Chapter 8 Hysterectomy
GENERAL PRINCIPLES
Definition
Abdominal hysterectomy is defined as the surgical removal of the uterus via a
laparotomy incision. A total hysterectomy removes both the uterus and
cervix. A subtotal or supracervical hysterectomy removes the uterus only. The
ovaries may remain in situ for both kinds of hysterectomy. The decision to
retain or excise ovaries is a complex decision to be made by the patient and
her physician after extensive counseling.
Differential Diagnosis
■ Uterine leiomyomas
■ Abnormal uterine bleeding
■ Endometriosis
■ Pelvic inflammatory disease
■ Pelvic organ prolapse
■ Malignant or premalignant disease
Nonoperative Management
Alternative therapies to surgical management are highly dependent on the
underlying disease. For example, symptomatic uterine fibroids can be treated
with uterine fibroid embolization techniques. Endometrial ablation or
intrauterine progestin delivering devices are often used to reduce
menorrhagia. Similarly, medical therapy including progesterone and
gonadotropin-releasing hormone agonist regimens are used to treat pelvic
pain caused by endometriosis. Progestins are also used in the treatment of
endometrial hyperplasia in select cases. Furthermore, the need for surgical
treatment of pelvic organ prolapse can sometimes be mitigated with the use
of pelvic floor strengthening exercises.
IMAGING AND OTHER DIAGNOSTICS
■ Depending upon the reason for hysterectomy, the use of preoperative
imaging and diagnostics will differ. For surgical planning of an abdominalhysterectomy, the best tool to determine uterine size in addition to pelvic
examination is pelvic ultrasound. This imaging provides an inexpensive and
accurate assessment of uterine size, endometrial stripe thickness, and the
adnexa. For peri- or postmenopausal women who are undergoing
hysterectomy for abnormal uterine bleeding, preoperative endometrial
sampling to rule out malignancy is imperative. Unless malignancy is
suspected, the use of pelvic MRI prior to abdominal hysterectomy for
benign disease is unlikely to provide additional information.
PREOPERATIVE PLANNING
■ It is essential to have a comprehensive discussion with the patient
regarding perioperative complication risk, choice of abdominal incision,
and whether the ovaries, fallopian tubes, and cervix will be removed. These
decisions should be well documented both in the patient’s medical record as
well as on the surgical consent form. The patient should be counseled that
decisions made preoperatively are subject to change intraoperatively for
patient safety.
■ Preoperative optimization strategies for women undergoing gynecologic
surgery include medical consultation for patients with medical
comorbidities and regarding perioperative medication management,
pregnancy testing in all women of reproductive age, up-to-date screening
with pap testing, mammography and colonoscopy, and endometrial
sampling in perimenopausal/postmenopausal women with abnormal uterine
bleeding. Further testing with EKG and CXR are recommended for women
>50 years. Laboratory testing including complete blood count, electrolytes,
creatinine, and type and screen are not required, however, may be useful in
the postoperative setting.
■ The type of abdominal incision is based on several factors that include
uterine size and the anticipation of anatomic abnormality such as
extensive adhesions. If a woman has a prior vertical abdominal scar, most
surgeons prefer to use this incision (Figs. 8.1.1 and 8.1.2). However, if
uterine size and the absence of adhesiophylic pathology permit, a
transverse abdominal incision is a good option that improves cosmesis
and decreases both postoperative pain and the incidence of incisional
hernias. Although earlier studies demonstrated an increase in vertical
incision dehiscence rates, compared to transverse abdominal incision,
more recent studies have found no difference in dehiscence rates between
these two incisions.1
Figure 8.1.1. Vertical midline incision.
