MANAGEMENT

SESSION

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Presenter :- Wondu (MD, OBGYN Resident)

6/7/2024 2
 OUTLINE
• INTRODUCTION
• INCIDENCE
• INDICATION
• SELECTING THE ROUTE OF HYSTERECTOMY
• FACTORS THAT INFLUENCE THE ROUTE OF HYSTERECTOMY
• ABDOMINAL HYSTERECTOMY
• VAGINAL HYSTERECTOMY
• RADICAL HYSTERECTOMY
• PERIPARTUM HYSTERECTOMY
• REFERENCE
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 • A hysterectomy is surgery to
remove uterus.
INTRODUCTION • It may also involve removal of
the cervix, ovaries, Fallopian
tubes, and other surrounding
structures.

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 Epidemiology

• It is a very common type of surgery for women in the United

States.
• The rate of hysterectomy in the United States was 1.62/1,000
women.
• Third most commonly performed reproductive surgical procedure
after cesarean delivery and repair of obstetric laceration.
• The rate of inpatient hysterectomy between 1998 and 2010
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decreased, with 36% fewer hysterectomies performed in 2010
 Hysterectomy is the most commonly performed gynecological
surgical procedure

 600,000 hysterectomies are performed yearly (US)

 90% done for benign conditions

 Abdominal hysterectomy was more common than vaginal

hysterectomy (65% vs. 35%)

 Proportion of vaginal hysterectomies performed with

laparoscopic assistance doubled (from 13% to 28%)
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 Indications for
Hysterectomy

• Uterine fibroids
• Abnormal vaginal bleeding
• Endometriosis / Pelvic
pain
• Benign ovarian neoplasms
• Uterine prolapse
• Gynecologic cancer 7
 TYPES OF HYSTERECTOMY

• Hysterectomy can be classified based on the routes

 Transabdominal route
 Transvaginally
 Laparoscopically or
 Caesarean Hysterectomy ( peripartum )
 Combinations of several techniques can be selected, such as a
laparoscopically assisted vaginal hysterectomy.

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 Type of tissue removed

Hysterectomy can be classified

 Total hysterectomy: removal of the
uterus and cervix.
 supracervical hysterectomy
removal of the body of the uterus
leaving the cervix behind.
 Radical hysterectomy: removal of the
uterus and cervix, the parametrium, a
vaginal cuff and part of or the whole
of the fallopian tubes.
 Time: emergency or elective

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 SELECTING THE ROUTE OF HYSTERECTOMY

• Surgical considerations — The choice of hysterectomy route is individualized

to the patient. Important factors include:
• Extent of gynecologic pathology
• Relative risks and benefits of hysterectomy route
• Need to perform additional procedures
• Patient preferences
• Surgeon’s competence

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 Which Route is Best?
• Abdominal Hysterectomy

 Results in greatest mean blood loss

 Has the highest incidence of febrile morbidity

 abdominal wound infection

 Longest hospitalisation

 slowest to recover

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 Vaginal Hysterectomy(VH)

 Is the preferred route when technically possible

 Vaginal hysterectomy is the method of choice
 In patients with benign gynaecological diseases
 Patients of advanced age and small uterus size
 VH procedure has some advantages over AH procedure,
including less complications, shorter hospital stay, and faster
recovery.
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 Laparoscopic Hysterectomy

 Requires training and equipment

 Longest operating time

 shortest hospitalization and recovery

 LH is associated with less hospital stay,

 less blood loss and use of analgesics

 There is debate about its cost effectiveness

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14
 FACTORS THAT INFLUENCE THE ROUTE OF
HYSTERECTOMY
• Uterine characteristics

 Uterine size greater than 12 weeks has historically been an

indication for AH.
 While a narrow pubic arch (< 90 degrees), a narrow vagina, an
undescended immobile uterus, and nulliparity have been
traditionally proposed as contraindications for VH.

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 Extrauterine pathology

• Disease outside the uterus, such as adnexal pathology, obliterated

cul-de-sac, endometriosis, pelvic adhesions, may prevent vaginal
hysterectomy.
• However, laparoscopy can be useful in these cases to assess
pelvic anatomy and pathology before choosing route of
hysterectomy.

• Prior cesarean delivery

• Clinician and patient factors 16

 Abdominal Hysterectomy

• Removal of the uterus via the abdominal route.

