Hysterectomy
BS. Nguyễn Hồng Anh
KEY POINTS
1 Hysterectomy is one of the most commonly performed surgical procedures in the United States.
2 Vaginal hysterectomy is the procedure of choice unless this route is contraindicated.
3 Randomized clinical trials do not demonstrate an advantage of robotic or single-port hysterectomy over conventional laparoscopic hysterectomy.
4 There appears to be no advantage to the routine use of supracervical hysterectomy when compared with total hysterectomy.
5 Salpingo-oophorectomy at the time of hysterectomy for benign disease in premenopausal women at average risk for ovarian malignancy is associated with an increase in long-term patient mortality from cardiovascular disease, and ovarian conservation should be strongly considered in these patients.
[1] Hysterectomy is one of the most common surgical procedures performed. According to the National Hospital Discharge survey, the rate of inpatient hysterectomy between 1998 and 2010 decreased, with 36% fewer hysterectomies performed in 2010 compared with 2002 (Table 27-1) (1). These data do not represent hysterectomies performed in ambulatory settings and recent data of outpatient hysterectomy volume in nonhospital ambulatory settings indicate that a shift in the location of the hysterectomy explains in part the observed drop in hysterectomy. Data from the US Healthcare Cost and Utilization Project State Ambulatory Surgery and Services Database (SASD) suggest that approximately 100,000 to 200,000 hysterectomies are performed in ambulatory settings (2). These procedures are overwhelmingly laparoscopic or robotic. Therefore laparoscopic, including robotic hysterectomies, accounts for the majority of hysterectomies performed, followed by abdominal and then vaginal. The decline in abdominal and hospital-based hysterectomies have important cost and training implications. Hysterectomy rates are higher for black women (3). Bilateral salpingo-oophorectomy decreased significantly, while bilateral salpingectomy increased significantly between 1998 and 2011 (4).
Table 27-1 Indications for Inpatient Hysterectomy Based on National Hospital
Discharge Survey United States 2010 (1)
Number of Hysterectomies
Uterine leiomyoma 195,000
Abnormal uterine bleeding 195,000
Endometriosis 83,000
Benign ovarian neoplasms 70,000
Pelvic organ prolapse 74,000
Gynecologic cancer 53,000
Numbers are rounded.
INDICATIONS
Leiomyomas
The number of hysterectomies performed for leiomyomas, abnormal uterine bleeding, endometriosis, benign ovarian masses and prolapse have decreased over time (1,5) (see Chapter 11). Fertility-preserving surgical management (myomectomy) is possible in most patients with leiomyomas. The decision to perform a hysterectomy for leiomyomas is usually based on the need to treat symptoms—abnormal uterine bleeding, pelvic pain, or pelvic pressure. Other indications for intervention have included “rapid” uterine enlargement, ureteral compression, or uterine growth after menopause. There is no clearly reproducible definition of rapid growth. The concept of rapid growth was challenged because these patients did not demonstrate clearly malignant conditions (6). Refuted reasons for hysterectomy in patients with leiomyomas are size greater than 12 weeks of gestation without symptoms, inability to palpate the ovaries on bimanual examination, and increased morbidity at hysterectomy with increased uterine size.
If the procedures are performed abdominally, there is no difference in surgical morbidity between patients with a 12-week–sized uterus and those with a 20 week–sized uterus (7). Hysterectomy for leiomyomas should be considered only in symptomatic patients who do not desire future fertility (7). To reduce uterine size before hysterectomy, patients with large leiomyomas may be pretreated with a gonadotropin-releasing hormone (GnRH) agonist (8,9). In many cases, the reduction of uterine size is sufficient to permit vaginal hysterectomy when an abdominal hysterectomy would otherwise be necessary. In one prospective trial, premenopausal patients with leiomyomas the size of 14 to 18 weeks’ gestation were randomized to receive either 2 months of preoperative depot GnRH agonist or no GnRH agonist (9). Treatment with a short course (8 weeks) of leuprolide acetate before surgery enabled the procedures to be converted safely from an abdominal hysterectomy to a vaginal hysterectomy (9). This preoperative regimen was associated with a rise in hematocrit before surgery and a shorter hospital stay and convalescent period because patients were more likely to have a vaginal rather than an abdominal hysterectomy.
Abnormal Uterine Bleeding
Abnormal uterine bleeding requires an extensive investigation to rule out reversible causes of bleeding (see Chapter 10). Anovulatory uterine bleeding is typically associated with polycystic ovary syndrome (PCOS), a condition in which anovulatory cycles are common. The bleeding can be controlled by medical intervention with progestin or a combination of progestin and estrogen given as oral contraceptives. Ovulatory abnormal uterine bleeding can be controlled by nonsteroidal anti-inflammatory agents, hormonal intervention, tranexamic acid, or the levonorgestrel intrauterine device. In patients with abnormal uterine bleeding, endometrial sampling should be performed before hysterectomy (10). Dilation and curettage is not an effective means of controlling bleeding and is not necessary before hysterectomy. Hysterectomy should be reserved for patients who do not respond to or cannot tolerate medical therapy. Alternatives to hysterectomy (e.g., endometrial ablation or uterine artery embolization) should be considered in selected patients because these operations may be cost-effective and have a lower morbidity rate. However, in a clinical trial that randomized endometrial ablation to hysterectomy, 29% of patients assigned to the ablation underwent hysterectomy by 60 months (11). In a follow-up of another randomized clinical trial comparing uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids, 31% of those randomized to uterine artery embolization ultimately underwent a hysterectomy (12).
Intractable Dysmenorrhea
About 10% of adult women are incapacitated for as many as 3 days per month as a result of dysmenorrhea (see Chapter 12). Dysmenorrhea can be treated with nonsteroidal anti-inflammatory agents used alone or in combination with oral contraceptives or other hormone agents. The levonorgestrel intrauterine device effectively reduces dysmenorrhea symptoms. Hysterectomy is rarely required for the treatment of primary dysmenorrhea. In patients with secondary dysmenorrhea, the underlying condition (e.g., leiomyomas, endometriosis) should be treated primarily. Hysterectomy should be considered only if medical therapy fails and if the patient does not want to preserve fertility.
Pelvic Pain
In a review of 418 women in whom hysterectomy was performed for a variety of nonmalignant conditions, 18% had chronic pelvic pain. Preoperative laparoscopy was performed in only 66% of these patients. After hysterectomy, there was a significant reduction in pain and an improvement in quality of life (13). In a review of 104 patients who underwent hysterectomy for chronic pelvic pain that was believed to be of uterine origin, 78% experienced improvement in their pain after follow-up for a mean of 21.6 months (14). However, 22% of patients had no improvement in or exacerbation of their pain. Hysterectomy should be performed only in those patients whose pain is of gynecologic origin and does not respond to nonsurgical treatments (see Chapter 12).
Cervical Intraepithelial Neoplasia
In the past, hysterectomy was performed as primary treatment of cervical intraepithelial neoplasia. More conservative treatments, such as laser or loop electrosurgical excision procedure (LEEP), can be effective in treating the disease, making hysterectomy unnecessary in most women with these conditions (see Chapter 16). For patients with recurrent high-grade dysplasia who do not desire to preserve fertility, hysterectomy may be an appropriate treatment option. After hysterectomy, these patients are at increased risk for vaginal intraepithelial neoplasia.
Obstetric Emergency
Most emergency hysterectomies are performed because of postpartum hemorrhage resulting from uterine atony. Other indications include uterine rupture that cannot be repaired or a pelvic abscess that does not respond to medical therapy. Hysterectomy may be required for patients with placenta accreta or placenta increta.
Pelvic Inflammatory Disease
Pelvic inflammatory disease can be treated successfully with antibiotics. The uterus, tubes, and ovaries rarely need to be removed in a patient with pelvic inflammatory disease that is refractory to intravenous antibiotic therapy (see Chapter 15). Whether one proceeds with conservative surgical management, abscess drainage, or organ removal is a subjective decision that must be based on the individual. If accessible, some pelvic abscesses may be drained successfully by percutaneous catheter drainage guided by ultrasonography or computed tomography (CT) scanning. Surgical intervention is necessary if the patient has acute abdominal findings associated with peritonitis and signs of sepsis in the presence of a ruptured tubo-ovarian abscess. For the patient who desires future fertility, consideration should be given to unilateral salpingectomy or salpingo-oophorectomy or bilateral salpingo-oophorectomy without hysterectomy. For the patient in whom bilateral salpingo-oophorectomy is required, the uterus can be left in place for possible ovum donation and in vitro fertilization.
Endometriosis
Medical and conservative surgical procedures are successful for treatment of endometriosis (15). Bilateral salpingo-oophorectomy, with or without hysterectomy, should be performed only in patients who do not respond to conservative surgical (resection or ablation of endometriotic implants) or medical therapy (see Chapter 13). Most patients with endometriosis who require hysterectomy have unrelenting pelvic pain or dysmenorrhea. Other less common situations include patients who do not desire future fertility and who have endometriosis involving other pelvic organs, such as the ureter or colon. Hysterectomy with or without salpingo-oophorectomy provides significant pain relief to the majority of patients. At the time of hysterectomy for endometriosis, consideration should be given to conserving normalappearing ovaries (16).
Pelvic Mass or Benign Ovarian Tumor
If a pelvic mass is palpated on pelvic examination, a transvaginal ultrasound should be performed (see Chapter 10). If the mass is suspicious, appropriate consultation with a gynecologic oncologist is recommended. Benign-appearing ovarian tumors that are persistent or symptomatic require surgical treatment. If the patient desires fertility, the uterus should be conserved. If fertility is not an issue or if the patient is perimenopausal or postmenopausal, a decision must be made regarding whether the uterus should be removed. In one study, 100 patients who underwent bilateral salpingo-oophorectomy plus hysterectomy for benign adnexal disease were compared with a group of risk-matched women who underwent bilateral salpingo-oophorectomy without hysterectomy for the same indication (17). There was a significant increase in operative morbidity, estimated blood loss, and the length of hospital stay for patients in whom hysterectomy was performed.
Pelvic Organ Prolapse
Hysterectomy is often performed for symptomatic pelvic organ prolapse at the time of pelvic floor reconstruction. Unless there is an associated condition requiring an abdominal incision, vaginal or laparoscopic hysterectomy is the preferred approach for pelvic organ prolapse. Following hysterectomy for prolapse, the vaginal apex must be suspended or the patient will likely have posthysterectomy prolapse. Uterine prolapse typically is not an isolated event and most often is associated with a variety of pelvic support defects. Each defect must be corrected to optimize the surgical outcome and decrease the risk of developing future pelvic support defects. Uterine-sparing approaches to pelvic organ prolapse have been studied (18,19).
