereas the external suture the one in the center if you can see it's going from the posterior vaginal wall onto the peritoneum then to the uterosacral go to the opposite uterocycle and back to the posterior vaginal wall what does meccal caldoplasty do it obliterates the caldisat it supports the vaginal apex and it lengthens the osteo vaginal wall there are certain modifications of the mackerel technique the one of the modification is if the vagina is too spacious or if there is a lot of enlargement of the vagina then a wedge of the vaginal mucosa is removed from the anterior and the posterior vaginal wall the anterosal sac is then sected free and excise at the neck as you all know now the prolapse is considered as a herniation so like in any hernia one has to dissect the sack go right at the neck of the hernia and one has to obliterate the neck at the at the level of the neck the internal meccal sutures are placed and tagged modified external macall sutures are placed by passing delayed absorbable suture materials through the posterior vaginal wall and peritoneum through the remainders of the uterus and the cardinal ligament [Music] place will depend on the size of the anterosal and the redundancy of the upper vagina as you can see this is an enterociel which is open and the dotted line shows the redundancy so that part will be excise then you go right at the neck of the interoseal obliterate obliterated with a pulse string suture by a delayed absorbable suture material and as you can see there are the two transfers inside are the internal meccal suture external macall sutures if you can see on the posterior vagina instead of being straight there is a wage of the vagina which is removed and they are passed through this posterior vaginal wall so that will also take care of the redundancy of the vagina once the surgery is complete as you can see in the lower one the internal mechan sutures are obliterating the interoseal by approximating the uterosacrals together whereas the upper picture will show that with the external macall suture now the wall is firmly attached to the uterus after seeing the prevention let's come to the actual management obviously it can be either a conservative or a non-surgical or it can be surgical non-surgical management with a pessary is a reasonable treatment and it in many a cases definitive surgical intervention may be required the non-surgical method one can use the silastic or rubber devices earlier we used to get only a rubber ring pessary which was made up of india rubber which is little more irritant as compared to the scientific devices which are available now and because of these the irritation of the vagina or a discharge is much lesser this provides mechanical support to the vaginal walls patient is fitted with the appropriate type and size how does one measure what size will be required one has to do the internal chip examination the tip of the middle finger will go into the posterior vaginal fornix whereas with the help of the other hand one has to mark a point on the index finger which will be just below the pubic symphysis and the distance between the point on the index finger to the tip of the middle finger is the size of the vaginal pessary they usually come as a diameter comes as a two inches two and a half inches three inches patient should be fitted with the appropriate type and size sometimes it may be a trial and error you can put a smaller pessary if it slips out one can put a little larger pieces optimally the patient should handle the pesary on her own it does require frequent removal and cleaning and especially in a postmenopausal women we can also add topical estrogen cream this is appropriate for elderly patients and for patients who are at high risk for operative or anesthesia it also may treat the incontinence the flip side is it does require constant handling risk of vaginal abrasion ulceration and rarely fistula formation is there sometimes these are the elderly patients and if they forget because once it goes inside the woman will not feel anything and if she just forgets about it it may abrade through the vagina this is a pessary a rubber ring pessary and second one is with the support with the holes in it so that whatever vaginal discharge which is there can be drained out usually pessary can be a first choice because it's easy to manipulate easy patient handling and requires but it will require adequate levator and perennial support if along with the world prolapse if the woman has a very lax perineum where the levators are widely separated then the pessary may not be head and in that case one may have to resort to the surgical intervention the surgical procedures can be vaginal they can be abdominal laparoscopic or they can be even obliterating usually a transvaginal approach is preferred reserving the abdominal sacral corpoxy for patients who have previous failed vaginal surgery the vaginal procedures are sacrospinous ligament suspension high utero sacral ligament suspension with a fibromuscular vaginal wall reconstruction and a iliococcygeus fascia suspension just to complete the list i have given all these three but first one that is the sacrospinous ligament suspension is the most commonly practiced vaginal procedure and that's why let's see that in details the right sacrospinous ligament is usually selected because it is easier for the right handed person to see the ligament and place the suture additionally the recto segment is not normally present on the right side a sacrosphinous ligament fixation is typically approached through the posterior vaginal wall incision like how we do a posterior corporate by taking a inverted t incision the transverse of the incision is at the introitus and the vertical is on the posterior vaginal wall after taking this incision and once you have separated the two flaps of the vagina if there is an enterocill it should be dissected right up to the neck the sack should be open the contents of the sack should be reduced excise the redundant