 Total hysterectomy
 supracervical

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 PREOPERATIVE

• PREOPERATIVE EVALUATION AND MANAGEMENT

 Hx and physical examination which may affect surgical route and
timing.
• Investigations
– Complete blood count, OFT
– Blood group and RH
– Cross matched blood
– Other tests based on indication
– in the setting of anemia, appropriate iron and nutrient
supplementation. 18
 Consent
• For most women with indications, hysterectomy is a safe and effective
treatment that typically leads to an improved postoperative quality of
life and psychologic outcome
• pelvic organs may be injured during surgery, and vascular, bladder,
ureteral, and bowel injury are most common.
• The risks of wound infection, blood loss, and transfusion are discussed
with the patient before surgery.
• Patients should understand the sterilizing effects of hysterectomy.

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 Total Vs supracervical hysterectomy
 Retention or removal of the cervix should be addressed with a patient
preoperatively.
 Retaining the cervix commits the patient to continued cervical
cancer screening
 The only absolute contraindication to subtotal hysterectomy is the
presence of a malignant or premalignant condition of the uterine
corpus or cervix.

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 Advantages of supracervical hysterectomy

• It is easier and quicker than total hysterectomy.

• For hemodynamically unstable or with extensive adhesions

• 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

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

• When compared to complete hysterectomy, supracervical

hysterectomy was associated with statistically but not clinically
significant reductions in operating time (11 minutes) and
estimated blood loss (57 cc).

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 Immediate postoperative fever and urinary retention were less
common in women after SCH.
 Urogenital fistula is less likely to develop after supracervical
hysterectomy but is rare (1/2,279 vs 1/540).
 After supracervical hysterectomy, 1% to 2% of women undergo
trachelectomy, most commonly for cervical prolapse.

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 Risk-reducing salpingo- oophorectomy
 In a woman at high risk of ovarian or breast cancer
 Prophylactic salpingo-oophorectomy
 For women at an average risk or those with a hereditary ovarian
cancer syndrome.

• Alternatives to BSO for ovarian cancer risk reduction

 Remove the fallopian tubes: 65%
 Tubal ligation: 34%
 Hysterectomy alone: 34%

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 Preoperative antibiotics

• 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.
• Redosing is recommended after 3 hours of surgery and with
excessivebleeding

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Perioperative Checklist

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 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

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 Surgical Technique
• The choice of incision :
 Simplicity of the incision
 Need for exposure
 Potential need for enlarging the incision
 Strength of the healed wound
 Cosmetics of the healed incision
 Location of previous surgical scars

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 INDICATION ABDOMENAL HYSTERECTOMY

 When uterine or adnexal disease, adhesions contribute to

anatomic distortion
 Experienced gynecologic surgeon
 Cardiopulmonary disease ( risks of anesthesia or intra-abdominal
pressure)
 Known or suspected malignancy
 Lack of facilities, instrumentation, or expertise to perform vaginal
or laparoscopic hysterectomy.
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 Surgical steps
• opening Abdomen and exploration

• Round ligament and peritoneum

• Infundibulopelvic ligament and adnexa

• Mobilization of bladder

• Cardinal Ligament

• Ampitation and closure of Vagina

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• Closing Abdomen
 Elevation of the Uterus
 The uterus is elevated by
placing broad ligament
clamps at each cornu.
 The distal portion of the round
ligament is ligated with a
suture .
 vesicouterine fold, separating
the peritoneal reflection of the
bladder from the lower uterine
segment 31
• Ligation of the round
and ovarian/infundibulopelvic
ligaments
• It is useful to ligate the round
and ovarian/infundibulopelvic
ligaments at an early stage in
the procedure so as to leave
the operative field as clear as
possible.

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 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.

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• 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

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 Sites of ureters injury

 1.The ureters enter the pelvis at

the pelvic brim at this point, the
ureter runs just medial to the
ovarian vessels .
 2.The ureters then descend into the
pelvis within a peritoneal sheath
(ureteric fold) attached to the
medial leaf of the uterine broad
ligament and the lateral pelvic
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sidewall .
 3. Just inferior to the internal
cervical os, the ureter passes
under the uterine arteries in
the cardinal ligament.

 4. The ureters then pass close

to the anterolateral fornix of
the vagina and enter the
posterior aspect of the bladder.
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 During laparoscopic surgery
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 Incising the uterovesical fold.
Reflecting the bladder

• It is logical to incise the peritoneum

overlying the bladder along the line
of the uterovesical fold.
• It is simple to run the scissors
under the tented peritoneum,
separating the bladder,

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 Uterine Vessel Ligation
• The uterus is retracted cephalad and
deviated to one side of the pelvis
• The uterine “skeletonized” from any
remaining areolar tissue
• a curved 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 .
• The vessels are cut, and the pedicle is
ligated.
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 Cardinal Ligament Ligation

