hysterectomy

Question 1

Indications for hysterectomy

Answer 1

• Heavy menstrual bleeding
• Fibroids
• Uterovaginal prolapse
• Malignant disease- endometrial, ovarian, cervical
• Chronic PID
• Endometriosis

Question 2

Procedure for vaginal hysterectomy

Answer 2

• GA -
• Lithotomy position, clean drape
• Bimanual to assess size and descent uterus
• Cervix grasped with 2x vulsella
• Infiltrate subepithelial tissues 10-15ml lignocaine and 1:200,000 adrenaline - defines planes and reduces bleeding
• circumferential incision around cervix and vaginal mucosa reflected upwards
• cervicovesical ligament divided anteriorly with scissors to allow reflection of bladder off cervix with care to reflect ureters laterally and upwards, peritoneum overlying uterus should become visible
• cervix lifted upwards to reveal PoD peritoneum, opened with blunt scissors. marker suture to posterior edge
• cervix moves to pts right, surgeon finger behind left cardinal ligament and uterosacral ligament, tissue forceps, cut medial and suture laterally to forceps. then repeat on right
• uterovesical peritoneal pouch is opened
• clamping dissection and ligation of uterine vessels bilaterally
• round ligament, ovarian ligament and Fallopian tube are clamped divided and ligated. uterus and cervix removed.
• inspect ovaries - +/- reinforce uterosacral ligaments with further suture inc lateral angle and posterior peritoneal edge (provide vault support and reduce enterocoele formation
• pedicles checked for homeostasis, vaginal vault is closed continuous or interrupted
• 24hr IDUC +- vaginal pack
• suture material polyglycolic acid (vicryl) or polyglactin (dexon)

Question 3

complications hysterectomy

Answer 3

• frequent risks:
  
  • infection
  • bruising
  • frequency of micturition
  • delayed wound healing
  • keloid formation
  • ovarian failure
  • altered skin sensation around scar
• Serious risks include:

● the overall risk of serious complications from abdominal hysterectomy is approximately 4/100 (common)

● damage to the bladder and/or the ureter (7/ 1000) and/or long-term disturbance to the bladder function (uncommon)

● damage to the bowel: 4/ 10 000 (rare)

● haemorrhage requiring blood transfusion, 23/1 000 (common)

● return to theatre because of bleeding/wound dehiscence, and so on: 7/ 1000 (uncommon)

● pelvic abscess/infection: 2/ 1000 (uncommon) ● venous thrombosis or pulmonary embolism, 4/1000 (uncommon) ● risk of death within 6 weeks, 32/ 100 000 (rare). The main causes of death are pulmonary embolism and cardiac disease.

Question 4

indications abdominal hysterectomy (over vaginal)

Answer 4

uterine size >12/40 endometriosis or PID hx prior CS malignant disease long vagina and/or narrow pelvic arch making vaginal approach technically difficult

Question 5

why would you perform a subtotal hysterectomy

Answer 5

womens preference technical difficulty of total (adhesions, endometriosis) will require ongoing smears, may get cyclical spotting or bleeding

Question 6

procedure for abdominal hysterectomy

Answer 6

-GA anaesthetic -IDUC, clean, prep, drape -skin incision subumbilical midline or lower transverse -rectus sheath incised and extended with scissors rectus muscles separated -peritoneum carefully entered bluntly or with scissors -loops of bowel removed from pelvis, packed and head down tilt -medium sized straight tissue forceps (kosher)placed on either side of uterus over Fallopian tubes and round ligaments - round ligaments clamped with curved tissue forceps ( Mayo) at midpoint and cut and secured - posterior fold broad ligament dissected - to preserve ovaries ovarian ligament (+- Fallopian tube) clamped, cut and sutured using larger tissue forceps ( Zeppelin or Maingot) - to remove ovaries zeppelin placed lateral to ovaries over infundibular pelvic ligament (with identification of ureters) -bladder is reflected by incision of uterovesical peritoneum and gentle downward pressure (minimises chance of bladder damage and moves ureters laterally away from cervix and upper vagina) - uterine artery clamped and ligated (with identification of ureter) using a zeppelin at right angles to uterus at midpoint -paracervical tissue clamped with zeppelin and divided with knife to reach vaginal angles (with out including any vaginal epithelium) - repeat for uterosacrals - ensure adequate reflection of bladder and pass knife into anterior fornix of vagina and dissect to the right and. left - posterior fornix incised under direct vision - secure pedicles - vaginal vault left open or closed continuous or interrupted - suture = vicryl or dexon - check all pedals for haemostasis, peritoneum left open - sheath closed with continuous vicryl, skin staples interrupted or subcuticular -IDUC for 24 hours

Question 7

risks and benefits of BSO at time of hysterectomy

Answer 7

Benefits: if genetic risk of breast/ ovarian cancer (BRCA mutation) risk reducing BSO is only way to reduce cancer risk - reducing perceived risk breast cancer - no clear age at which women may benefit from BSO but <65 clearly benefit from ovarian conservation Risks: - increased mortality due to coronary heart disease - depression, anxiety - increased morbidity and mortality due to osteoporosis fractures - increased risk of cognitive dysfunction including dementia -in premenopausal women more prolonged and severe vasomotor symptoms and reduced libido and sexual function