peritoneum and the first string suture is taken at the neck by delayed absorbable suture material after doing this one has to go ahead with the dissection of the vaginal wall down to the right rectal pillar and perforation of the rectal pillar over the ischial spine so that as you can see in this figure you can directly now approach the ischial spine because the sacral spinous ligament on one end is attached to the ischial spine and then it goes medially and upwards to get attached to the lateral aspect of the sacrum after a three centimeter wide opening is made into the pararectal space the ischial spine and the sacrospinous ligament which is embedded within the muscle are cleared of the overlying tissue under the visual guidance the sacrospinous ligament is grass with alice clamp approximately two centimeters from the ischial spine the manure both bunches up the ligament and ensures that there is no suture inadvertently placed closer to two centimeters from the spine as you can see is shell spine and the sutures are spliced at least two centimeters medial to the ischial spine and this is because the pringle now and the pidental vessels go around the initial spine and if we are very near the ischial spine we are likely to enjoy this why i said that we hold it with alice because the western books do mention certain specific or a specialized instrument like how you can see in this it's a mia hook the other instrument which can be used is a deschamps ligature carrier usually most of us we don't have this instrument that's why we can just hold it with the alice's forces and then it becomes easier to take a suture as a pictorial it may appear easy but actually when you are doing it inside the patient it becomes very difficult because it's a very narrow area you are just manipulating with your fingers and that's really difficult the two sutures are placed one centimeter apart through this ligament medial to the previously placed alice's clamp either you can use two non-absorbable or two absorbable sutures the absorbable suture is placed through the full thickness of the vagina and knotted within the vagina where it is easy to tie down and ensure an air knot does not occur whereas if it is a non-absorbable obviously you cannot put it to and through the vagina because if the sutures are inside the vaginal epithelium that is going to be always there it is unabsorbable and it can be a nidus of an infection and patient can have a continuous discharge the upper portion of the vaginal wall must be partially closed prior to tying down the sutures just imagine if you have tied the sutures to the uterosacral then the whole of the vagina is going to go up and then you will not be able to suture the vagina that's why you suture at least half of the vagina how you do it in a pee repair then you tie the uterus the sutures which are taken through the sacrospinals and then complete it the pulley knot is usually used for a non-absorbable suture so that when the knot is tight the vaginal wall is pulled down securely to the ligament in some of the newer technique one can use one absorbable and one delayed absorbable suture non-absorbable suture is usually taken medially whereas the delayed absorbable suture is taken laterally as you can see the lower portion of the picture shows a non-absorbable and that's why it's a pulley knot and it's not gone through the whole thickness of the vagina whereas the upper motion shows the absorbable where it has gone through the whole of the vagina and one can directly tie it a sacrospinous ligament fixation can be performed bilaterally however this requires a wide vaginal wall and mobilization of the rectum over the sacral spinous ligament on the left side when a unilateral sacrospinous ligament fixation is performed the vaginal wall should be reduced giving the vagina a cylinder like shape and lessening the possibility of any excess proximal vaginal mucosa to event the posterior repair is routinely performed and the vaginal mucosa is closed in a usual fashion this is the end result of a sacral spinous fixation and this is a pictorial uh result of the sacral spinals of course is shown little going up right towards the sacrum but it should have been little down more towards the ischial spine any surgery can having complications and this can be inadvertent proctectomy hemorrhage damage to the pre sacral vessels especially if you are you have to retract the rectum away from the field and when you are doing that if your retractor goes little posteriorly it can go right at the pre sacral vessels pidental nerve injury if you are not careful to place your sutures at least two centimeters medial to the ischial spine and lastly constriction ring due to the aggressive posterior repair then we come to the next two operations i'll just go quickly because this is just to complete it as a picture or a theory because in practice it becomes little difficult to do this high suspension ligament with the fibromuscular vaginal wall construction richardson introduced a new approach to the management of interracial and world problems two alice's clamps grasp the vaginal apex with the traction on the analysis vaginal epithelium overlying the enterosilic in size once you incise the vaginal epithelium you come across the interval seal sat which is as i have described in details in the sacrospinals dissected right up to the neck of the hernia a non-absorbable or delayed absorbable sutures are passed through the uterosacral ligament at the level of the ischial spine sutures are tried across the midline creating a firm bridge which to which the vagina will be anchored and by tying this you are also obliterating the enteroseal absorbable sutures are used to suspend the anterior and the posterior vaginal walls with their fascia to the utero sacral ligament tying of these sutures suspends the vagina into the hollow of the sacrum and restores the continuity of the endopelvic fascia of anterior and the posterior vaginal wall this is something like a