PREOPERATIVE CONSIDERATIONS
The preoperative discussion should include an informed consent that documents the options, risks, benefits, alternatives, expected outcomes, and personnel involved with the procedure. The medical record should reflect the completion of childbearing and that adequate trial of medical or nonsurgical management was offered, attempted, or declined. Specific sterilization consent forms are required in most states.
Health Assessment
An assessment of a patient’s health status is important in order to obtain an optimal outcome after hysterectomy for benign disease. There are no routinely recommended tests, although individual hospitals may have their own requirements. The patient should be evaluated for risk factors associated with venous thromboembolic events (20). Age, medical history, such as inherited or acquired thrombophilias, obesity, smoking, and hormonal medication, including contraceptives or hormone therapy, may increase the risk. It is important to assess and correct underlying anemias before surgery. Blood product use can be minimized with preoperative iron supplementation or the use of GnRH agonists.
Hysterectomy Versus Supracervical Hysterectomy
There is a trend toward retention of the cervix at hysterectomy because of the perception that several outcome parameters, including sexual function and pelvic support, are better after a supracervical hysterectomy. Three prospective randomized clinical trials as summarized in a Cochrane review challenge this perception (21). [4] There is no evidence to support the concept that leaving the cervix improves sexual function or lower rates of incontinence or constipation. All of these studies included hysterectomies that were performed by laparotomy.
The Cochrane review did find that surgical time was decreased by approximately 11 minutes. This decreased surgical time may be more significant for laparoscopic cases, as the most difficult part of the surgery is the detachment of the cervix from the lateral ligaments and from the vagina. This is where most ureteral injuries occur during laparoscopic hysterectomy. This advantage should be balanced with the potential risk of ongoing cyclic bleeding from the cervix that is reportedly between 5% and 20% from the randomized clinical trials and 19% from a prospective observational laparoscopic trial (22). With conservation of the cervix, the patient should be told there is a potential 1% to 2% risk for reoperation to remove the cervix and that trachelectomy is associated with a risk of intraoperative complications. Patients with suspected gynecologic cancers, endometrial hyperplasia, or cervical dysplasia are not candidates for supracervical hysterectomy.
Prophylactic Salpingo-Oophorectomy
The decision to remove the ovaries and tubes should be based on assessment of risk and not the route of hysterectomy (23). Premenopausal women who are at average risk of ovarian cancer (approximate lifetime risk of 1.4%) should have their ovaries preserved when they are undergoing hysterectomy for benign conditions where the ovaries and fallopian tubes are healthy (23). Elective removal of the ovaries at the time of hysterectomy has declined with 53% having no adnexal surgery (4). Elective salpingectomy at the time of hysterectomy has increased (4).
Salpingo-oophorectomy can be performed prophylactically to reduce the risk of ovarian cancer and to eliminate the potential for further surgery for either benign or malignant disease. Arguments against prophylactic salpingo-oophorectomy center on the need for earlier and more prolonged hormone therapy, the potential increased risk of cardiovascular disease and bone loss and poor compliance with long-term estrogen replacement therapy (24). [5] There is no overall survival benefit of prophylactic salpingo-oophorectomy in women at average risk for ovarian cancer. In premenopausal women younger than 50 years at average risk for ovarian cancer who underwent bilateral salpingo-oophorectomy, there was a significant increase in mortality from cardiovascular disease compared to women who had ovarian preservation (24). A Markov decision analysis model was used to estimate the best strategy for maximizing a woman’s survival when salpingooophorectomy is considered in women at average risk for ovarian cancer who are undergoing hysterectomy for benign disease, and in the women who had salpingo-oophorectomy before age 55 years, there was an 8.58% excess mortality by age 80 (25). The American College of Obstetricians and Gynecologists and the Society of Gynecologic Oncologists recommend carefully assessing risk, and considering ovarian conservation in premenopausal women who are at average risk of ovarian cancer (23,26).
Because salpingo-oophorectomy is associated with a reduced risk of ovarian and breast cancer, women with a strong family history of ovarian and breast cancer and those who carry germline mutations, BRCA1 or BRCA2, should consider risk-reducing salpingo-oophorectomy as their lifetime risk of ovarian cancer is between 10% and 50% (23,26–28). A genetic counselor or gynecologic oncologist can provide an individual risk assessment.
Based on the finding that many serous carcinomas arise in the fallopian tube rather than in the ovary, it was proposed that bilateral salpingectomy with ovarian conservation should be performed in patients with these high penetrance germline mutations while awaiting more definitive surgical intervention (29). Opportunistic bilateral salpingectomy in average-risk women has been associated with decreased rates of ovarian cancer in population-based cohort data (30). This potential benefit of salpingectomy should be discussed with patients prior to hysterectomy for benign disease.
Although salpingo-oophorectomy and salpingectomy can be accomplished by laparoscopy or laparotomy in nearly 100% of cases, the success rate for vaginal hysterectomy ranges from 65% to 95% for experienced vaginal surgeons (31,32).
Concurrent Surgical Procedures
Pelvic Support Procedures
Patients with pelvic organ prolapse should be offered surgical repair of prolapse at the time of hysterectomy. Typically pelvic support procedures are performed after the completion of the hysterectomy. Patients with pelvic organ prolapse must have a thorough preoperative evaluation that details bladder and bowel function and an examination that describes all pelvic floor defects. Procedures to treat pelvic organ prolapse or incontinence should be performed by a surgeon who regularly performs these operations (33).
Appendectomy
Appendectomy may be performed concurrently with hysterectomy to prevent appendicitis and to remove disease that may be present. The former use is of limited value because the peak incidence of appendicitis is between 20 and 40 years of age, whereas the peak age for hysterectomy is 10 to 20 years later. However, there is no increase in morbidity associated with appendectomy performed at the time of hysterectomy.
Cholecystectomy
Gallbladder disease is about four times more common in women than men, and its highest incidence occurs between 50 and 70 years of age, when hysterectomy is most often performed. Women may require both procedures and a combined procedure does not appear to result in increased febrile morbidity or length of hospital stay.
Abdominoplasty
Abdominoplasty performed at the time of hysterectomy is associated with a shorter hospital stay, a shorter operating time, and a lower intraoperative blood loss than when the two operations are performed separately. Liposuction can be performed safely at the time of hysterectomy.
Tissue Extraction Techniques
Morcellation of the enlarged uterus has allowed minimally invasive approaches to hysterectomy. This can be accomplished by simple scalpel or with a power morcellator. The U.S. Food and Drug Administration (FDA) has discouraged the use of a power morcellator because of concerns of prognosis if the tissue contains uterine sarcomas (34). Following FDA communications, utilization of minimally invasive approaches has decreased in patients that have a large uterus that cannot be easily delivered vaginally. The frequency of supracervical hysterectomy has also decreased (35,36). However, based on many reports, including a large analysis of over 30,000 women by Pritts et al. (37), the Agency for Healthcare Research and Quality (AHRQ) Report on the Management of Uterine Fibroids (38) concluded that an unexpected leiomyosarcoma will be identified in fewer than 1 and up to 13 of every 10,000 surgeries performed for symptomatic fibroids, and that it is unclear whether the type of morcellation impacts the survival of women with this poor prognosis malignancy. Contained tissue extraction techniques have been introduced in the belief that this could reduce the risk of power morcellation of the large uterus (39). Uterine morcellation is still widely used with vaginal extraction (40). Choice of Surgical Access: Vaginal, Abdominal, or Laparoscopic
Hysterectomy
Increased utilization of the minimally invasive approach to hysterectomy by laparoscopy or robotic assistance has decreased hysterectomy rates by laparotomy. Vaginal hysterectomy rates have been stable. There are no specific criteria that can be used to determine the route of hysterectomy. The route chosen should be based on the individual patient, but the vaginal approach is preferred, when feasible. Characteristics that make the vaginal approach more challenging include a narrow pubic arch (less than 90 degrees), a narrow vagina (narrower than two fingerbreadths, especially at the apex), and uterine immobility. The presence of an adnexal mass, cul-de-sac disease, pelvic adhesions, or the assessment of chronic pain may require the addition of laparoscopy for assessment. A previous cesarean section or nulliparity does not contraindicate a vaginal approach (Table 27-2) (41).
Table 27-2 General Factors Influencing the Route of Hysterectomy for Benign Disease
Vaginal shape and accessibility to the uterus
Uterine size and shape
Extent of extrauterine disease and need for concurrent procedures
Other clinical factorsa
Surgeon competence and available support facilities
Preference of the informed patient
Examples include accessibility of laparoscopy or laparotomy as with prior abdominoplasty or hernia repair, hip disease limiting leg abduction, anesthesia issues, morbid obesity, other factors.
Table 27-3 Comparison of Three Approaches to Hysterectomy for Benign
Gynecologic Disease
Vaginal hysterectomy compared with abdominal hysterectomy
Shorter return to normal activities (mean difference –9.5 days, 95% CI –12.6 to –6.4)
Laparoscopic hysterectomy compared with abdominal hysterectomy
Shorter return to normal activities (mean difference –13.6 days, 95% CI –15.4 to –11.8)
More urinary tract injuries (odds ratio [OR] 2.4, 95% CI 1.2 to 4.8)
Laparoscopic hysterectomy compared with vaginal hysterectomy
No evidence of a difference between the groups for any primary outcomes
Robotic-assisted laparoscopic hysterectomy compared with laparoscopic hysterectomy
No evidence of a difference between the groups for any primary outcomes
Data from Aarts JWM, Nieboer TE, Johnson M, et al. Surgical approach to hysterectomy for benign gynecological disease. Cochrane Database Syst Rev 2015;
[2] A systematic review validated the perception that vaginal hysterectomy is the surgical route of choice for hysterectomy (42). There were 24 manuscripts comparing laparoscopic with vaginal hysterectomy. Outcomes and complications were similar with vaginal hysterectomy, which is a less expensive approach. Vaginal hysterectomy has fewer perioperative complications compared with laparoscopic or robotic approaches, with laparotomy having the highest (43). Cost-analysis trials demonstrate that laparoscopic hysterectomy can be costeffective relative to the abdominal approach but not compared with vaginal hysterectomy (44). [3] Robotic surgery has shown no advantage over the conventional laparoscopic approach for hysterectomy (Table 27-3) 45).
The practice style and personal preferences of surgeons probably play a significant role in selection of hysterectomy type. With appropriate evidencebased treatment guidelines and adequate surgical education and skill, the proportion of hysterectomies performed vaginally can be increased (46,47). Adopting published guidelines for choosing the route of hysterectomy increased the proportion of hysterectomies performed vaginally to over 90% and reduced the ratio of abdominal to vaginal hysterectomy from 3:1 to 1:11 (48).