■ The decision to remove both fallopian tubes and ovaries at the time of
hysterectomy is complicated and requires a frank discussion between the
patient and her surgeon. Benign indications for oophorectomy at the time
of hysterectomy include endometriosis, tubo-ovarian abscess, and pelvic
pain. In 2005, a nationwide study reported that unilateral or bilateral
salpingo-oophorectomy was performed in 68% of women undergoing
abdominal hysterectomy in the United States.2 Historically, the rationale
for elective oophorectomy at the time of hysterectomy was ovarian
cancer prevention in women nearing menopause. More recently, the
thought has shifted to favor ovarian conservation, as new evidence
suggests there are long-term health benefits associated with ovarian
preservation and more risks than previously appreciated with elective
oophorectomy.3 Furthermore, the incidence of ovarian cancer in the
general population remains low and does not warrant elective
oophorectomy at the time of hysterectomy.
■ In contrast, there are no proven medical or surgical benefits to
performing a subtotal hysterectomy if the cervix can easily be removedwith the uterus. Retaining the cervix commits the patient to continued
cervical cancer screening and may result in posthysterectomy bleeding.
The only absolute contraindication to supracervical hysterectomy is a
malignant or premalignant condition of the uterus or cervix.
Figure 8.1.2. Vertical midline incision—skin incision.
SURGICAL MANAGEMENT
■ Women undergoing abdominal hysterectomy require venous
thromboembolism (VTE) prophylaxis. Guidelines for perioperative
thromboprophylaxis published by both the American College of
Obstetricians and Gynecologists and the American College of Chest
Physicians consistently define patients undergoing abdominal hysterectomy
as at least moderate risk of VTE.4,5 Therefore, mechanical VTE prophylaxis
with sequential compression devices should be used in all women
undergoing abdominal hysterectomy. Consideration for pharmacologic
prophylaxis with heparin should be based upon risk factors further
delineated in the aforementioned guidelines. Many institutions havedeveloped routine, perisurgical thromboprophylaxis protocols, and
administer both mechanical and pharmacologic therapies for women
undergoing abdominal hysterectomy.4
■ Prophylactic antibiotics to prevent surgical site infection are given as a single
intravenous injection prior to induction of anesthesia. The greatest efficacy
for antibiotic administration is within an hour prior to bacterial inoculation
(i.e., abdominal incision).6 For women greater than 50 kg, a dose of 2 g
cefazolin is routinely used (1 g for women with BMI <30). If bowel
penetration is anticipated, metronidazole 500 mg may be given in addition
to cefazolin. Alternatively, cefoxitin 2 g can be administered to cover a
broader spectrum of bacteria. Women who are penicillin-allergic require a
combination of clindamycin (600 mg) and gentamicin (1.5 mg/kg; max 240
mg). For lengthy procedures, additional intraoperative doses of antibiotic
are given at intervals of one or two times the half-life of the drug to
maintain adequate levels throughout the operation (Table 8.1.1). For
cefazolin, a second dose is necessary at 3 hours. An increased blood loss
greater than 1,500 mL also warrants a second dose of antibiotic.3
Table 8.1.1 Prophylactic Antibiotic Regimens for Abdominal Hysterectomy
■ Bowel preparation is not indicated in women undergoing abdominal
hysterectomy unless there is a high probability of bowel injury secondary
to adhesions. In these cases, it is reasonable to consider using a parenteral
antibiotic regimen that is effective in preventing infection among patients
undergoing elective bowel surgery. There is no evidence that mechanical
bowel preparation further reduces infection risk.3Positioning
■ After the patient is brought to the operating room, preoperative
prophylactic antibiotics and subcutaneous heparin are administered prior to
the start of the procedure. Sequential compression devices are placed
bilaterally on the patient’s lower extremities. The patient may be positioned
in either the dorsal supine or lithotomy position using Allen stirrups with
careful attention to pressure points to avoid neurologic injury. A “time-out”
is performed in which the surgeon, anesthesia, and operating room staff
confirm and agree upon the patient’s identity, indicated treatments and
surgery including any procedure laterality (i.e., right salpingooophorectomy) followed by an examination under anesthesia. The vagina,
perineum, and abdomen (from the anterior thighs to xiphoid) are then
prepared with antiseptic solution and draped in a sterile fashion. In sterile
fashion, a Foley catheter is placed in the bladder and drained to gravity.
The surgeon then changes her gloves before moving to the abdomen.