mccall's external suture so i hope this picture you can see the transverse ones are the ones which are delayed absorbable which will obliterate the two utero sacral thus obliterating the entorosine whereas the lower one is the one which will anchor the vaginal wall to this uterus rarely the complications can occur ureteral injury because this is post hysterectomy so utero sacrals have gone very high only a small part of the utero sacrals is remaining and that's the place where the ureter crosses the urine uterus so one has to be careful to avoid this injury hemorrhage bowel or bladder injury rarely then the next procedure which can be performed which was described by inmon is iliococcygeus fascia suspension excise a diamond shaped section of the tissue from the peritoneum to the introitus vaginal epithelium is freed from the rectum and the recto vaginal fibromuscular vaginal wall dissection is carried laterally to the levator ni and kephallite to the cuff the iliococcijus muscle is identified lateral to the rectum and anterior to the ischial spine the rectum is pressed down and medial suture is placed just anterior to the initial spine both ends of the sutures are passed through the ipsilateral vaginal apex same procedure is repeated on the opposite side if delayed absorbable sutures are used they should not be they can be passed through the full thickness of the vagina but if it is a non-absorbable obviously you have to be short of the vaginal mucosa the posterior corporate is done and then the sutures are tied so with that we finish the vaginal operations just to recapitulate though i have explained three of the procedure the most commonly performed procedure is the sacrospinal fixation of the wall let's now move on to the abdominal procedures the abdominal sacral corpoxy and high utero sacral ligament suspension suspension of the vagina to the sacral promontory or into the hollow of the sacrum with an intervening mesh it's durable and gives a strong surgical correction it's indicated in young patients or in a previously failed vaginal approach or because of the previous operation if the vagina is shortened and lastly who have other coexisting conditions which will predispose to the continued marked increase in the intra-abdominal pressure and a subsequent failure a low transverse or a midline vertical incision is taken the position which is usually given is a lithotomy but the operation is mainly from the abdominal one has to put two alice's forceps in the vagina and the vagina is elevated the peritoneum is dissected of the interior vaginal wall so that you take the bladder away the peritoneum on the posterior aspect of the vagina is incised in the midline and carried down to the calde sac so that the victim now falls back then the peritoneum is dissected laterally three to five pairs of non-absorbable sutures are placed on the posterior aspect of the vagina about one and a half to two centimeters apart incorporating the full thickness of the vaginal wall the sutures are then placed through the mesh we will have the pictorial picture later but let me just finish the theory part of it and then extend the mesh approximately halfway down the posterior wall place two to four non-absorbable sutures on the anterior aspect of the vagina and attach a separate piece of the vagina so ultimately it's going to be a y-shape a entire vagina is one in one part of the y the posterior vagina is the other part of the y and that arm is a slightly longer both these and then the main the stem of the y will be going on to the sacral promontory so place two to four pairs of non-absorbable sutures of the interiors aspect of the vagina and attach a separate piece of a mesh this anterior mesh is sewn to the posterior mesh just proximal to the vaginal apex moscowitz or hellbent procedure is performed to obliterate the cardiac that expose the pre sacral area by incising the peritoneum over the sacral promontory and carrying it down over the entire surface of the sacrum as you can see the front portion that is a short arm of the y is on the anterior vaginal wall the long arm of the y has gone on to the posterior vaginal wall whereas the main step of the white is going towards the sacral promontory the sacral promontory and the anterior longitudinal ligament are exposed by dissection and you take about few sutures non-absorbable material through the longitudinal ligament over the sacral promontory appropriate amount of the graft material that is the mesh is cut and these sutures are placed through the graft and tied there should be no tension on the graft material because if there is a tension the rectum and the sig retro sigmoid is just besides and this may alter the anatomy and the function of the rectosigmoid the peritoneum over the sacrum is closed and the penum over the entire vaginal wall is also closed that's why that's how you cover the mesh completely you cannot leave the mesh any part of the mesh open in the abdominal cavity because it's a foreign material and the intestinal adhesions can occur as you can see in this picture if you start from above that is over the sacral promontory going on to the sacrum and then on the vaginal wall going down on the anterior surface of the vagina now by peritonizing this the mesh is completely extra peritoneal this is just a pictorial picture uh illustration that how the vaginal wall with a short anterior mesh a longer posterior mesh and it has gone right up to the sacral promontory rarely one can have a bubble bladder or a ureteric injury bleeding can occur and very very rarely since it's a synthetic mesh it can erode through the vagina just to finish or to complete the list a high uterosacral ligament suspension remnants of the uterosacral ligaments are identified by opening the abdomen and the tact with the sutures near the ischial spine and mind you it's really difficult for hysterectomy to trace those uterus the ureters are identified bilaterally the internal cell is then addressed by obliteration of the cul