• The cardinal ligament is divided by

placing a straight 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.
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 Incising the vagina (showing all clamps in place)

Removal of the Uterus

• The uterus is placed on traction

cephalad, and the tip of the cervix
is palpated.
• Curved clamps are placed
bilaterally, incorporating the
uterosacral ligament and upper
vagina just below the cervix.
• Care should be taken to avoid
foreshortening the vagina. 41
 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 , incorporating
the uterosacral and cardinal ligament at
the angle of the vagina
• A running-locked or figure-of-eight sutures
can be used for hemostasis along the cuff
edge

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 Concluding steps

• All sites are examined carefully for

bleeding

• Check integrity of urinary tract;

inspection or selective cystoscopy

• Inspect each pedicle for

hemostasis

• Pelvic peritoneum closure or not

• Count
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• Laparotomy closure
 VAGINAL HYSTERECTOMY

• Vaginal hysterectomy is a surgical procedure to remove the uterus

through the vagina.

• In general, this approach is chosen by surgeons if the uterus is

relatively small, extensive adhesions are not anticipated, no
significant adnexal pathology is expected, and some degree of
pelvic organ descent is present.
• During approach selection, if all factors are equal, vaginal
hysterectomy is preferred.
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• There are no absolute contraindications to vaginal hysterectomy.

• Relative anatomic contraindications include malignancy,

extremely enlarged uterine size, and significant pelvic adhesions.

• Patient characteristics that can make a vaginal approach to

hysterectomy more challenging include nulliparity, increased body
mass index, history of pelvic radiation, and lack of uterine descent.

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 Technique for Vaginal Hysterectomy

• Adequate general or regional anesthesia

• patient is placed in standard lithotomy position to achieve full

access for surgeon and surgical assistants

• Evaluate pelvic arch and vaginal caliber.

• Assess size of the uterus and mobility (uterine descent).

• Rectovaginal exam to assess adnexa and for any extrauterine

pathology.
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 Vaginal Incision
• Infiltrate vasoconstrictive agents
into the vaginal epithelium if
desired.
• Grasp both lips of the cervix locate
the cervical-vaginal junction.
• If posterior entry is desired first,
elevate the uterus, make an
incision from 4 to 8 o'clock, through
full-thickness vaginal epithelium,
and incised the posterior 47

it
• Confirm posterior cul-de-sac entry.
• Place long weighed speculum into
posterior cul-de-sac.
• Retract bladder anteriorly with a
vaginal retractor.
• Create anterior vaginal incision
from 10 to 2 o'clock; continue
anterior dissection and enter
peritoneum.
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 Separate Ligamentous Attachments

• Clamp the uterosacral ligament.

• Cut and suture ligate the

uterosacral ligament.

• Grasp the cardinal ligament Cut

and suture

• Proceed with anterior entry into the

anterior culde-sac if not already
accomplished.

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 Secure the Blood Supply

• Identify the uterine vessels.

• Secure the uterine vessels between the anterior and posterior

peritoneum

• Clamp at the level of the internal os.

• Cut and suture ligate.

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 Deliver the Fundus Posteriorly
• After the blood supply is secured,
grasp the fundus of the uterus.
• Deliver the uterine fundus through the
posterior cul-de-sac.

• Secure the utero-ovarian vessels;

typically, these are doubly clamped
and ligated.

• 6/7/2024
Remove the uterus. 51
 Cuff Closure
• Attach the cuff to the uterosacral
ligament for apical support;
consider McCall culdoplasty.

• Perform cuff closure either in an

interrupted or running fashion.

• Perform cystourethroscopy to
document bladder and ureteral
integrity.

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 LAPAROSCOPIC HYSTERECTOMY

 Innovations in technology led to the performance of the first

laparoscopic hysterectomy in 1989.

 As of 2009 United States surveillance data, the distribution of

surgical approach to hysterectomy for benign disease was 56
percent abdominal, 20 percent laparoscopic, 19 percent
vaginal, and 5 percent robotic.

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 Laparoscopic approach may be favored in patients who are
morbidly obese, who have a constricted pelvic anatomy

 Laparoscopic hysterectomy is particularly useful in patients with

limited vaginal access, a fixed immobile uterus, and in those
women who desire supracervical hysterectomy.

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 Type of laparoscopic hysterectomy

Total laparoscopic hysterectomy (TLH)

 The entire procedure, including suturing of the vaginal vault,
is performed laparoscopically.
 Alternately, some surgeons may prefer to suture the vaginal
cuff using a vaginal approach.
 The uterine specimen is typically removed through the
vaginal vault, either intact or after morcellation.
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 Laparoscopic subtotal (supracervical) hysterectomy (LSH)

The uterine specimen is morcellated and removed

through the abdominal ports or incisions.
A systematic review of 40 studies published in 2014
reported the rate of urinary tract injury in TLH to be
approximately 0.84%, which fell to under 0.23% with LSH.