Approach
■ The skin incision may be transverse or midline vertical and is determined
by a variety of factors, such as the presence of a prior surgical scar, need
for upper abdomen exploration, uterine size, shape, and mobility, and
desired cosmetic results. If a prior incision exists, most surgeons prefer to
use this incision. If the prior scar is cosmetically unacceptable, it may be
excised at the beginning or end of the procedure. This is accomplished by
elevating the old scar with Allis clamps and creating an elliptical incision
around the old scar.
■ If a transverse abdominal incision is desired, consider a few options. The
most commonly used transverse incision is a Pfannenstiel incision;
however, this incision provides the least amount of exposure because the
recti remain intact. Transverse Cherney and Maylard incisions improve
exposure because the rectus muscles are transected. A Cherney incision
transects the rectus muscles at their tendinous insertions into the symphysis
pubis, while the Maylard incision is a true transverse transection through
all layers, including the rectus muscles, and necessitates identification and
suture ligation of the deep, inferior epigastric vessels.Procedures and Techniques (Video 8.1)
Incision and exploration
■ Using a vertical abdominal approach, a midline vertical skin incision is made from
the umbilicus down to the pubic symphysis (see Figs. 8.1.1 and 8.1.2). The
underlying subcutaneous tissues are then divided down to the fascia (Tech Figs.
8.1.1 and 8.1.2). The fascia is incised in the midline over the rectus diastasis and
along the length of the incision (Tech Figs. 8.1.3 to 8.1.6). The underlying
posterior sheath is then elevated and entered sharply with Metzenbaum scissors
(Tech Figs. 8.1.7 and 8.1.8). The peritoneum is grasped with smooth pick-ups or
Kelly clamps, elevated, and entered sharply with the knife to gain uncomplicated
entry into the abdominal cavity (Tech Fig. 8.1.9). The incision is then extended
along its entire length paying careful attention to the location of the bladder.
Tech Figure 8.1.1. Dissection through subcutaneous adipose.
Tech Figure 8.1.2. Dissection through subcutaneous adipose.
Tech Figure 8.1.3. The fascia is revealed.
Tech Figure 8.1.4. Fascia is incised in the midline.
Tech Figure 8.1.5. Underlying rectus muscles are revealed.
Tech Figure 8.1.6. The midline fascial incision is extended superiorly.
■ A Pfannenstiel incision is a transverse incision made at a level suitable to the
surgeon. It usually measured 10 to 15 cm transversely and extends through the
skin, subcutaneous fat, and to the level of the rectus fascia. The rectus fascia is
then incised transversely on either side of the midline with a scalpel and
extended laterally with curved Mayo scissors. Kocher clamps are then placed on
the inferior aspect of the fascial incision. While pulling vertically on the Kocher
clamps with one hand, the surgeon uses her opposite hand to simultaneously
and bluntly dissect the anterior rectus sheath from the underlying rectus muscle.
The anterior aspect of the fascial incision is similarly dissected. The rectus
muscles are then separated in the midline, and the peritoneum is opened
vertically.
■ As with a Pfannenstiel incision, the skin and fascia are divided transversely with
the Cherney incision; however, the rectus muscles are divided at their tendinous
insertion into the symphysis pubis with a monopolar instrument or scalpel. The
recti are then retracted cephalad to improve exposure. Similarly, the Maylard
incision requires a transverse incision through skin, subcutaneous tissue, and
fascia. However, once the fascia is transversely incised, it is not detached from
the underlying muscle. The surgeon must identify the lateral borders of the rectus
muscles, then identify, clamp cut, and suture ligate the inferior epigastric vessels
lying on the posterior lateral border of each muscle. After these vessels are
secured, the rectus muscles are transected using a monopolar instrument.
Tech Figure 8.1.9. The peritoneum is grasped and tented up for sharp entry.
