🔘 Hysterectomy

Hysterectomy :-

Introduction:

• Hysterectomy is an operation in which the uterus is removed.

• The cervix, ovaries and/or fallopian tubes might also be removed.

• It may be done abdominally or vaginally.                                

• Vaginal hysterectomy usually done for some cases of uterine prolapse.

Indications:

• Fibroids

• Endometriosis

• Uterine prolapse

• Cancer of the uterus, cervix, or ovaries

• Vaginal bleeding, dub 20%

• Uncontrollable PPH

• Adenomyosis

• Rupture or injury to uterus

• Vaginal bleeding

• Pelvic inflammatory disease

• Severe pelvic adhesions

• Bilateral ovarian pathology

• Pelvic congestion syndrome

• Uterine anomalies

• Recurrent intrauterine polyps

• Uterine perforation

• Mentally retarded patient with no hygiene control

• Pregnancy 

• Placenta increta, percreta, or acreta

• Atonic uterus 

• Uterine perforation

Types/routes for Hysterectomy:

1) Abdominal hysterectomy(AH):

 Total

 Subtotal

 Radical

2) Vaginal Hysterectomy (VH)

 Laparoscopically-Assisted Vaginal (LAVH)

 Totally Laparoscopic Hysterectomy

3) Laparoscopic Hysterectomy

4) Caesarean Hysterectomy

1) Abdominal Hysterectomy:

Patient Preparation:

• For patients at risk, thromboembolism prophylaxis is begun preoperatively, or pneumatic compression boots are applied in the procedure

• Prophylactic antibiotic agent should be given as a single dose 30 minutes prior to the incision.

Incision Choice:

• Transverse or Vertical

• Need for exploration of The Upper abdomen

• Size of the Uterus

• Presence of prior incisions

• Desired cosmetic results

Procedure:

• Hysterectomy through abdomen, an incision is given over the lower abdominal skin. 

• The incision is about 5 inches, and it may be given vertically or horizontally. 

• Abdominal muscles, fascia and blood vessels are carefully separated. 

• The ligaments holding the uterus are cut. 

• Care is taken to avoid damage to adjoining healthy organs, nerves and blood vessels.

• The uterus is removed. Muscles and other organs are positioned as before and the surgical incision is closed with a suitable, medically designed thread. 

• For enlarged uterus, this route of hysterectomy is more preferred, as the surgical incision is big enough to remove the uterus without much hassles.

Post-operative care:

• Not necessary to leave a bladder catheter in place postoperatively

• IV fluids for the first 24 hours to ensure that the patient remains well hydrated

• Early feeding of a regular diet can stimulate the bowel and decrease the length of hospitalization

• Deep breathing to prevent atelectasis

• Ambulation is encouraged

• Intermittent compression boots

• Adequate control of postoperative pain

Advantages of subtotal Hysterectomy:

• It is easier and quicker than total hysterectomy 

• There is less danger of injuring the bladder. 

• Less danger of pelvic infection. 

• The cervix left to act as a support for vagina. 

• The cervix discharge lubricates the vagina

Advantages of total Hysterectomy:

• Provides better drainage of the operation area. 

• If the cervix is lacerated or infected, the source of irritant discharge is removed.

Postoperative complications of abdominal Hysterectomy:

• Shock. 

• Hemorrhage can cause anemia 

• Infection, wound dehiscence 

• Intestinal complications as acute gastric dilatation

• Pulmonary complications e.g. bronchitis, pneumonia, pulmonary collapse. 

• Venous thrombosis (DVT, SVT.) 

• Post-operative anesthetic complications e.g. cyanosis, vomiting. 

• Remote complications e.g. vaginal discharge (infection), vaginal vault prolapse, low back ache

• Menopausal symptoms e.g. sadness, irritability (in younger female). depression or sexual dysfunction 

• Incisional hernia

2) Vaginal Hysterectomy:

Introduction:

• The uterus is removed through the vagina. 

• Less invasive than abdominal hysterectomy 

• Incision site at inner vagina 

• Hospital stay 1-3 days 

• Recovery time 4-6 weeks 

• Cervix cannot be preserved

Indications of vaginal Hysterectomy:

• Some cases of uterine prolapse

• Some cases of dysfunctional uterine bleeding

• Some cases of cancer body

Vaginal Hysterectomy procedure:

• A prophylactic antibiotic agent should be given as a single dose 30 Minutes prior to the first incision for vaginal hysterectomy – cefazolin, Cefoxitin, and cefuroxime – metronidazole (500 mg IV) may be used in patients with cephalosporin allergies 

• A course of appropriate preoperative antibiotics in women with bacterial Vaginosis can reduce the frequency of cuff infection

• Patient positioning - dorsal lithotomy 

• Bimanual pelvic examination is performed – assess uterine mobility and descent – confirm that no unsuspected adnexal pathology is found 

• A bladder catheter may be inserted – some surgeons believe that a distended bladder helps with recognition of a bladder injury and thus do not use a catheter.

Advantages of vaginal Hysterectomy:

• Absence of an abdominal scar. 

• Lower incidence of intestinal complication

• An associated genital prolapse can be treated at the same time

Disadvantages of vaginal Hysterectomy:

• It is unsafe and difficult in the presence of pelvic adhesions

• The ovaries cannot be removed in some cases

• It cannot be done if the size of the uterus is larger than a 14 weeks pregnant uterus.

3) Laparoscopic Hysterectomy:

• The uterus is removed in sections through small incisions using a

• Laparoscope 

• Hospital stay 1-3 days 

• Recover time is 4-6 weeks 

• Longer duration of procedure 

• Requires greater surgical expertise 

• Urinary tract injuries are more likely 

• Fewer abdominal wall infections or febrile episodes 

• Less blood loss

Risks and side effects:

• Earlier onset of menopause 

• Greater risk of cardiovascular disease 

• Increased chance of osteoporosis and bone fractures 

• Uncontrolled urination 

• Reduced libido 

• Vaginal dryness

4) Caesarean Hysterectomy:

After Hysterectomy:

• Most women don’t need pap smears except those who had previous CIN >2 ,ca cervix or ca corpus uterus 

• Oestrogen only HRT (ERT) is an option  except when BSO was performed for oestrogen responsive cancer or severe endometriosis 

• Symptoms control in these patients can be a real problem 

• Current research suggests that ERT has many benefits and few risks.