de sac may be by called moscowitz sutures the peritoneum over the vaginal apex is open the endopelvic fibromuscular fascia vaginal wall is identified and reapproximated to form a continuous covering of the endopelvic fibromuscular vaginal wall over the vaginal epithelium and lastly the non-absorbable sutures are then used to suspend the vagina to now intact endopelvic fibromuscular vaginal wall to the uterus ligament uh if you have to compare vaginal versus abdominal surgery benson and associates demonstrated that the abdominal sacral corpoxy was most likely to result in an optimal outcome maher and colleagues compared abdominal sacral cortopix to the unilateral sacrospinous fixation and they found that the results were equally good both the studies suggest that the vaginal root to be safer and require less operative time the choice of surgery depends upon the individual patient and a combined approach sometimes may be needed comparison of vaginal to the abdominal vaginal approach is preferable it is decreases the operative time decrease incidence of adjacence because you are not entering the peritoneal cavity and a quicker recovery time plus we gynecologists we are more oriented vaginally that's why we do find it technically easier and the last we come to the obliterative procedures these are done if the woman is not interested in a sexual function the vaginal mucosa is completely excised from the underlying endopelvic fibromuscular vaginal wall a series of string sutures are used to invert the prolapse and the endopelvic fibromuscular vaginal wall once the prolapse is reduced a posterior corpora perineurophene and the liver toroplasty is performed the abdominal sacrocalpopexy which i have described in detail it also can be done by laparoscopy and nowadays even with the robotic surgery the advantage of these are these are tiny incision with resultant less pain less morbidity less hospital stay and that's why faster recovery the base surgical practice what should it be the ultimate goal of treating a world prolapse is to restore the anatomy to maintain and restore the visceral function just because you have corrected her wall prolapse she should not land up with some bladder dysfunction or a difficulty in passing stools and lastly maintain and restore the normal sexual function so coming to the conclusion mackel's caldoplasty and its various modifications are the most commonly used transvaginal techniques to prevent wall prolapse at the time of primary surgery for significant wart prolapse sacrospinous ligament fixation is very useful transvaginal technique abdominal sacral chalcopaxy is preferred for the treatment of a recurrent prolapse after prior surgical failure thank you for a patient hearing and if there are any questions i'll be happy to answer them uh thanks a lot firstly for this uh beautiful explanation of the topic uh there are a few questions which i'll take up uh so one question was what are the early signs and symptoms of vaginal prolapse so you have actually uh discussed that initially but how does that patient post hysterectomy and they can come variable period of time they can come as early as even six weeks if it is not a properly performed surgery and most of the times why it happens is because i have exp i have had a patient who had a prolapse but somehow the hysterectomy was done laparoscopically and within six weeks of the surgery so probably not selection of a proper operation are not properly done surgery so they can come as early as 6 weeks or they can come even 15 years after it and the most common symptom is something coming out through the vagina okay okay so uh in the vault prolapse incidence uh is it same in both abdominal and vaginal hysterectomies or is there any differentiation uh usually it will be more in a vaginal hysterectomy because why do you do a journalist technique many a times it's done for the prolapse so as it is the there is a lot of weakness of the supporting tissue so if the proper technique is not used or if the proper operation is not chosen then it's more likely to occur in a vaginal astectomy especially if the initial hysterectomy was done for the prolapse operation okay understood so uh the rest of the questions are addressed so uh to everyone if you have any questions uh mom can address a live right now so you feel free to uh put in comment section uh mom there is one question can we treat vaginal uh prolapse conservatively non-surgical management as you have discussed which i have already said and yes really only requirement is the it should not be a vaginal opening should not be wide there should be some tone or the some levator plate should be there otherwise that peso is just going to come out so we have patients we have been treated for years together these are elderly patients who are not fit for the surgery because of their cardiac condition or because of the respiratory problems so yes it is a very very good alternative than i mean for a surgeon yeah okay so uh after psychospinous fixation or hysterectomy uh will there be any chance of urinary incontinence and like how to manage that usually there should not be urinary incontinence and by urinary incontinence do you mean the true incontinence which can occur if someone has damaged the bladder and that has gone unnoticed but stress urinary incontinence usually should not occur because the level of the weakness is somewhere between the urethra and the cycle junction whereas what we are doing it is much at a higher level which is at the level of the if you remember d lens is the level one or the upper level so that should not be altering the anatomy it can occur sui if primarily patient had a sui and the concentration was mainly for the wall prolapse because that's the one which was coming out so actually it may have been that initially only patient had a world prolapse which was not detected you corrected the world prolapse that portion has been taken care and now she's more worried about the sui or urinary incontinence but