Exposure
■ Once the peritoneum has been opened, a self-retaining retractor is placed and
the target organ is exposed and delivered (Tech Figs. 8.1.10 to 8.1.12). The
type of retractor used depends on the type of incision (vertical or transverse) and
surgeon preference. When positioning retractors it is important to avoid placing
the lateral blades over the femoral nerve as it emerges lateral to the psoas
muscle. This can lead to peripheral neuropathy and postoperative difficulty with
walking. To ensure safe placement, lift the abdominal wall as the retractor is
placed, then check to confirm no bowel has been trapped beneath a blade and
that the blade is not pressing on the sidewall of the pelvis (Tech Fig. 8.1.13).
■ If pelvic or intra-abdominal adhesions are present, first mobilize the pelvic
organs and restore normal anatomy before packing the bowel away from the
pelvis. This may require dividing omental, intestinal, or abdominal wall adhesions
with either Metzenbaum scissors or radiofrequency energy. Once normal
anatomy is restored, use moist laparotomy sponges to pack away small and
large bowels, carefully placing the blades of the retractors in such a way that no
bowel is strangulated.
Tech Figure 8.1.10. The uterus is delivered through the incision.
Tech Figure 8.1.11. Bookwalter post and ring.
Tech Figure 8.1.12. Bookwalter assembled.
Tech Figure 8.1.13. Bookwalter with side-wall retractors in place.
Broad ligament dissection
■ Large Kelly clamps are placed across each uterine cornu including the round
ligament to allow easy retraction of the uterus during surgery (Tech Fig. 8.1.14).
The round ligament is then clamped at approximately the mid-portion and divided
with a monopolar instrument (Tech Fig. 8.1.15). The clamped end is then suture
ligated and the clamp removed. If the round ligament is divided too close to the
uterus, exposure of the broad ligament becomes limited making the incision of
the peritoneum over the broad ligament more difficult.
Tech Figure 8.1.14. The round ligament is identified.
Tech Figure 8.1.15. The round ligament is clamped and divided.
■ The anterior and posterior leaves of the broad ligament are incised. Anteriorly,
the broad ligament is divided to the level of the uterine artery, then medially along
the vesicouterine peritoneum, separating the bladder from the lower uterine
segment and underlying vagina (Tech Figs. 8.1.16 and 8.1.17). The
retroperitoneum is then entered by extending the incision on the posterior leaf of
the broad ligament superiorly, remaining lateral to the infundibulopelvic ligament
(Tech Figs. 8.1.18 and 8.1.19). Blunt dissection with a Yankauer suction tip or a
finger clears the loose connective tissue overlying the external iliac arteryallowing for identification of the ureter (Tech Figs. 8.1.20 and 8.1.21). By
following the external iliac artery superiorly to its bifurcation, the ureter can be
identified at its most superficial point crossing into the pelvis over the bifurcation
of the internal and external iliac arteries. The ureter can then be traced to the
medial leaf of the peritoneum coursing inferior to the infundibulopelvic ligament.
Visualization of ureteral peristalsis confirms the ureter’s identity.
Tech Figure 8.1.16. The vesicouterine peritoneum is incised over the underlying cervix.
Tech Figure 8.1.17. By incising the vesicouterine peritoneum, the bladder is dissected
off the cervix.
Tech Figure 8.1.18. The posterior leaf of the broad ligament is tented up.
Tech Figure 8.1.19. The posterior leaf of the broad ligament is incised lateral to the
gonadal vessels.
Tech Figure 8.1.20. The peritoneum is extended to better visualize the
retroperitoneum.
Tech Figure 8.1.21. Vessel loop around the identified ureter.
Adnexal removal
■ If the ovaries are to be removed, first identify the ureter, then create a peritoneal
window located inferior to the infundibulopelvic ligament, superior to the ureter
and lateral to the ovary (Tech Fig. 8.1.22). This is accomplished by dissecting the
vessels away from the ureter and clamping the intervening tissue with two curved
clamps. The vessels are then transected and suture ligated first with a free tiefollowed by a suture ligature placed just medial to the free tie. This technique
prevents hematoma formation. The underlying medial leaf of the broad ligament
is then skeletonized up to the utero-ovarian ligament.