PERIOPERATIVE CHECKLIST
It is important to systematically perform a checklist of perioperative measures to effectively reduce potential complications (Table 27-4). If excessive blood loss is expected, intraoperative blood salvage techniques should be considered. All patients undergoing hysterectomy for benign disorders are at (at least) moderate risk for venous thromboembolism and require prophylaxis (20). Mechanoprophylaxis (intermittent pneumatic compression devices) or chemoprophylaxis (unfractionated heparin or low–molecular-weight heparin) or a combination of chemoprophylaxis and mechanoprophylaxis are indicated, depending on the patient’s risk. Patients on oral contraceptives up to the time of hysterectomy should be considered for chemoprophylaxis. Minimally invasive hysterectomy is associated with a decreased incidence of venous thromboembolism. However, prolonged operative time may dampen the benefit
(49). Mechanical bowel preparation for prevention of infection complications from bowel injury is not recommended (50).
Table 27-4 Perioperative Checklist
1. Is the informed consent signed specifically stating the disposition of the ovaries?
2. Is cervical cancer screening up to date?
3. Documentation that future fertility is not desired
4. Documentation of laboratory results indicating that the patient is not pregnant
5. Are blood products available if needed?
Appropriate antibiotic selected according to American College of Obstetricians and Gynecologists guidelines
7. Was the appropriate prophylaxis for venous thromboembolic events chosen?
8. Document that prophylactic antibiotics will be discontinued within 24 hrs after surgery
9. Documentation of discontinuing the Foley catheter within 24 hrs
TECHNIQUE
Abdominal Hysterectomy
General Preparation
Surgical site infections occur in 2% of hysterectomies. Obesity, diabetes, smoking, steroid use, poor nutrition and prior surgery all increase the risk (51). Excellent glycemic control in diabetics can lower the frequency of infection in this population. To reduce the colony count of skin bacteria, the patient is asked to wash or bathe with chlorhexidine preoperatively (51). Although treating all patients with bacterial vaginosis may decrease vaginal cuff cellulitis, universal screening preoperatively awaits further clinical trials (51). Hair surrounding the incision area may be removed at the time of surgery with a hair clipper. The area should not be shaved.
Preoperative antibiotics are given, typically a single dose 30 to 60 minutes before skin incision. Cefazolin 1 to 2 g and increased to 3 g for obese patients is recommended. Alternatives should be given for patients with severe penicillin allergies. Redosing is recommended after 3 hours of surgery and with excessive bleeding (52).
Skin Preparation
Chlorhexidine-alcohol–based skin preparations have a lower odds of surgical site infection compared with povidone-iodine preparations. Concentrations of 4% or less can be used in the vagina (51).
Patient Positioning
For most abdominal cases, the patient is placed in the dorsal supine position for the operation. After the patient is anesthetized adequately, her legs are placed in the stirrups and a pelvic examination is performed to validate the in-office pelvic examination findings. A Foley catheter is placed in the bladder, and the vagina is cleansed with a chlorhexidine alcohol or iodine solution. The patient’s legs are straightened.
Surgical Technique
Incision
The choice of incision should be determined by the following considerations:
1. Simplicity of the incision
2. Need for exposure
3. Potential need for enlarging the incision
4. Strength of the healed wound
5. Cosmetics of the healed incision
6. Location of previous surgical scars
The skin is opened with a scalpel, and the incision is carried down through the subcutaneous tissue and fascia. With traction applied to the lateral edges of the incision, the fascia is divided. The peritoneum is opened similarly. This technique minimizes the possibility of inadvertent enterotomy while entering the abdominal cavity.
Abdominal Exploration
Cytologic sampling of the peritoneal cavity, if needed, should be performed before abdominal exploration. The upper abdomen and the pelvis are explored systematically. The liver, gallbladder, stomach, kidneys, para-aortic lymph nodes, and large and small bowel should be examined and palpated.
Retractor Choice and Placement
A variety of retractors were designed for pelvic surgery. The Balfour and the O’Connor–O’Sullivan retractors are used most often. The Bookwalter retractor has a variety of adjustable blades that can be helpful, particularly in obese patients. Figure 27-1 demonstrates pertinent anatomy.
Elevation of the Uterus
The uterus is elevated by placing broad ligament clamps at each cornu so that it crosses the round ligament (Fig. 27-2 inset).
Round Ligament Ligation or Transection
The uterus is deviated to the patient’s left side, stretching the right round ligament. With the proximal portion held by the broad ligament clamp, the distal portion of the round ligament is ligated with a suture ligature or simply transected with an electrosurgical device (Fig. 27-2). The distal portion can be grasped with forceps, and the round ligament is cut to separate the anterior and posterior leaves of the broad ligament. The anterior leaf of the broad ligament is incised with Metzenbaum scissors or electrosurgery along the vesicouterine fold, separating the peritoneal reflection of the bladder from the lower uterine segment (Fig. 27-2).
FIGURE 27-1 Surgical view of pertinent anatomy in abdominal and laparoscopic hysterectomy.
FIGURE 27-2 The uterus is elevated by placement of clamps across the round and uteroovarian ligaments. The round ligament is transected and the anterior broad ligament is incised and opened (inset).
Ureter Identification
The retroperitoneum is entered by extending the incision cephalad on the posterior leaf of the broad ligament. Care must be taken to remain lateral to the infundibulopelvic ligament and iliac vessels. The external iliac artery courses along the medial aspect of the psoas muscle and is identified by bluntly dissecting the loose alveolar tissue overlying it. By following the artery cephalad to the bifurcation of the common iliac artery, the ureter is identified crossing the common iliac artery. The ureter should be left attached to the medial leaf of the broad ligament to protect its blood supply (Fig. 27-3).
Utero-Ovarian Vessel and Ovarian Vessel (Infundibulopelvic Ligament) Ligation
If the ovaries are to be preserved, the uterus is retracted toward the pubic symphysis and deviated to one side, placing tension on the contralateral ovarian vessels (also called infundibulopelvic ligament), the tube, and the ovary. If the fallopian tube is taken, the mesosalpinx is incised with progressive clamping, cutting, and ligating. The tube is left attached to the uterus. With the ureter under direct visualization, the utero-ovarian ligaments are clamped on each side with a curved Heaney or Ballantine clamp, cut, and ligated with a free-tie and a suture ligature. The medial clamp at the uterine cornua should control back bleeding; if it does not, the clamp should be repositioned to do so (Fig. 27-3A).
If the ovaries are to be removed, the peritoneal opening is enlarged and extended cephalad to the ovarian vessels (infundibulopelvic ligament) and caudad to the uterine artery. This opening allows proper exposure of the uterine artery, the ovarian vessels, and the ureter. In this manner, the ureter is released from its proximity to the uterine vessels and ovarian vessels. A curved Heaney or Ballantine clamp is placed lateral to the ovary (Fig. 27-3B); care is taken to ensure that the entire ovary is included in the surgical specimen.
Bladder Mobilization
Using Metzenbaum scissors or an electrosurgical device, the bladder is dissected from the lower uterine segment and cervix. An avascular plane, which exists between the lower uterine segment and the bladder, allows for this mobilization. Tonsil clamps may be placed on the bladder edge to provide counter traction and easier dissection.
FIGURE 27-3 The incision in the anterior broad ligament is extended along the vesicouterine peritoneal fold. When an ovarian-sparing hysterectomy is planned, the uteroovarian ligament is cross-clamped (A). When bilateral salpingo-ophorectomy is planned, the infundibuloligament is cross-clamped (B).
FIGURE 27-4 Identification of the ureter in the retroperitoneal space on the medial leaf of the broad ligament. The course of the ureter is traced and the uterine vessels are skeletonized prior to ligating the uterine vessels.
Uterine Vessel Ligation
The uterus is retracted cephalad and deviated to one side of the pelvis, stretching the lower ligaments. The uterine vasculature is dissected or “skeletonized” from any remaining areolar tissue, and a curved Zeppelin or Heaney clamp is placed perpendicular to the uterine artery at the junction of the cervix and body of the uterus. Care is taken to place the tip of the clamp adjacent to the uterus at this anatomic narrowing (Fig 27-4). The vessels are cut, and the pedicle is ligated.
The same procedure, beginning with the round ligament is repeated on the contralateral side.
FIGURE 27-5 Ligation of the cardinal and uterosacral ligaments.
FIGURE 27-6 Removal of the uterus by transection of the vagina.
Incision of Posterior Peritoneum
If the rectum is to be mobilized from the posterior cervix, the posterior peritoneum between the uterosacral ligaments just beneath the cervix and rectum may be incised. A relatively avascular tissue plane exists in this area, allowing mobilization of the rectum inferiorly out of the operative field.
Cardinal Ligament Ligation
The cardinal ligament is divided by placing a straight Zeppelin or Heaney clamp medial to the uterine vessel pedicle for a distance of 2- to 3-cm parallel to the uterus. The ligament is cut, and the pedicle is suture ligated. This step is repeated on each side until the junction of the cervix and vagina is reached (Fig. 27-5).
Removal of the Uterus
The uterus is placed on traction cephalad, and the tip of the cervix is palpated. Curved Heaney clamps are placed bilaterally, incorporating the uterosacral ligament and upper vagina just below the cervix. Care should be taken to avoid foreshortening the vagina. The uterus is removed with scalpel or curved scissors (Fig. 27-6).
Vaginal Cuff Closure
A figure-of-eight suture of 0 braided absorbable material is placed at the angle of the vagina for traction and hemostasis. The pedicles are sutured with a Heaney stitch, incorporating the uterosacral and cardinal ligament at the angle of the vagina (Fig. 27-7). A running-locked or figure-of-eight sutures can be used for hemostasis along the cuff edge (Fig. 27-7).
Irrigation and Hemostasis
The pelvis is thoroughly irrigated with saline. Meticulous hemostasis in the pelvis, particularly of the vascular pedicles, should be ensured. Ureteral position and integrity are checked to ensure that they are intact and do not appear dilated.
Peritoneal Closure and Fascia Closure
The pelvic peritoneum is not reapproximated. The parietal peritoneum is not reapproximated as a separate layer. Fascia can be closed with an interrupted or continuous 0 or 1 monofilament absorbable suture. A prospective randomized trial did not show any advantage of interrupted versus continuous fascial closure (53). Bites should be taken about 1 cm from the cut edge of the fascia and about 1 cm apart to prevent wound dehiscence.
FIGURE 27-7 Vaginal cuff closure incorporating the uterosacral and cardinal ligaments.
Skin Closure
The subcutaneous tissue should be irrigated, with careful hemostasis. Wound disruption seems to be decreased with closure of the subcutaneous fat layer in women with 2 cm or more fat (54). Skin staples or subcuticular sutures are used to reapproximate the skin edges. A dressing is applied and left in place for about 24 hours.
