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Total Abdominal Hysterectomy

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Hysterectomy Classification

Diagram of female reproductive system with labels indicating types of hysterectomies.

Source: Williams Gynecology 2nd edition

Preoperative Issues

  • Indications and alternatives
    • Informed consent
  • Surgical planning
    • Incision choice
    • Elective oophorectomy
    • Total versus subtotal

Prophylactic Antibiotics

  • Cephalosporins are the antibiotics of choice
    • Adjust dose for Body Mass Index (BMI) >35
  • Should be administered just before induction
  • Redosing should occur if surgery > 3 hrs or blood loss >1500ml
  • Agents of choice in women with hypersensitivity to penicillin or cephalosporins include:
    • Clindamycin plus gentamycin or quinolone
    • Metronidazole plus gentamycin or quinolone

Prophylaxis for Venous Thromboembolism

Risk Classification for Venous Thromboembolism in Patients Undergoing Surgery Without Prophylaxis

Level of Risk Definition Successful Prevention Strategies
Low Surgery lasting less than 30 minutes in patients younger than 40 years with no additional risk factors No specific prophylaxis; early and "aggressive" mobilization
Moderate Surgery lasting less than 30 minutes in patients with additional risk factors; surgery lasting less than 30 minutes in patients aged 40-60 years with no additional risk factors; major surgery in patients younger than 40 years with no additional risk factors Low-dose unfractionated herapin (5,000 units every 12 hours), low molecular weight heparin (5,000 units dalteparin or 40 mg enoxaparin daily), or intermittent pneumatic compression device
High Surgery lasting less than 30 minutes in patients older than 60 years or with additional risk factors; major surgery in patients older than 40 years or with additional risk factors Low-dose unfractionated heparin (5,000 units every 8 hours), low molecular weight heparin (5,000 units dalteparin or 40 mg enoxaparin daily), or intermittent pneumatic compression device
Highest Major surgery in patients older than 60 years plus prior venous thromboembolism, cancer, or molecular hypercoagulable state Low-dose unfractionated heparin (5,000 units every 8 hours), low molecular weight heparin (5,000 units dalteparin or 40 mg enoxaparin daily), or intermittent pneumatic compression device/graduated compression stockings + low-dose unfractionated heparin or low molecular weight heparin

Consider continuing prophylaxis for 2-4 weeks after discharge

 

Modified from Geerts WH, Pineo GF, Heit JA, Bergquist D, Lassen MR, Colwell CW, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference in Antithrombotic and Thrombolytic Therapy. Chest 2004;126(suppl):338S-400S.

Supracervical Hysterectomy

  • Lack of data demonstrating clear benefits of a supracervical hysterectomy. No difference in the following:
    • Sexual function
    • Urinary symptoms
    • Future pelvic organ prolapse
  • Potential advantages of a supracervical hysterectomy over total hysterectomy is a decrease in operative time and blood loss (though transfusion rates are similar)
  • Potential complications of a supracervical hysterectomy include:
    • Cyclical vaginal bleeding
    • Need for continued cervical cancer screening
  • Contraindications:
    • Suspected cancer
    • Current or recent cervical dysplasia
    • Endometrial hyperplasia

Elective Oophorectomy<

  • Factors favoring oophorectomy
    • Genetic risk for ovarian cancer
    • Bilateral ovarian neoplasms
    • Severe endometriosis
    • Pelvic Inflammatory Disease (PID) or tubo-ovarian abscesses
    • Postmenopausal status
  • Factors favoring ovarian conservation
    • Premenopausal status
    • Desire for fertility
    • Impact on sexual function/libido/quality of life
    • Osteopenia/osteoporosis or risk factors

Indications for Hysterectomy

  • Abnormal bleeding
  • Leiomyoma/Adenomyosis/Endometriosis (with endometriosis consider bilateral salpingooophorectomy (BSO)
  • Pelvic organ prolapse (add cuff support procedure)
  • PID unresponsive to medical or interventional treatment
  • Malignant disease

Relative Indications for Abdominal Hysterectomy

  • Large leiomyoma, abnormal position of leiomyoma
  • Uterus >12 week size
  • PID, extensive adhesions/endometriosis
  • Cancer, extensive metastases