Tech Figure 8.1.22. Formation of peritoneal window between gonadal vessels and the
ureter.
Conservation of ovaries and tubes
■ If the ovaries are to be conserved, identify the ureter, and then create a
peritoneal window in the posterior leaf of the broad ligament located under the
utero-ovarian ligament and fallopian tube. Clamp the utero-ovarian with two
clamps (the large Kelly clamp placed on the cornua initially may be adjusted to
ensure complete occlusion of the utero-ovarian vessels at the uterine cornua, the
second clamp used is generally a Heaney clamp), incise and ligate with a free tie
followed by a suture ligature placed medially to the free tie (Tech Figs. 8.1.23 to
8.1.26). See Tech Figure 8.1.27 for technique differentiation of adnexal
conservation versus adnexal excision.
Tech Figure 8.1.23. Haney clamps on the utero-ovarian ligament.
Tech Figure 8.1.24. Division of the utero-ovarian ligament.
Tech Figure 8.1.25. The utero-ovarian ligament is suture ligated.
Tech Figure 8.1.26. The utero-ovarian pedicle is released once hemostatic.
Tech Figure 8.1.27. Technique for adnexal conservation versus oophorectomy at the
time of abdominal hysterectomy.
Uterine artery ligation
■ Prior to ligating the uterine artery, it is imperative to dissect both the bladder and
rectum away from the uterus. By dissecting the bladder off the lower uterine
segment, the ureter is concomitantly lateralized, reducing the risk for ureteral
injury during uterine artery ligation. This is accomplished by incising the
vesicouterine peritoneum and identifying the avascular plane between the
bladder and the lower uterine segment (Tech Fig. 8.1.16). Once this plane is
entered, gently dissect the bladder away using small amounts of monopolar
energy with blunt dissection or sharply with the Metzenbaum scissors (Tech Fig.
8.1.17).
■ If the rectum requires mobilization from the posterior cervix, identify a similarly
avascular plane between the rectum and vagina. This plane can be found by
incising the posterior peritoneum between the uterosacral ligaments just beneath
the cervix. Dissecting this plane mobilizes the rectum away from the posterior
vagina and cervix.
■ Identify and skeletonize the uterine vessels using a monopolar instrument to
dissect away any loose connective tissue overlying the vessels. Place a curved
clamp perpendicular to the uterine artery at the junction of the cervix and lower
uterine segment. The tip of the clamp should rest directly adjacent to the cervix
(Tech Fig. 8.1.28). Place a clamp medial to the curved clamp to prevent bleeding
from the uterus (Tech Fig. 8.1.29). Finally, cut and ligate the uterine artery (Tech
Figs. 8.1.30 to 8.1.32).
■ For an extrafascial technique, the cardinal ligament and any remaining broadligament are divided by placing straight clamps medial to the uterine vascular
pedicle and parallel to the cervix, incising with a scalpel, or radiofrequency
electrical energy, and suture ligating these pedicles until the end of the cervix is
reached (Tech Figs. 8.1.33 to 8.1.36). Colpotomy can then be made either by
placing curved clamps across the vagina just beneath the cervix. Be careful to
preserve as much vagina as possible, then amputate the cervix from the vagina
using Jorgenson scissors (Tech Figs. 8.1.37 to 8.1.39). Another technique is
to place a sponge stick in the vagina pushing anteriorly in order to delineate the
anterior vaginal apex. Using a monopolar instrument, incise the vagina where
the vaginal sponge stick is demarcated and until the sponge is identified.
Continue this incision circumferentially around the cervix with an active
electrode or with clamps placed along the vaginal–cervical junction and incise
with Mayo scissors (Tech Fig. 8.1.40). Deliver the specimen through the
abdominal incision and carefully inspect the tissue to ensure the entirety of the
cervix has been removed.
Tech Figure 8.1.28. The utero-ovarian pedicle is released once hemostatic.
Tech Figure 8.1.29. The uterine artery is clamped at the level of the internal os.
Tech Figure 8.1.30. The uterine artery is cut.