per se only with the sacrospinas sui should not be a complication right and uh like giggle exercises are they advised here or should be avoided no no of course you can advise them but what is kegel is going to do is it will develop the tone of the pelvic muscle the levator and i or the perineum whatever has already come will not go inside it may increase the further progress of the world prolapse yes kegels is definitely has to be our advice especially if you are treating them by a pessary pessary along with kegels will give a good result but it will not reduce per se it will prevent the further coming out of the world okay okay so uh there is one question asked by dr sushmita uh so mesh migration and erosion how frequent is it migration should not occur because if you remember they have really really sutured it properly you have anchored it to the entire vaginal wall you have anchored it to the posterior part of the vagina and then you have anchored into the sacral promontory and the interior longitudinal ligament on the sacral hollow so migration should not occur if your sutures are very near or they have gone through the vagina then very very rarely it can erode the vagina and then in that case one may have to remove the suture okay and if it is really bad one may even have to remove the mesh mesh as well okay so uh doctor another thing is just to add uh if the students i don't know what uh level of the students are there if they're post graduate they may know there was a vaginal reconstruction by the mesh apogee and perigee which may be about five seven years back was that was made very popular the popularity reached absolutely in a very heightened manner and in the same manner it came down because there was a mesh erosion but there the mesh was put vaginally and it was just beneath the vagina whereas here in the abdominal sacral corpoxy the most part of the mesh is intra-abdominal so chances of erosion are much lesser as compared to those apogee and perish okay okay okay so uh the postgraduate students here may be able to relate to what mom said about one case so uh ma'am there is one interesting case uh dr priyanka has mentioned uh maybe we can take that up so there is a young uh female who had a grade one cystocele and she's uh planning for a family planning and uh but there is a difficulty during enter course due to prolapse of anterior vaginal wall and retroverted uh you tell us to so uh what is the treatment for that there is low abdominal pain currently so how do we go first of all uh grade one and cystocele will not cause difficulty in the uh keeping physical relation and what was the other thing you said one was great one and retroverted uterus again retroverted uterus unless there are other problems and why is it retrovirted if it is a retroverted mobile uterus it's usually you will see in almost 30 percent of the women but if it is a retrovirted fixed uterus because of the endometriosis or because of the pelvic inflammatory disease where along with the retroversion the ovaries are just at the posterior vaginal fornix then it can cause a deep seated dysperonia but only retroverted uterus which is mobile should not cause dysperonia right uh i hope dr priyanka this answers uh the case that you have mentioned here um how long does the surgery uh benefits for older patients who underwent like a sacrospinal fixation oh if it helps it can be permanent also if it is done properly it is permanent see because you are anchoring it to the fixed ligament that ligament is not going to move sacrospinous is at one end fixed to the ischial spine and then the other end is on the lateral surface of the sacrum so this is a solid structure if you have properly anchored your vagina over there unless the sutures are not taken properly or if they cut through then only it can recur but if it is done properly it's a permanent cue right so there will be a permanent solution to its understanding so uh dr p use has asked if uh covet vaccine can be taken if she's uh going to get operated soon but i think that's uh it should be taken by everyone and including pregnant and lactating women if you all are practicing please please tell all your patients that take vaccine especially if they are pregnant they have a lot of reservation you should tell them that it will protect them as well as it will form the antibodies and these antibodies are passively form passed to the baby and even the baby is protected so when you tell them this they are more amenable to your suggestions right so it's very uh gentle question not actually related to this i know but i take this opportunity so so everyone actually needs to advise all of their patients irrespective of the stage they are currently in they should take vaccine and listen until it but getting covered and landing up with complications is more real than the so-called complications of the vaccine yeah very important so there is no pro there shouldn't be any apprehension about it at all so uh i guess we have already answered my uh all the questions uh here uh which were really relevant so yeah with this mom i'll end session and thanks a lot for joining us today uh it was really great and i actually learned a lot of things from you thank you and thanks a lot to netflix for giving me this opportunity maybe some other time we can again meet on this platform thank you definitely have a good evening bye

BEING ATTENDED BY

Dr. Deepak Najan & 1691 others

SPEAKERS

dr. Vanita Raut

Dr. Vanita Raut

Consultant Obstetrician and Gynecologist at L H Hiranandani Hospital, Mumbai

+ Details
dr. Vanita Raut

Dr. Vanita Raut

Consultant Obstetrician and Gynecologist at L...

+ Details

About Medflix

Medflix is a new platform by PlexusMD, India's most active and trusted doctor community. On Medflix, you can discover live surgeries, discussions, conferences and courses from some of the top doctors and institutions across the world. Join clubs in your areas of interest and access hundreds of amazing live discussions everyday.