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 COMPLICATIONS
 Data from large studies of laparoscopic hysterectomy report
the following rates of complication:

 Conversion to laparotomy – 2.7 to 3.9 percent

 Hemorrhage – 2 to 5.1 percent

 Urinary tract injury – 1.2 to 3 percent

 Vaginal cuff dehiscence – 1 to 2 percent

 Bowel injury – 0.2 to 0.4 percent

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 RADICAL HYSTERECTOMY

 The excision of the uterus and cervix with the parametrium (ie, round,
broad, cardinal, and uterosacral ligaments) and the upper one-third to one-
half of the vagina.
The surgeon usually also performs a bilateral pelvic lymph node
dissection.
The procedure requires a thorough knowledge of pelvic anatomy,
meticulous attention to sharp dissection, and careful technique to allow
dissection of the ureters and mobilization of both bladder and rectum
from
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the vagina. 58
  Particular care must be taken with the vasculature of the
pelvic side walls and the venous plexuses at the lateral corners
of the bladder to avoid excessive blood loss.

 Removal of the ovaries and fallopian tubes is not part of a

radical hysterectomy; they may be preserved if clinically
appropriate.

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 INDICATIONS
 Radical hysterectomy is performed as a primary therapy for:

 Stage IB or IIA cancer of the cervix.

 Selected patients with stage II adenocarcinoma of the

endometrium in whom radical surgery seems feasible.

 Upper vaginal carcinoma,

 uterine or cervical sarcomas, and

 malignancies confined to the area of the cervix, uterus, and/or

upper vagina.
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Types of radical Hysterectomy

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 PERIPARTUM HYSTERECTOMY

 Peripartum hysterectomy can be defined as a hysterectomy

performed at the time, or within 24hrs of delivery or Any time from
delivery to discharge from the same Hospital.
 lifesaving surgical procedure that should be within the capabilities
of all obstetricians

 associated with maternal morbidity and mortality, especially in

developing countries
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  Figure 1: Changes in rate of peripartum hysterectomy from the Nationwide
Patient Sample, United States, 1994–2007. (Data from Bateman BT, Mhyre JM,
Callaghan WM, et al:
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 Pelvic physiologic changes

 Blood vessels throughout the pelvis are dilated and varices

 The uterus is large and fills the pelvis

 The cervix may be quite soft and difficult to identify

 Tissues may be friable and prone to tear when clamped

 The bladder wall may be edematous and friable during labor

 The myometrium surrounding an invasive placenta may be very thin or

absent
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 Preparation Needed
 Informed consent

 Notify the anesthesia team

 Ensure adequate IV access

 Prophylactic antibiotics and intraoperative redosing

 Thromboprophylaxis

 Cross-match

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 Postoperative care

 The average length of hospital stay after AH in the United States is

three days.

 Routine postoperative care includes monitoring of a patient's

hemodynamic and fluid status, pain control, and reintroducing normal
diet and activity.

 Postoperative pain control is a critical part of a satisfactory surgical

outcome.
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 Bladder Drainage

 Overdistention of the bladder resulting from bladder trauma or

 The patient’s hesitation to initiate voiding.

 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.

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 Discharge instructions

 A woman is encouraged to resume her normal daily activities as quickly

as is comfortable.

 She may return to work as soon as she has regained sufficient stamina
and mobility.
 We ask that patients avoid heavy lifting(20lbs) for 4 to 6 weeks to
minimize stress on the healing fascia.

 Vaginal intercourse is also discouraged for 6 weeks to prevent cuff

infection and allow the vaginal cuff to heal completely.
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 Reference
 Te Linde's Atlas of Gynecologic Surgery (2014), 12th Edition chapter 2 - 5 page 15 - 45

 Berek Operative Techniques Gynecologic Surgery 2017 chapter 8 page 192- 268

 Bonney’s Gynaecological Surgery 12th edition chapter 11 page 116- 133

 Berek & Novak’s Gynecology 6th edition Chapter 27 Page 1407 - 1556

 Williams obstetrics, 4th edition. chapter 43 page 956 - 969

 Te Linde's Operative Gynecology, 12th Edition chapter 19- 21 page 574- 640

 Up-to-date 21

 Atlas
6/7/2024 of Pelvic Anatomy and Gynecologic Surgery 5th EDITION chapter 13 & 14 page 230 -6469
Thank You
Thank You

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