Tech Figure 8.1.31. The cut uterine artery is suture-ligated.
Tech Figure 8.1.32. The contralateral uterine artery is clamped, cut and suture-ligated.
Tech Figure 8.1.33. In this particular case, the uterus is amputated from the cervix
before completing the hysterectomy for better visualization.
Tech Figure 8.1.34. The uterus is amputated from the cervix using radiofrequency
electrical energy.
Tech Figure 8.1.35. The cervical stump is grasped with a clamp.
Tech Figure 8.1.36. The cardinal ligament is clamped with a straight clamp, cut, and
suture-ligated.
Tech Figure 8.1.37. The anterior vagina is incised, exposing the cervix.
Tech Figure 8.1.38. Curved clamps are placed on the posterior vagina.
Tech Figure 8.1.39. Jorgensen scissors are used to incise the posterior vagina and
amputate the cervix.
Tech Figure 8.1.40. Radiofrequency electrical energy is used to make a colpotomy.
■ An intrafascial hysterectomy is performed in theory to preserve the
neurovascular supply at the cervicovaginal junction by maintaining the
pubovesicocervical fascia. This technique differs from an extrafascial
hysterectomy after the uterine artery has been ligated (see Tech Fig. 8.1.41).
Make transverse incisions on the anterior and posterior surfaces of the cervix,
below the level of the uterine vasculature. Then, bluntly dissect the
pubovesicocervical fascia off the lower uterine segment and cervix (i.e., with agauze-covered finger). If the incision is made too deeply into the cervix, the
loose fascial plane can be easily missed and cause unnecessary bleeding.
Place a curved clamp inside the fascia on each side of the uterus to
incorporate the uterosacral ligaments and upper vagina just below the cervix.
Incise the vagina with Mayo scissors and amputate the uterus and cervix.
Tech Figure 8.1.41. Extrafascial versus intrafascial hysterectomy technique.
Supracervical hysterectomy
■ In order to preserve the cervix, transect the cardinal and broad ligaments midway
between the level of the internal and external cervical ostia. Then, amputate the
cervix with a scalpel or a monopolar instrument. To avoid continued cyclical
bleeding from retained endometrial tissue, use an electrocautery loop or
radiofrequency energy to resect or fulgurate the endocervix.7 Use a large
absorbable suture, to approximate the cervical stump in either a running fashion
or with interrupted figure-of-eight sutures.
Vaginal cuff closure
■ Place Kocher clamps on the anterior and posterior aspects of the vaginal cuff.
Using large absorbable suture, secure both angles with figure-of-eight stitches
being careful to incorporate full thickness vagina with vaginal mucosa in each
stitch. If curved clamps are used to incise the vagina, then the clamps at each
angle can be used to facilitate angle stitch placement. Once the angles are
secured, place interrupted figure-of-eight stitches between the angles to close
the vaginal cuff and to achieve hemostasis.
■ The association between hysterectomy and pelvic organ prolapse is
controversial; however, many experts agree that the vaginal apex should be
suspended at the time of hysterectomy. This can be accomplished either by
performing an intrafascial hysterectomy or by incorporating the uterosacral
ligaments in the vaginal cuff closure, specifically while placing the angle stitches.8
Unfortunately, there is no data to support either method. Therefore, the decisionto perform an apical suspension and the technique are largely based on surgeon
preference.
Abdominal closure
■ Thoroughly irrigate the pelvis with warm saline or Ringer’s lactate solution.
Confirm hemostasis of all pedicles and inspect the bladder and ureters. For a
vertical incision, it is not required to close the peritoneum. Approximate the fascia
with permanent suture in a running unlocked fashion. Fascial closure of a
Pfannenstiel or Maylard incision may be performed using large delayed
absorbable suture. A Cherney incision requires a more tailored closure in order
to provide additional support for the approximated musculature. Close the
peritoneum using a running absorbable stitch. Transfix the ends of the rectus
tendons to the inferior portion of the lower flap of the rectus sheath with five or six
interrupted delayed-absorbable or permanent sutures in a horizontal mattress
configuration. To avoid osteomyelitis, do not suture the rectus muscles to the
periosteum of the symphysis pubis.PEARLS AND PITFALLS
To avoid ureteral injury, open the peritoneum and identify the ureter along the medial
leaf inferior to the gonadal vessels.