Intraoperative Complications
Every surgeon must be prepared to recognize and repair operative injuries, because despite a high level of attention to detail, injuries and complications, recognized and unrecognized, can still occur.
Ureteral Injuries
Ureter injuries usually occur at three separate areas: at the pelvic brim as it crosses over the common iliac vessels, in the midpelvis as the uterine artery crosses over it, and near the cervix at the internal os. Most ureteral injuries can be avoided by opening the retroperitoneum and directly identifying the ureter. The use of ureteral catheters as a substitute for direct visualization is often of little help in patients with extensive fibrosis or scarring resulting from endometriosis, pelvic inflammatory disease, or ovarian cancer. In these instances, a false sense of security may increase an already high risk for ureteral injury. The use of ureteral catheters is associated with hematuria and acute urinary retention, although their complications are usually temporary in nature.
Direct visualization is accomplished by opening the retroperitoneum lateral to the external iliac artery. Blunt dissection of the loose areolar tissue is performed to visualize the artery directly. The artery may be traced cephalad to the bifurcation of the internal and external iliac arteries. The ureter crosses the common iliac artery at its bifurcation and may be followed throughout its course in the pelvis.
Despite these precautions, ureteral injuries may occur. Prompt consultation is necessary if the surgeon is not trained in ureteral repair. If a ureteral obstruction is suspected, confirmation may be obtained by intravenous injection of sodium fluorescein or indigo carmine followed by cystoscopy to demonstrate a brilliant colored ureteral jet minutes after injection. The integrity of the ureters should be confirmed by the presence or absence of bilateral spill of tinted urine. Thermal injury is not usually detected with this test and may present days after the hysterectomy.
Bladder Injury
Because of the close anatomic relationship of the bladder, uterus, and upper vagina, the bladder is the segment of the lower urinary tract that is most vulnerable to injury. Bladder injury may occur on opening the peritoneum or, more frequently, during the dissection of the bladder off the cervix and upper vagina. Unless there is involvement of the bladder trigone, a bladder laceration is easily repaired. In the nonirradiated bladder, a one- or two-layer closure with a small-caliber braided absorbable suture such as a 3-0 polyglycolic acid is adequate. The bladder should be drained postoperatively. The length of time that drainage is required is controversial. If the bladder is not compromised, drainage should be continued at least until gross hematuria clears, which may occur as soon as 48 hours postoperatively. A more conservative practice is to continue drainage for 3 to 14 days, depending on the type of injury. The use of routine cystoscopy to diagnose an unsuspected ureter or bladder injury has been proposed by several groups. In low-risk patients that do not undergo pelvic floor procedures the probability of identifying an unsuspected injury is small (55).
Bowel Injury
Small bowel injuries are the most common intestinal injuries in gynecologic surgery. Small defects of the serosa or muscularis may be repaired using a single layer of continuous or interrupted 3-0 braided absorbable suture. Although single-layer closure of the small bowel has proved adequate, it is safer to close defects involving the lumen in two layers using a 3-0 braided absorbable suture. The defect should be closed in a direction perpendicular to the intestinal lumen. If a large area is injured, resection with reanastomosis may be necessary.
The transverse colon rarely is injured in normal gynecologic procedures because it is well outside the operative field. However, the descending colon and the rectosigmoid colon are intimately involved with the pelvic structures and are at significant risk for injury during gynecologic surgery. Injuries not involving the mucosa may be repaired with a single running layer of 2-0 or 3-0 braided absorbable suture. If the laceration involves the mucosa, it may be closed as with small bowel injuries.
Hemorrhage
Significant arterial bleeding usually arises from the uterine arteries or the ovarian vessels near the insertion of the infundibulopelvic ligaments. Blind clamping of these vessels presents a risk for ureteral injury; therefore, the ureters should be identified in the retroperitoneal space and traced to the area of bleeding to avoid inadvertent ligation. It is best to apply a pressure pack to tamponade the bleeding and slowly remove the pack in an effort to visualize, isolate, and individually clamp the bleeding vessels. Mass ligatures should be avoided. The use of surgical clips may be helpful. Venous bleeding is less dramatic but often is more difficult to manage, particularly in the presence of extensive adhesions and fibroids. This type of bleeding can be controlled with pressure alone or with suture ligation. Bleeding from peritoneal edges or denuded surfaces may be controlled with pressure, application of topical agents such as thrombin or collagen, or electrosurgery.
Postoperative Management
Bladder Drainage
Overdistention of the bladder resulting from bladder trauma or the patient’s reluctance to initiate the voluntary phase of voiding is one of the most common complications after abdominal hysterectomy. An indwelling bladder catheter can be used for the first few postoperative hours until the patient is able to ambulate and urinate but should be removed within 24 hours. If urogynecologic procedures such as a retropubic urethropexy are performed, a catheter may be needed for a longer period of time. This catheter may be removed when satisfactory postvoid residual levels of less than 100 mL are obtained.
Postoperative Pain Management
Postoperative pain control is a critical part of a satisfactory surgical outcome. Ideally, it starts perioperatively and is initiated at any time before the hysterectomy is completed as surgical length and intraoperative blood loss are not affected (56). Although hospital length of stay is not affected by the use of preemptive analgesia, it decreases the use of postoperative opioid analgesics and improves pain assessment. The recommended medications for preemptive use are gabapentin, acetaminophen, and COX-2 inhibitors. Preemptive opioids such as fentanyl resulted in lower postoperative pain scores and use of opioids. In patients with a higher risk of nausea and vomiting preemptive antiemetics such as promethazine should be administered.
Diet
As soon as the patient is alert, diet is resumed, offering solid foods as tolerated with return of appetite. Early postoperative feeding was shown to be safe and to speed return of bowel function and recovery.
Activity
Early ambulation decreases the incidence of thrombophlebitis and pneumonia. Patients are encouraged to begin ambulation on their first postoperative day if possible and to increase their time out of bed progressively as their strength improves. On discharge, the patient is instructed to avoid lifting more than 20 pounds for 6 weeks, thereby minimizing stress on the fascia to allow full healing. Sexual intercourse is not recommended until at least 6 weeks after surgery, when the vaginal cuff is fully healed. Patients are instructed to avoid driving until full mobility returns because postoperative pain and tenderness may hinder sudden braking or steering maneuvers in emergency situations. With these exceptions, the patient is encouraged to return to normal activities as soon as she feels comfortable doing so.
Wound Care
The abdominal incision normally requires little attention, except for ordinary hygienic measures. The wound is kept covered with a sterile dressing for the first 24 hours after surgery, by which time the incision has sealed. After the dressing is removed, the incision should be cleaned daily with mild soap and water and kept dry.
Vaginal Hysterectomy
Preoperative Evaluation
Evaluation of Uterine Descent, Uterine Size and Shape, and Bony Structure The vaginal approach to hysterectomy is appropriate for many hysterectomy indications. The one disadvantage is that the vaginal approach precludes visual evaluation of the abdominal cavity. When considering vaginal hysterectomy, it is critical to determine if vaginal hysterectomy is feasible. Though the best evaluation occurs under anesthesia immediately prior to hysterectomy, office evaluation suffices in most cases. Office evaluation includes bimanual examination to assess uterine mobility, evaluation of the bony pelvis, and review of available imaging. Of these components, uterine mobility is the most important factor in determining the feasibility of a vaginal hysterectomy.
Often at the initial pelvic examination, uterine descent may not be obvious. In patients with no apparent prolapse, poor pelvic support can often be demonstrated by observing descent of the uterus with a series of Valsalva or strong cough maneuvers. Although vaginal hysterectomy is easier to perform when the uterine support ligaments are lax, it is not an absolute requirement. Some surgeons advocate the practice of applying traction to the cervix with a tenaculum to demonstrate descent of an apparently well-supported uterus, however, this is not recommended as it is uncomfortable and not necessarily predictive of success of the vaginal approach to hysterectomy. Uterine size and shape should be carefully considered when contemplating whether the vaginal approach to hysterectomy is feasible. If the office examination is not adequate as a result of patient body habitus, imaging can be helpful. The most critical aspect of uterine size and shape is the width of the uterus, specifically in the lower uterine segment, because one must control the blood supply (uterine vessels) before morcellating, which is often required in an enlarged uterus. Typically, it is difficult to clamp the uterine arteries if the width of this area is >9 to 10 cm, because this width often will not allow enough descent to safely ligate these vessels. There is no firm upper limit on the vertical measurement of the uterus but most surgeons are not comfortable with the vaginal approach if the uterine size is greater than 16 to 18 weeks.
Assessment of the bony pelvis should be performed. Ideally, the angle of the pubic arch should be 90 degrees or greater and the bituberous diameter, should exceed 10 cm. The size and shape of the female pelvis contributes to increased exposure. The importance of a wide pubic arch was underscored by the result of a study of 25 failed vaginal hysterectomies that were compared with 50 successful vaginal hysterectomies. Risk factors, such as age, parity, body weight, surgical indication, uterine size, presence of leiomyomata in the anterior lower uterine segment, previous pelvic surgeries, adhesions, location and length of the cervix, and narrow pubic arch (less than 90 degrees), were examined. In the study, only the presence of a narrow pubic arch increased the risk of failed vaginal hysterectomy (57).
No additional work-up (laboratory, imaging) specific to the vaginal approach is required. In cases where the surgeon is uncertain if the vaginal approach to hysterectomy can be successfully performed, a patient may be consented for “hysterectomy, vaginal or laparoscopic/abdominal approach.” A more thorough evaluation can be performed under anesthesia and the final determination of approach can be made at the time of surgery.
FIGURE 27-8 The patient in high lithotomy position. Care is taken to not overflex or overextend at the hips and knees.
Perioperative Considerations
Patient Positioning
When the patient is in the dorsal lithotomy position, the buttocks should be positioned just over the table’s edge (Fig. 27-8). Several stirrup types are available, including those that support the entire leg and those that suspend the feet in straps. The advantage of the stirrups that suspend the feet in straps is that it allows two assistants to actively assist during the hysterectomy. To avoid nerve injury, adequate padding should be used; flexion at the hip should be >60 degrees and flexion at the knee should range from 90 to 120 degrees and pressure points should be avoided. Trendelenburg (10- to 15-degree) positioning aids in the intravaginal visualization needed during surgery.
Examination Under Anesthesia and Patient Preparation
When the patient is positioned, a thorough examination under anesthesia is performed. In most cases, it is much easier to determine uterine mobility, uterine descent, and uterine size and shape at this time. A tenaculum can be placed on the cervix to thoroughly evaluate uterine descent without causing the patient discomfort.