Informed Consent

  1. Alternative treatment options
  2. Elective oophorectomy
  3. General risks of surgery
    • Bleeding requiring transfusion < 2%
    • Infection: Urinary tract infection is most common complication
  4. Specific risks of hysterectomy
    • Sterility
    • Potential damage to lower urinary tract or rectum requiring further surgery
    • Potential need for open abdominal surgery if vaginal hysterectomy is not feasible
  5. Specific risks associated with abdominal hysterectomy
    • Increased operative time
    • Increased complications: fever, blood transfusion
    • Longer hospital stay
    • Wound complications (seroma)

Preoperative Planning

  • Patient Positioning
    • Supine versus lithotomy
  • Instruments and Retractors
  • Incision choice
    • Transverse
    • Midline vertical
    • Obese patients
  • Prophylactic measures
    • Thromboprophylaxis
    • Preoperative antibiotics

Preparation

  • CBC (if suspected anemia)
  • Type and screen
  • Cross-match 2 units of PRBCs for Hgb< 10 g/dl
  • Current cervical screening
  • Endometrial biopsy for abnormal uterine bleeding
  • Transvaginal ultrasound advisable
  • Bowel prep not necessary
  • Enema optional

Fundamental Anatomy

  • Blood supply
    • Major blood supply from uterine arteries via cardinal ligaments
    • Ascending uterine artery branch communicates with ovarian arteries
    • Ovarian arteries
  • Bladder
  • Connected to the cervix only by 1-2 cm, then an avascular plane is entered
  • Ureters
  • Retroperitoneal structures that should be identified during a hysterectomy

Complications

  • Bleeding
    • Most common site is between utero-ovarian and uterine artery pedicles
    • Second most common is posterior vaginal cuff
  • Bladder injury
    • Cystotomy: usually occurs well above trigone, not near ureteral orifices
    • Avoid blunt dissection, especially with a history of previous cesarean delivery
  • Nerve injury: Risk factors for retractor injuries
    • Prolonged operating time (> 4 hours)
    • Improper retractor placement
    • Large transverse incision
    • Narrow Pelvis
    • BMI < 20
  • Complications

    • Nerve injuries from gynecologic pelvic surgery
      • Femoral Nerve: Typically compression against lateral sidewall from retractors
      • Obturator: Typically injuries occur with concomitant trans-obturator tape (TOT) or lymph node dissection
      • Pudendal: Injury during sacrospinous ligament fixation or pelvic reconstructive procedures during which sutures are placed in the arcus tendinous fascia
      • Peroneal: Injury can be secondary to leg positioning during surgery
      • Iliohypogastric /ilioinguinal: Usually suture entrapment at lateral angles of incision
    • Ureteral injury
      • Risk increased based on patient risk factors that distort anatomy:
        • Endometriosis
        • Obesity
        • Leiomyomas and large pelvic masses (particularly cervical)
        • Bleeding from uterine artery pedicle or lateral vaginal cuff
        • History of pelvic radiation
        • Prior pelvic surgery

Steps in Performance of Abdominal Hysterectomy

  • The round ligament is transected and the broad ligament is incised and opened.
  • Choice of instruments:
    • Large Kelly® clamp or Heaney clamp used to grasp uterine cornua
    • Kelly® clamps may be used to clamp round ligaments and divided
Illustration of round ligament being sutured.
Suture ligation of the round ligament. With permission from Mann/Stovall Gynecologic Surgery. Churchill Livingston 1996.


References

  1. ACOG Committee Opinion No 388, Reaffirmed 2013.
  2. ACOG Practice Bulletin No 21, Reaffirmed 2013.
  3. ACOG Practice Bulletin No 89, Reaffirmed 2012.
  4. Hoffman et al. Williams Gynecology, 2nd edition. McGraw-Hill, 2012.
  5. Mann WA, Stovall TG. Gynecologic surgery. Churchill Livingstone, 1996.

Contributing Authors

  • Elizabeth Deckers, MD
  • Amy Johnson, MD
  • Angela Kueck, MD
  • Christopher Morosky, MD
  • Aaron Shafer, MD
  • Joel Sorosky, MD

Developed in association with the Society of Gynecology Oncology.