Retroperitoneal dissection is easiest with a blunt instrument such as the Yankauer
suction tip.
The urinary bladder should be dissected off the cervicovaginal junction prior to
ligation of the uterine arteries.
To help identify the cervicovaginal junction, insert a sponge stick (4 × 4 cm sponge
folded into a ringed forceps) into the vagina applying pressure in a caudal and
anterior direction.
If excessive bleeding is encountered, a clamp should never be placed blindly which
may cause inadvertent injury. Instead, hold pressure with a finger or sponge and
identify key structures prior to vessel ligation.
Use the 0-vicryl tie on the specimen side of the IP ligament to secure the ovaries to
the Kelly clamp on the uterine cornua for better exposure.
In order to optimize exposure, large uteri with benign disease can be removed in a
supracervical fashion, followed by removal of the cervix secondarily.
Placing the patient in a small degree of Trendelenburg helps to clear the pelvis of
bowel and improve exposure.
Prior to terminating the procedure, inspect all vascular pedicles and the vaginal cuff
to assess for hemostasis.
If delineation of the urinary bladder proves difficult, the bladder can be back-filled
with sterile milk or methylene blue which will identify any defects.
Use sterile water to irrigate instead of saline for clear visualization of bleeding
vessels.
POSTOPERATIVE CARE
■ The average length of hospital stay after abdominal hysterectomy in the
United States is 3 days.9 Routine postoperative care includes monitoring a
patient’s fluid and hemodynamic status, pain control, and rehabilitation
toward resuming normal diet and activity. Postoperative pain is often
initially controlled with intravenous medications such as narcotics and
nonsteroidal anti-inflammatory drugs (NSAIDs). Patient-controlled
analgesia is also frequently used. Parenteral analgesics may be transitioned
to oral medications fairly rapidly, as soon as the same day of surgery or the
first postoperative day. An early transition to oral medications should be
encouraged to reduce the effects of intravenous narcotics on the bowel.
■ Typically, postoperative colonic stasis resolves after 3 days. Evidence doesnot support the routine use of nasogastric tubes to decrease this interval.10
Early feeding of a regular diet is recommended which may help stimulate
the bowel and decrease the length of hospital stay. Early ambulation, as
soon as the night of surgery, is recommended
■ Remove the bladder catheter within 24 hours after surgery and as early as
the day of surgery. Bladder catheter discontinuation by postoperative day 1
decreases urinary tract infections.11
■ Upon discharge from the hospital, the patient is encouraged to resume
normal activity as quickly as is comfortable with a few exceptions. These
include abstaining from sexual intercourse to allow the vaginal cuff to heal
and abstaining from heavy lifting greater than 10 pounds to prevent fascial
dehiscence for 6 weeks. Unfortunately there is no strong evidence to
support these recommended limitations; however, studies implicate vaginal
intercourse as the most common inciting event in vaginal cuff dehiscence.12
The patient should be seen within 2 to 4 weeks postoperatively by her
physician for a gentle vaginal and abdominal examination to ensure her
incisions are healing well.