The pubic hair is clipped from the labia majora from the clitoris to the perineal body to prevent the pubic hair from compromising the field.
A dilute 4% chlorhexidine-alcohol is applied to the vagina, vulva, mons, inner thigh, perineal, and anal areas (51). A Foley catheter is inserted into the bladder. Several methods for draping are proposed, including individual or single-piece drapes; the method chosen is at the surgeon’s discretion, though an adhesive barrier surrounding the operative site should be used.
Instruments
Instruments specific to and useful in performing a vaginal hysterectomy include weighted specula, single- or double-toothed tenacula, right-angled retractors, Heaney needle holders, and Breisky–Navratil vaginal retractors. Heaney and Heaney–Ballantine hysterectomy clamps are preferable. Curved Mayo scissors, Russian pick-ups, rat-tooth pick-ups, and scissors to cut suture will also be used.
Some surgeons advocate the use of a vessel-sealing device and data are accumulating. These instruments may be helpful in cases of big uteri and have been shown to decrease operative time, but increase the cost of the operation, and may not be necessary in an average case.
Lighting
Overhead high-intensity lamps should be used and positioned to direct light over the operator’s shoulder. The surgeon may use a headlight, which can be worn to provide direct horizontal lighting. A fiberoptic-lighted irrigating suction system can provide additional light.
Suture Material
Various suture materials are advocated for gynecologic surgery. The type of suture material chosen is based on the surgeon’s preference. A synthetic-delayed– absorbable polyglactin or polyglycolic acid suture and tapered needles are preferable.
Procedure
Grasping and Circumscribing the Cervix
A short-weighted speculum in placed in the vagina. Sidewall retractors are placed lateral to the cervix. The anterior and posterior lips of the cervix are grasped with a single- or double-toothed tenaculum. With downward traction applied on the cervix, the locations of the bladder and posterior cul-de-sac are evaluated (Fig. 27-9). The incision should be made at least 1-cm distal to the bladder and with the goal of preserving vaginal length. If the initial incision is made too close to the external cervical os, a greater amount of dissection is required and anterior and posterior peritoneal entry can be challenging. In cases where the bladder location cannot be determined, the Foley catheter can be manipulated, the bladder can be back-filled, or a uterine sound can be bent and inserted into the bladder. The epithelium of the planned incision is injected with dilute local anesthetic and epinephrine. A circumferential incision is made in the vaginal epithelium at the junction of the cervix (Fig. 27-9). The incision is carried slightly toward the cul-de-sac at the posterior cervix in order to facilitate posterior entry (Fig. 27-9 inset).
Dissection of Vaginal Epithelium
After the initial incision is made with a scalpel, additional dissection perpendicular to the cervix may be required to reach the right plane. The goal is to divide all tissue to the level of the cervical stroma. When the cervical stroma is reached, the vaginal epithelium may be dissected sharply from the underlying cervix using curved Mayo scissors. This will be performed circumferentially.
FIGURE 27-9 A tenaculum is placed on the cervix. A circumferential incision of the cervical epithelium is made.
FIGURE 27-10 The posterior peritoneum is identified and entered sharply. Interrupted suture is placed on posterior vaginal cuff and peritoneum for hemostasis.
Posterior Cul-de-Sac Entry
The posterior cul-de-sac is examined and the peritoneal reflection of the posterior cul-de-sac (cul-de-sac of Douglas) is identified. The vaginal portion of the epithelium is placed on traction and the peritoneum is entered sharply (Fig. 27-10). One finger is inserted to assure proper entry and the incision is extended sharply. The posterior peritoneum is secured to the posterior epithelium with a figure-of-eight suture for hemostasis and orientation. The posterior pelvic cavity is examined for pathologic alterations of the uterus or adhesive disease of the culde-sac.
If gaining posterior entry into the peritoneal cavity is difficult (e.g., if the cervix is elongated or the peritoneum is not evident), there are several options: (a) The hysterectomy may begin extraperitoneally by clamping and cutting the uterosacral and cardinal ligaments close to the cervix. This will often allow additional descent and the posterior cul-de-sac will be identifiable; (b) Entry into the anterior peritoneum can be performed first, and a finger can be hooked into the posterior cul-de-sac to place tension on the peritoneum; (c) The posterior cervix and vaginal epithelium may be incised vertically (from the cervix toward the cul-de-sac) to the point at which the cul-de-sac becomes more apparent.
Uterosacral Ligament Ligation
With retraction of the lateral vaginal wall and counter traction on the cervix, the uterosacral ligaments are clamped with the tip of the clamp incorporating the lower portion of the cardinal ligaments (Fig. 27-11). The clamp is placed perpendicular to the uterine axis, with the clamp tips touching the cervix, and the pedicle is cut and sutured close to the clamp. A small pedicle (<0.5 cm) distal to the clamp is optimal because a larger pedicle becomes necrotic.
When suturing any pedicle, the needle point is placed at the tip of the clamp, and the needle is passed through the tissue by a rolling motion of the operator’s wrist. The suture is moved around the back of the clamp, the needle is placed through the middle of the pedicle, and the suture is tied behind the clamp (Fig. 27-11 inset). This suture is held with a hemostat to identify the most inferior pedicle and facilitate localization of any bleeding at the completion of the procedure. A long weighted speculum is placed into the abdominal pelvic cavity (Fig. 27-12).
Entry into the Vesicouterine Space (Cul-de-Sac)
Downward traction is placed on the cervix. Using Mayo scissors, with the points directed toward the uterus, the anterior dissection is performed, separating the bladder from the uterus. When the correct plane is achieved, the dissection will become much easier and gentle dissection with one’s finger can be performed. If any resistance is encountered digitally, this is not the right plane and additional sharp dissection is required. After the bladder is advanced, a Heaney retractor is placed in the midline, holding the bladder out of the operative field (Fig. 27-13).
If the vesicouterine peritoneal reflection is identified at this point, it can be elevated with forceps, and the vesicouterine space may be entered sharply with scissors with tips pointed toward the uterus (Fig. 27-14). A finger is placed into the peritoneal cavity, proper entry is confirmed, and a Heaney retractor is placed between the uterus and the operator’s finger (Fig. 27-15). This retractor serves to keep the bladder out of the operative field.
FIGURE 27-11 The uterosacral ligament is cross-clamped, transected, and suture ligated (inset).
FIGURE 27-12 A long-weighted speculum is placed in the peritoneal cavity.
FIGURE 27-13 Dissection is carried along the cervix until the vesicouterine peritoneum is identified. A retractor protects the bladder.
FIGURE 27-14 The vesicouterine peritoneum is entered sharply.
FIGURE 27-15 A long right-angle retractor is placed in the peritoneal cavity to protect the bladder.
FIGURE 27-16 Clamps are advanced medial to the previous pedicle and the cardinal ligament and uterine vessels are ligated.
The anterior peritoneal cavity should not be opened blindly because of the increased risk of bladder injury. In cases where the peritoneum cannot be identified, there is no danger in delaying entry so long as the operator ascertains that the bladder is continually advanced prior to each additional pedicle.
Cardinal Ligament Ligation
With traction on the cervix continued, the cardinal ligaments are identified, clamped, cut, and suture ligated (Fig. 27-16). If possible, the anterior and posterior peritoneum is incorporated into the clamp during this step. This assists in anatomic definition and aids in hemostasis. If bowel is noted in the operative space, it can be packed cephalad using a moistened, tagged laparotomy sponge.
Uterine Artery Ligation
Contralateral and downward traction are placed on the cervix. With an effort to incorporate the anterior and posterior leaves of the visceral peritoneum, the uterine vessels are identified, clamped, cut, and the pedicle is suture ligated. A single suture and single clamp technique is adequate and decreases the potential risk for ureteral injury. When the uterus is large or when a fibroid distorts the anatomic relationships, a second suture may be required to ligate any remaining branches of the uterine artery. With the posterior and anterior peritoneum opened, the remainder of the broad ligament and uteroovarian ligaments are clamped, cut, and ligated.
Delivery of the Uterus
A tenaculum is placed onto the uterine fundus to deliver the fundus posteriorly (Fig. 27-17). The operator’s index finger is used to identify the utero-ovarian ligament and aid in clamp placement.
FIGURE 27-17 The uterine fundus is grasped, traction is placed inferiorly, delivering the fundus posteriorly. The surgeon’s finger is placed behind the utero-ovarian ligament, allowing the surgeon to place the clamp tip against her index finger and safely deliver the clamp around the pedicle.
FIGURE 27-18 The utero-ovarian ligaments are cross-clamped, transected, and suture ligated.
Utero-ovarian and Round Ligament Ligation
In order to atraumatically place the clamp, the clamp tips can be placed on the operator’s index finger, which can guide the clamp in the correct plane (Fig. 27- 17). The utero-ovarian and round ligament complexes are cut (Fig. 27-18) and double ligated with a suture tie followed by a ligature medial to the first suture (Fig. 27-18, inset). If the pedicle is large, the surgeon may consider having the assistant briefly flash the second clamp while the first tie is placed, in order to assure the pedicle is secure. A hemostat is placed on the sutures to define this as the upper pedicle and aid in the identification of any bleeding (Fig. 27-19).
Removal of the Ovaries and/or Fallopian Tubes
During the removal of the adnexa, the round ligaments should be separated from the adnexal pedicles. Traction is placed on the utero-ovarian pedicle. If the uterus has been removed, the round ligament portion of the utero-ovarian pedicle can be clamped lateral to the suture ligation. This smaller pedicle can be cut and independently ligated. The ovary is drawn medially into the operative field by grasping it with a Babcock clamp. A Heaney clamp is placed across the ovarian vessels (infundibulopelvic ligament), and the ovary and tube are excised (Fig. 27- 20). A transfixion tie and suture ligature are placed on the ovarian vessels. In cases where the adnexa is high or the pedicle is too large to be taken safely, the surgeon may take several bites along the mesosalpinx until the infundibulopelvic ligament can be isolated and safely ligated (31). Care must be taken during these steps as the mesosalpinx is delicate and prone to shearing. If the surgeon wishes to perform opportunistic salpingectomy, a similar technique can be used. The round ligament is isolated and the ovary is retracted medially. The fimbria is identified, grasped, and moved caudad. With the entire fallopian tube in view, the surgeon places a clamp across the mesosalpinx lateral to the fallopian tube, not including the infundibulopelvic ligament. This pedicle is cut and the suture ligated.
FIGURE 27-19 All pedicles are inspected for hemostasis. The most superior pedicle is the utero-ovarian ligament and the most inferior pedicle is the uterosacral ligament.
FIGURE 27-20 The infundibulopelvic ligament is ligated.