OUTCOMES
■ The outcomes of abdominal hysterectomy are very good. Without
complication, most patients fully recover and are pain free within 4 to 6
weeks after surgery. Most women report symptom relief, no change in
sexual function, and satisfaction with the procedure. Complication rates are
low, and the rate of unintended major surgical procedures such as operative
injury to intra-abdominal organs requiring repair or return to the operating
room within 8 weeks postoperatively is approximately 0.3% to 0.7%.13
COMPLICATIONS
■ The most common major complications after abdominal hysterectomy are
hemorrhage, urinary tract injury, and bowel injury.13 Hemorrhage
complicates approximately 2% of abdominal hysterectomies, with an
average blood loss of 300 to 400 mL.13 Careful intraoperative inspection of
pedicles before closure may help prevent this complication. Diligent
attention to a patient’s postoperative hemodynamic status, including vital
signs and oliguria, is necessary to identify excessive bleeding early and to
reduce the patient’s risk for long-term sequelae. Depending on the source of
bleeding, the approach may differ in evaluation and treatment. When the
patient is stable and hemorrhage of any kind is suspected, CT imaging of
the abdomen and pelvis with intravenous contrast provides the best way to
identify active intra-abdominal hemorrhage. Stable patients with
intraperitoneal hematoma can be managed expectantly or with radiographicembolization of the hypogastric vessels. Clotting parameters should be
checked and any coagulopathy should be treated to expedite bleeding
resolution. In contrast, an unstable patient with a surgical abdomen should
return to the operating room as quickly as possible for surgical exploration.
Profuse vaginal bleeding may resolve with an examination under anesthesia
and additional vaginal cuff suture placement at the site of bleeding.
■ Suspected intraoperative urinary tract injury must be evaluated and
repaired if present. A postoperative ureteral injury may be asymptomatic or
may present as flank or groin pain, fever, or prolonged ileus. The incidence
of ureteral injury after total abdominal hysterectomy is 0.4 of 1,000 and
the incidence of bladder injury is less than 1%.13 Ureteral injury most
commonly occurs while ligating the ovarian vessels or the uterine artery.
Urinary bladder injury occurs most commonly during bladder dissection off
the lower uterine segment, cervix, and upper vagina. Therefore,
identification of the ureter through retroperitoneal dissection and careful
dissection of the vesicouterine peritoneum to push the bladder away from
the cervix thus displacing the ureter laterally is essential to reduce the risk
of urinary tract injury.
■ Bowel injuries primarily occur during adhesiolysis or upon entering the
abdominal cavity and have a reported incidence of approximately 0.2% to
1%.13 Superficial serosal defects do not require repair; however, injuries
involving the muscularis or the mucosa require primary repair either with
direct closure or resection/anastomosis depending upon the size of the
injury. Small injuries to the bowel do not require postoperative dietary
restrictions or a nasogastric tube. The risk of small bowel obstruction after
abdominal hysterectomy is 13.6/1,000 and presents most commonly with
abdominal distention, abdominal pain, vomiting, and an inability to pass
flatus.13 Abdominal films can confirm the diagnosis. The majority of small
bowel obstructions resolve with conservative management that includes
nasogastric tube placement and parenteral hydration. Persistent obstruction
despite these measures may require surgical correction.
■ Other complications of abdominal hysterectomy include infection,
thromboembolic disease, and vaginal cuff dehiscence. Routine prophylactic
antibiotics reduces postoperative infection overall; however, despite their
administration, a low rate of urinary tract (4%), wound (3%), vaginal
(0.2%), and intra-abdominal (0.1%) infections remains.14 Subcutaneous or
intra-abdominal abscesses may require drainage by either re-opening the
abdominal incision and applying packing, or by placing percutaneous drains
(Fig. 8.1.3). For women receiving thromboembolic prophylaxis for
abdominal hysterectomy, the rate of VTE is 0.2%.14 A postoperative patient
who develops localized tenderness, asymmetric swelling in an extremity,dyspnea, pleuritic pain, tachypnea, or tachycardia should be evaluated for
pulmonary embolism and deep VTE and treated accordingly. Vaginal cuff
dehiscence is a rare complication that can become a surgical emergency if
bowel eviscerates and becomes incarcerated. The risk of vaginal cuff
dehiscence after abdominal hysterectomy is approximately 0.12%.13 A
woman may present with abdominal pain, profuse vaginal discharge, pelvic
or vaginal pressure, or protrusion of bowel from the vagina. A simple
dehiscence may be repaired vaginally; however, in the case of evisceration
the bowel must be carefully inspected for damage which requires
abdominal exploration.
Figure 8.1.3. Pelvic abscess after hysterectomy.
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