Hemostasis
A retractor or tagged sponge is placed into the peritoneal cavity, and each of the pedicles is visualized and inspected for hemostasis. Having previously tagged the most superior and inferior pedicles aids in assuring that all pedicles are evaluated (Fig. 27-19). Additional sutures may be placed to obtain hemostasis. These can be placed freely or an Allis clamp or Tonsil clamp can be placed on the bleeding area.
Peritoneal Closure
Because the pelvic peritoneum does not provide support and reforms within 24 hours after surgery, the peritoneum need not be reapproximated routinely.
McCall Culdoplasty
McCall culdoplasty prevents and treats vaginal apex prolapse and should be performed following vaginal hysterectomy when feasible (58,59). An absorbable suture is placed through the full thickness of the posterior vaginal wall at the point of the highest portion of the vaginal vault. The patient’s left uterosacral ligament pedicle is identified and a suture is placed lateral to medial through the ligament. The suture is run toward the patient’s right side incorporating the posterior peritoneum, between the uterosacral ligaments. The right uterosacral ligament is identified and the suture is placed lateral to medial through the right uterosacral ligament. The suture is passed from the inside to the outside at the same point at which it was begun and tagged (Fig. 27-21).
FIGURE 27-21 A McCall culdoplasty is placed.
FIGURE 27-22 Closure of the vaginal cuff.
Vaginal Epithelial Closure
The vaginal epithelium can be reapproximated in a vertical or horizontal manner, using either interrupted or continuous sutures (Fig. 27-22). The vaginal epithelium is, in this case, reapproximated horizontally using a running locked suture. Care must be taken not to place sutures through the previously placed McCall culdoplasty suture as it will make it difficult to tie down the McCall suture following cuff closure. The epithelial closure sutures are placed through the entire thickness of the vaginal epithelium, with care taken to avoid entering the bladder anteriorly. These sutures will obliterate the underlying dead space and produce an anatomic approximation of the vaginal epithelium, thereby decreasing the postoperative formation of granulation tissue. The McCall suture is now tied, thereby approximating the uterosacral ligaments and the posterior peritoneum.
Bladder Drainage
After completion of the procedure, the Foley catheter may be continued overnight or discontinued prior to leaving the operating room. Unless there is a complication or the patient is unable to void, the catheter should be discontinued within 24 hours. For a routine vaginal hysterectomy, vaginal packing is not recommended.
Surgical Techniques for Selected Patients
Morcellation of the Large Uterus
Vaginal uterine morcellation is a well-known but underutilized surgical procedure whereby the uterus is removed piecemeal. Several methods of uterine morcellation have been described, including hemisection or bivalving, wedge or “V” incisions, and intramyometrial coring (32). Before beginning any morcellation procedure, the uterine vessels must be ligated, and the peritoneal cavity must be entered anteriorly and posteriorly.
When uterine hemisection or bivalving is performed, the cervix is split at the midline, and the uterus is cut into halves, which are removed separately (32). This method seems best suited for fundal, midline leiomyomas. Wedge morcellation is best suited for anterior or posterior fibroids or for fibroids in the broad ligament. A single tooth tenaculum is placed at an angle from lateral to medial above the cervix bilaterally so that the tips meet in the middle. A wedge, including the cervix, is sharply removed distal to the clamps.
This reduces the midline bulk, allowing the remaining lateral portions of the uterus to move medially. Keeping the apex of the wedge in the midline, the tenacula are advanced and additional wedges are resected. This process is repeated until the uterus can be removed or until a pseudocapsule of a fibroid can be grasped with a Leahy clamp or towel clamp. Traction is applied, and a “myomectomy” is performed.
When the intramyometrial coring technique is used, the myometrium above the site of the ligated vessels is incised parallel to the axis of the uterine cavity and serosa of the uterus. This incision is continued around the full circumference of the myometrium in a symmetrical fashion beneath the uterine serosa. Traction is maintained on the cervix, and the avascular myometrium is cut to allow the undisturbed endometrial cavity, with a thick layer of myometrium, to be delivered with the cervix. As a result, the inside of the uterus with its unopened endometrial cavity is brought closer to the operator. Incision of the lateral portions of the myometrium medial to the remaining attachment of the broad ligament results in considerable additional descent of the uterus and greatly increases the mobility of the uterine fundus. The uterus is converted from a globular to an elongated tissue mass. The cored uterus is removed by clamping the utero-ovarian pedicle and fallopian tubes.
Limited data are available on outcomes following uncontained vaginal morcellation using cold-knife techniques. However, that which is available does not demonstrate an increased risk of worsening disease prognosis following the diagnosis of occult uterine malignancy (40).
Schuchardt Incision
When vaginal exposure is difficult, the Schuchardt incision may be used. To decrease blood loss, the area can be infiltrated with lidocaine-containing epinephrine. The incision follows a curved line from the 4-o’clock position at the hymenal margin to a point halfway between the anus and the ischial tuberosity. The incision may be continued into the vaginal vault as high as necessary to gain exposure. The depth of the incision is the medial portion of the pubococcygeus muscle, which may be divided in extreme cases. The incision must be closed in layers at the completion of the procedure.
Intraoperative Complications
Bladder Injury
Injury to the urinary bladder is one of the most common intraoperative complications associated with vaginal hysterectomy. If the bladder is inadvertently entered, the cystotomy should be carefully inspected. Its relationship to the trigone and ureteral orifices should be examined. Concomitant injury to the ureter should be ruled out. Ideally, the repair should be performed when the injury is discovered and not delayed until completion of surgery.
However, if it occurred during a difficult part of the case, access to the bladder can be utilized to define tissue planes and prevent additional injury. If a delayed repair is planned, the cystotomy should be marked with a single suture to aid in future identification. When repairing a bladder injury, the edges of the wound should be mobilized to assess the full extent of the injury and allow repair without tension. The bladder may be repaired with a single- or double-layered closure with a small-caliber absorbable suture. If the repair is close to the trigone or ureteral orifices, it is critical to verify ureteral patency. This can be performed by filling the bladder with just enough fluid to see the trigone and administering 0.25 to 1 mL of sodium fluorescein IV. Following bladder injury and repair, the bladder should be continuously drained for 3 to 10 days depending on the size and location of the injury.
Bowel Injury
Because patients with suspected pelvic adhesions or obvious pelvic disease are excluded as candidates for vaginal hysterectomy, bowel injuries do not occur often. Rarely, small bowel injury can occur during pedicle ligation. If the small bowel is injured, the area should be marked and a consultant should be called. In the event a consultant is not available, the bowel may be repaired. It is controversial whether this can be done from a vaginal approach or if laparotomy is required. Ideally, the bowel is run to verify no other injuries are present. Small defects of the serosa or muscularis may be repaired using a single or double layer of continuous or interrupted 3-0 braided absorbable suture. The defect should be closed in a direction perpendicular to the intestinal lumen. If a large area is injured, resection with reanastomosis may be necessary. Rectal injury can occur when the posterior colpotomy is performed in cases of an obliterated cul-de-sac.
If the rectum is entered, the injury is repaired with a single- or double-layer closure using a small-caliber absorbable suture, followed by copious irrigation. Postoperatively, the patient should be given a stool softener or osmotic laxative to prevent constipation.
Hemorrhage
Intraoperative hemorrhage invariably is the result of failure to ligate securely a significant blood vessel, bleeding from the vaginal cuff, slippage of a previously placed ligature, or avulsion of tissue before clamping. Most intraoperative bleeding can be avoided with adequate exposure and good surgical technique. Using square knots with attention to proper knot-tying mechanisms will prevent bleeding in most cases. The use of Heaney-type sutures may minimize ligature slippage and subsequent bleeding from bulky pedicles. When bleeding does occur, blind clamping, which may endanger the ureter, should be avoided.
The surgeon should first optimize exposure by packing away bowel, using additional retractors, and adjusting the OR lights. The bleeding vessel should be identified and precisely ligated, with visualization of the ureter if necessary. If the vessel cannot be identified or ligated or the pertinent anatomy cannot be visualized, conversion to a laparotomy may be necessary.
Perioperative Care
Bladder Drainage
Postoperative bladder drainage should be employed after any procedure in which spontaneous, complete voiding is not anticipated. Reasons to consider closed bladder drainage include significant local pain, additional vaginal reconstructive procedures, surgery for stress incontinence, and the use of a vaginal pack. After vaginal hysterectomy without additional repair, most patients can void spontaneously, and catheter drainage is not required. The relative amount of pain after a vaginal hysterectomy is less than with abdominal hysterectomy and, in the absence of additional repairs or a pack, no obstructive effect should be present.
If a catheter is required, the catheter is removed without clamping within 24 hours. There is no need to obtain a urine specimen for culture and sensitivity.
Diet
The patient is often the best judge of what she can tolerate following surgery. There is no medical reason to limit any type of food that the patient wishes to eat. Given the possibility of nausea, small frequent meals can be encouraged.
Laparoscopic Hysterectomy
Preoperative Preparation
The main limitations to a laparoscopic approach are medical or anesthetic disorders that do not allow adequate pneuomperitoneum or proper ventilation (32). Extensive and dense pelvic abdominal adhesions from previous surgery and very large uterine size are relative contraindications, although this decision can be made after assessing the peritoneal cavity (see Chapter 26). If the uterine size limits access to the uterine vessels, laparoscopic hysterectomy may not be possible. Obesity is not a contraindication to laparoscopic hysterectomy. The increased morbidity from laparotomy in patients with high body mass (BMI) can be minimized with laparoscopy.
Different classifications were proposed for the types of laparoscopic hysterectomy. Laparoscopic hysterectomy is defined as a laparoscopicassisted vaginal hysterectomy (LAVH) if the uterine vessels are occluded vaginally. The Cochrane review authors recommended that if the vessels are occluded laparoscopically, or if part of the operation is performed vaginally, the procedure be called laparoscopic hysterectomy, and, if no component is performed vaginally, the procedure should be called a total laparoscopic hysterectomy (32).
Patient Positioning
The patient is placed in dorsal lithotomy position with legs placed in Allen or Yellowfin stirrups (Allen Medical Systems, Acton, MA). Attention to proper leg placement will avoid nerve injury. Hyperflexion of the hips should be avoided because this may cause femoral nerve palsy. The patient should be placed on an egg crate mattress or beanbag cushion to limit patient movement in the Trendelenburg position. The arms are tucked on the patients’ side and protected with egg crate–type material. No shaving or clipping is necessary. Shoulder braces should not be used as they are associated with brachial plexus injury.
The steps to follow before introducing the first trocar are:
Perform an examination under anesthesia.
Place a Foley catheter to drain the bladder.
Introduce a uterine manipulator (e.g., Koh colpotomizer [Cooper Surgical
Inc., Trumbull, CT] or VCare [Conmed Corp., Utica, NY]).
Place an oral gastric tube.
Instrumentation
The most important instrument is the one used to occlude blood vessels. A multitude of energy forms exist, including electrosurgery, lasers, and ultrasonic scalpel (see Chapter 26). Some surgeons use stapling devices, although the cost of these stapling devices is high, and an energy-occluding device is needed to access areas that a stapler cannot. The versatility of the devices with energy makes them the method of choice to occlude vessels. There are no valid clinical data showing that one instrument is safer than another. The preferred one involves bipolar energy because gynecologists are experienced with this form of energy.
Surgical Technique of Laparoscopic Hysterectomy
Peritoneal Access
The most important technical consideration for all laparoscopic surgery is port placement (see Chapter 26). The umbilical site typically is used in patients without a previous history of surgery or intra-abdominal infection. In cases of previous surgery where there was a midline incision or a history of a pelvicabdominal incision, an open laparoscopy is recommended or an alternate site can be chosen to introduce the primary cannula. The open laparoscopy is essentially a mini-laparotomy at the umbilicus. The alternative site is the left upper quadrant. The standard closed technique involves the use of pneumoperitoneum needle (Veress needle), insufflation, and primary trocar insertion. An alternative technique is the direct trocar insertion (no insufflation prior to trocar insertion).
There is no advantage of one technique over the other (32). Gynecologists should use the approach with which they have most experience. If the left upper quadrant is used, the surgeon should be aware of the closest anatomic structures to the left costal margin (see Chapter 26, Fig. 26- 7). Typically the cannula is introduced below the left costal margin in the midclavicular line. The closest structures to this area are the stomach and the left lobe of the liver. Therefore, an oral gastric tube should be introduced to empty the stomach before starting the procedure.
The patient is kept in a horizontal (not Trendelenburg) position until proper peritoneal access is confirmed. The angle of insertion of the primary trocar will depend on the size of the patient. Typically for nonobese or overweight patients a 45-degree angle from the horizontal is used and with obese patients a 60- to 80-degree angle or open technique is used.
Proper placement of accessory ports is critical to allow the steps of a laparoscopic hysterectomy. The authors typically use three lateral accessory ports and do not use a suprapubic port (Fig. 27-23). Lateral ports offer the surgeon an ergonomic approach in which both hands can be used comfortably.
The most important step when placing lateral ports is to avoid the inferior epigastric vessels, which are branches of the external iliac artery and vein (see Chapter 26, Fig. 26-7). Direct visualization is best. These vessels (typically two veins and an artery) are seen through the peritoneum medial to the insertion of the round ligament in the deep inguinal ring. They cannot be transilluminated. Ports are placed approximately 8 cm from the midline and 8 cm above the pubic symphysis.
Laparoscopic hysterectomy requires traction and countertraction to identify the vascular pedicles and the ureter, which is accomplished with the uterine manipulator. In the case of a large uterus, a laparoscopic tenaculum is required. If the fallopian tubes are removed, the procedure starts with coagulating and transecting the mesosalpinx, followed by the same actions with the round ligament (Figs. 27-24 and 27-25). The incision is carried anteriorly to create a bladder peritoneal flap by sharp dissection of the loose areolar cervicovesical tissue. The utero-ovarian ligaments are coagulated and transected, depending on whether the ovaries will be removed (Figs. 27-25 and 27-26). The retroperitoneal space is opened and the ureter identified on the medial leaf of the broad ligament (Figs. 27-24 and 27-25). The surgeon can proceed vaginally (LAVH), but there will not be any improved uterine descent because the transected tissue has no major role in uterine support.
FIGURE 27-23 Port placement for laparoscopic hysterectomy.
The uterus is torqued away from the uterine artery to be occluded. The uterine artery is skeletonized by cutting the posterior peritoneum up to the uterosacral ligament, coagulated, and transected (Fig. 27-27). The procedure is carried out on the other side. This area of occlusion is approximately the level of the internal os. If a supracervical hysterectomy was performed, the uterus can now be amputated. When this is done, the remaining endocervical canal should be ablated.
The anterior dissection should be completed so that the bladder is completely off the anterior fornix area of the vagina. Using a vaginal device such as the Koh, the surgeon can identify this area. Ensuring that no CO2 escapes from the vagina, and an incision is made on the vagina circumferentially around the cervix (Fig. 27-28). The uterus can be pulled out though the vagina or can be morcellated, and removed either vaginally or laparoscopically, whichever is easier.
FIGURE 27-24 Ligation and transection of the mesosalpinx.
FIGURE 27-25 The round ligament is transected and the posterior broad ligament is opened toward the uterosacral ligament.
The vaginal cuff is closed laparoscopically or vaginally with interrupted or continuous-delayed absorbable suture (Fig. 27-29). To give added pelvic support, the uterosacral ligaments are reattached to the vagina (McCall culdoplasty) with delayed absorbable suture (Fig. 27-29). Intravenous sodium fluorescein is given and the integrity of the bladder and ureters confirmed with cystoscopy, if desired, by the surgeon.
At the end of the procedure, the secondary ports should be removed under direct visualization to ensure that there is no bleeding. In order to minimize the risk of herniation, the fascia should be closed at port sites that are greater than 8 mm and at those sites where smaller ports have been used but there has been prolonged manipulation.
FIGURE 27-26 The utero-ovarian ligament is transected.
FIGURE 27-27 With the ureter in view, the uterine artery is identified and coagulated.
Robotic-Assisted Laparoscopic Hysterectomy
A surgical robot consists of a surgeon’s console with the instrument manipulators and view screen, a robot tower with telerobotic arms that are attached to the patient, and the computer interface equipment, which is housed in a separate tower (see Chapter 28 for a more complete discussion). Robotic assistance at laparoscopy has some advantages, including a three-dimensional view, instruments with articulating tips that offer 7 degrees of movement, scaling of movement, and more precise movements. The disadvantages are the bulky device around the patient that limits the assistant’s movements, the lack of haptic feedback, and the high cost of the robot. The robot device uses a 12-mm laparoscope and instruments that require 8-mm ports.
The robotic tower can be docked between the legs or on the patient’s side (side docked). Side docking allows access to the perineum and vagina so that the assistant can comfortably manipulate the uterus. A robot-assisted hysterectomy goes through the same steps as a laparoscopic hysterectomy. A right-handed surgeon should have the monopolar scissors or harmonic scalpel through a right robotic port and a vessel-sealing device such as a bipolar instrument through a left-sided robotic port.
FIGURE 27-28 Monopolar cautery is used to make the colpotomy against the uterine manipulator.
FIGURE 27-29 The vaginal cuff is closed. The uterosacral ligaments are incorporated to provide vaginal apex support.
Laparoendoscopic Single-Site Surgery
Another modification of laparoscopic hysterectomy is the introduction of laparoendoscopic single-site surgery or single-port surgery. Because some surgeons use multiple ports at one site, laparoendoscopic single-site surgery is probably the best term. Specifically designed umbilical port systems that admit multiple instrument access have enabled the development of this technique. The availability of flexible instruments and flexible tip laparoscopes allows the surgeon to perform a hysterectomy by reducing instrument crowding and clashing at the umbilicus. The basic hysterectomy steps are the same. Although quite feasible the data do not show any advantage over conventional laparoscopy (60).
Intraoperative Complications: Laparoscopic Hysterectomy
The intraoperative complications of a laparoscopic hysterectomy are similar to an open hysterectomy. These are injury to the ureter, bladder, bowel, and hemorrhage. Recognition and management are similar. Intraoperative bleeding during a laparoscopic procedure is handled by use of a bipolar electrosurgery instrument. The same principles apply as with an open case. Electrosurgery should not be used without proper localization of the ureters. If it is not apparent where the bleeding is occurring, the procedure should be converted to an open one. As with abdominal hysterectomy the value of intraoperative cystoscopy in the setting of laparoscopic hysterectomy without pelvic support procedures is unclear and depends on the incidence of urinary tract injury (51).
Perioperative Care
Many surgeons remove the bladder catheter at the end of the laparoscopic hysterectomy. A regular diet as tolerated is given on the same day as the surgery. Preemptive analgesia with intravenous acetaminophen, anticonvulsants such as gabapentin and ketorolac demonstrate opioid-sparing benefits (61). Postoperative pain control is similar to that described for abdominal hysterectomy. Transition to oral analgesics can be made the same day. Ambulation is encouraged as soon as possible. Median time to return to work is 3 to 4 weeks (45).
POSTOPERATIVE COMPLICATIONS OF HYSTERECTOMY
A comprehensive discussion of postoperative complications after gynecologic surgery is presented in Chapter 25.
Incisional Pain and Infections
Wound infections occur in 2% of abdominal hysterectomies but incidence is thought to be far less with laparoscopic surgery (51). Incisional pain can occur at trocar sites, especially if located in the region of the ilioinguinal or iliohypogastric nerves (62). Pfannenstiel incisions can be a source of chronic pain at the incision site as a result of nerve entrapment (63).
Hemorrhage
Immediately after hysterectomy, hemorrhage may become apparent in one of two ways. Bleeding from the vagina may first be noted by the nursing staff or physician within the first few hours after surgery. Second, the patient may be noted to have little bleeding from the vagina but deteriorating vital signs manifested by low blood pressure and tachycardia, falling hematocrit level, and flank or abdominal pain. The first presentation is in the form of bleeding from the vaginal cuff or one of the pedicles. The second presentation may be a retroperitoneal hemorrhage. Each situation is approached differently in its evaluation and treatment, but both involve the same general principles of rapid diagnosis, stabilization of vital signs, appropriate fluid and blood replacement, and constant surveillance of the patient’s overall condition.
After vital signs are assessed, attention should be directed to the amount of bleeding. A small amount of bleeding is expected after any hysterectomy. Steady bleeding 2 to 3 hours after surgery suggests lack of hemostasis. The patient should be taken promptly to the examining room, where the operative site is viewed using a large speculum and good lighting. If bleeding is not excessive, the vaginal cuff can be inspected, and in many instances, bleeding from the cuff edge will be found. Hemostasis can easily be achieved with one or two sutures placed through the epithelium.
If bleeding is excessive or appears to be coming from above the cuff, or if the patient is too uncomfortable to tolerate adequate examination, she should be taken to the operating room. General anesthesia should be administered and the vaginal operative site should be thoroughly explored. Any bleeding point may be sutured or ligated. Bleeding that is coming from above the cuff or is extremely heavy usually cannot be controlled through the vaginal route. An exploratory laparotomy is necessary to examine the pelvic floor, identify and isolate the bleeding vessel, and achieve hemostasis. The ovarian vessels and uterine arteries should be thoroughly inspected because they often are the source of excessive vaginal bleeding. If it is difficult to localize bleeding to a specific pelvic vessel, or if these maneuvers do not work, ligation of the hypogastric artery may be performed.
In the patient with little vaginal bleeding in whom vital signs have deteriorated, retroperitoneal hemorrhage should be suspected. Input and output should be monitored. Hematocrit assessment, along with crossmatching of packed red blood cells, should be performed immediately.
Examination may reveal tenderness and dullness in the flank. In cases of intraperitoneal bleeding, abdominal distention may occur. Diagnostic radiologic studies can be used to confirm the presence of retroperitoneal or intra-abdominal bleeding. Ultrasonography is one option for viewing low pelvic hematomas; CT provides better visualization of retroperitoneal spaces and can delineate a hematoma.
If the patient’s condition stabilizes rapidly with intravenous fluids, one of the two approaches may be used for continued care. The first is to give the patient a transfusion and follow serial hematocrit assessments and vital signs. In many instances, retroperitoneal bleeding will tamponade and stop, forming a hematoma that may eventually be resorbed. The risk with this approach is that the hematoma will become infected, necessitating surgical drainage. In some instances when the patient’s condition is stable, radiologic embolization may be considered.
Another option is to perform abdominal exploratory surgery while the patient’s condition is stable. This approach adds the morbidity of a second procedure but avoids the possibility of the patient’s condition deteriorating with continued delay or the formation of a pelvic abscess. When adequate exposure is obtained, the peritoneum over the hematoma should be opened and the blood evacuated. All bleeding vessels should be identified and ligated. If bleeding is difficult to control, consideration should be given to unilateral or bilateral ligation of the anterior division of the internal iliac artery. After hemostasis is achieved, the pelvis should be drained using a closed system.
Urinary Tract Complications
Urinary Retention
Urinary retention after hysterectomy is an uncommon occurrence. If the urethra is unobstructed and retention occurs, it is usually the result of either pain or bladder atony resulting from anesthesia. Both are temporary effects. If a catheter was not placed after surgery, retention can be relieved initially with the insertion of a Foley catheter for 12 to 24 hours. Most patients are able to void after the catheter is removed 1 day later.
Ureteral Injury
In patients who develop flank pain soon after hysterectomy, ureteral obstruction should be suspected. In a patient with flank pain in whom ureteral obstruction is suspected, a CT urogram and a urinalysis should be performed. If obstruction is noted on CT scan, it is usually present near the ureterovesical junction. The immediate step is attempted passage of a stent through the ureter under cystoscopic guidance. If a catheter can be passed through the ureter, it should be left in place for at least 4 to 6 weeks, allowing sutures to absorb and the obstruction or kinking to release. If the catheter cannot be passed through the ureter, the best course is to perform abdominal exploratory surgery and repair the ureter at the site of obstruction. If an exploratory surgery cannot be performed immediately, a temporary percutaneous nephrostomy tube may be considered.
Vesicovaginal Fistula
In developed countries, vesicovaginal fistulas occur most often after total abdominal hysterectomy for benign gynecologic disease. Intraoperative steps to avoid the formation of a vesicovaginal fistula include correct identification of the proper plane between the bladder and cervix, sharp rather than blunt dissection of the bladder, and care in clamping and suturing the vaginal cuff. The development of a postoperative vesicovaginal fistula after hysterectomy is rare; the incidence is as low as 0.2%.
Patients who have a postoperative vesicovaginal fistula develop a watery vaginal discharge 10 to 14 days after surgery. Some fistulas resulting from surgery are noted as early as the first 48 to 72 hours after surgery. After vaginal examination with a speculum, the diagnosis can usually be confirmed with the insertion of a cotton tampon into the vagina followed by the instillation of methylene blue dye through a transurethral catheter. If the tampon stains blue, a vesicovaginal fistula is present. If no staining occurs, the presence of an ureterovaginal fistula can be ruled out by the administration of oral pyridium.
Within 20 minutes, the tampon should stain orange if an ureterovaginal fistula is present. A CT urogram should be performed in cases of suspected vesicovaginal fistula and ureterovaginal fistula to fully evaluate ureteral integrity and rule out obstruction.
If a vesicovaginal fistula is diagnosed, a Foley catheter should be inserted for prolonged drainage. Up to 15% of fistulas close spontaneously with 4 to 6 weeks of continuous bladder drainage. If closure has not occurred by 6 weeks, operative correction is necessary. Waiting 3 to 4 months from the time of diagnosis before operative repair is recommended to allow reduction of inflammation and to improve vascular supply. After hysterectomy, the fistula site is above the bladder trigone and away from the ureters. Vaginal repair can be anticipated in most patients. The surgical correction is undertaken in a fourlayered closure: the bladder mucosa, the seromuscular layer, the endopelvic fascia, and the vaginal epithelium.
Incidental cystotomy at the time of hysterectomy is more common than vesicovaginal fistula. When identified and repaired correctly, cystotomy rarely results in the development of a fistula.
Prolapse of the Fallopian Tube
Posthysterectomy prolapse of the fallopian tube is a rare event and can be confused with granulation tissue at the vaginal apex. Predisposing factors for the development of fallopian tube prolapse include development of a hematoma and an abscess at the vaginal apex. In patients in whom granulation tissue persists after attempts to cauterize it or pain is experienced with attempts to remove it, fallopian tube prolapse should be suspected. A biopsy of the area is warranted and usually reveals tubal epithelium if a fallopian tube is present.
If fallopian tube prolapse is diagnosed, it should be repaired with surgery. The surrounding vaginal mucosa should be opened and undermined widely. The tube is ligated high and removed, followed by closure of the vaginal epithelium.
Vaginal Cuff Dehiscence
Patients with cuff dehiscence present with pain, vaginal bleeding, vaginal discharge, or gush of fluid 2 to 5 months after surgery. The most common initiating event is coitus. Immediate examination for cuff integrity is necessary. Treatment typically requires surgical repair in the operating room. Some studies show a higher frequency with robotic surgery (64).
DISCHARGE INSTRUCTIONS
Before discharging the patient, instructions should be reviewed. Printed postoperative instructions are helpful to the patient and a suggested set of instructions are as follows:
1. Avoid strenuous activity for the first 2 weeks, and increase activity level gradually.
2. Avoid heavy lifting, douching, or sexual intercourse until instructed by the physician.
3. Keep the wound (if applicable) clean and dry.
4. Bathe as needed using shower or tub baths.
5. Follow a regular diet.
6. Avoid straining for a bowel movement or urination. To prevent constipation, use a stool softener (docusate sodium), fiber, or osmotic laxative (polyethylene glycol). To treat constipation, increase the use of an osmotic laxative or consider a stimulant laxative (magnesium hydroxide, senna, or bisacodyl).
7. Call the physician if excessive vaginal bleeding or fever occurs.
8. Schedule a return appointment at the time specified by the physician. The physician should provide telephone numbers for emergencies during and after office hours. Typically, the first postoperative visit is scheduled about 4 to 6 weeks after discharge from the hospital. At the time of that visit, the patient should be ambulating well, and vaginal discharge or bleeding should be minimal. Speculum examination of the cuff should be gentle and cursory, but the patient should be assured that the healing process is proceeding normally. Finally, the patient’s questions should be answered and advice given on increasing her activity level, including sexual activity, work, and normal household activity.
Readmission and Emergency Department Visits after Discharge
In one study, after hysterectomy for benign disease approximately 9% of women return to the emergency with a condition that does not require admission (65). Pain control was the presenting complaint in almost 30% of patients. Better education and communication should improve this outcome. Other presenting complaints were gastrointestinal such as nausea, vomiting, constipation, and diarrhea and genitourinary such as urinary tract infection or retention (65). Risk factors for readmissions after hysterectomy for benign pathology include preoperative comorbidities such as diabetes and hypertension, long operative time and major intraoperative or postoperative surgical or medical complications such as sepsis and return to the operating room (66).
GENERAL PELVIC SYMPTOMS AND QUALITY OF LIFE
Patient satisfaction after hysterectomy is related to the initial indication for surgery and patient expectation. The Maine Women’s Health Study evaluated the effect of hysterectomy for nonmalignant disorders on quality of life (13). They documented a marked improvement in pelvic pain, urinary symptoms, and psychological and sexual symptoms at 1 year in the majority of patients. In the Maryland Women’s Health Study patients were followed for up to 2 years after hysterectomy for nonmalignant conditions (67). Symptoms related to the underlying indication for surgery, and associated symptoms of depression and anxiety and quality of life, improved after hysterectomy. Each study reported that about 8% of patients had new symptoms, such as depression and lack of interest in sex or lack of improvement in quality of life. Although women with pelvic pain and depression did not show the same level of improvement as other groups, there was significant improvement over baseline. Patient satisfaction is very high after hysterectomy (67).
Sexual Function
There is considerable debate in the lay literature about the effect of hysterectomy on sexual function, although evidence consistently suggests that the majority of women have unchanged or improved sexual function 1 to 2 years after hysterectomy (13,67). Few women who had a hysterectomy had a measurable worsening in sexual function during this time period. The long-term effects of hysterectomy on sexual function remain largely unknown. Studies have addressed the short-term effects of hysterectomy on dyspareunia, frequency of intercourse, orgasm, libido or sexual interest, vaginal dryness, and overall sexual function. The Maine Women’s Health Study demonstrated a significant decrease in the number of women who reported dyspareunia 12 and 24 months after hysterectomy compared to the preoperative period (13). Eighty-one percent of the women who experienced dyspareunia preoperatively had an improvement in this symptom at 24 months after hysterectomy, while only 1.9% of women without preoperative dyspareunia developed it by 24 months after surgery. In this study, 39% of women reported dyspareunia preoperatively, and only 8% had this complaint 12 months after hysterectomy. Women who were managed nonsurgically showed no decline in the mean frequency of dyspareunia (13).
Most studies report that hysterectomy has little impact on the frequency of intercourse, libido, and sexual interest. Orgasmic function before and after hysterectomy is somewhat more controversial, but the largest study by Carlson et al. reported a slight increase in the proportion of women who experienced orgasms after a hysterectomy (13). It is plausible that removal of the uterus and/or cervix (especially if the ovaries are also removed) may adversely affect sexual function in some women, but this may be offset by the improvement in sexual function that could result from cessation of abnormal or heavy vaginal bleeding, dysmenorrhea, or symptoms of prolapse. It is likely that vaginal dryness is not affected by hysterectomy and depends more on age and postoperative hormonal status. Body image and sexual function are improved after vaginal, abdominal, and laparoscopic hysterectomy, but no differences were found between the three routes (13).
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