Diagnostic Tests to Detect Occult Cancer
Prior to hysterectomy, all patients should have a baseline evaluation to detect occult cancer. A Pap smear should be performed within 3 months before operation, and abnormalities should be followed with colposcopic examination with biopsy and endocervical curettage before surgery. Cervical conization is indicated prior to hysterectomy if (1) colposcopy fails to demonstrate the entire squamocolumnar junction, where cervical cancers typically arise; (2) colposcopically guided biopsies reveal cervical intraepithelial neoplasia I or less after a preceding high-grade squamous intraepithelial lesion Pap smear; (3) endocervical curettage demonstrates atypical endocervical cells; and (4) biopsy reveals microinvasive squamous cell carcinoma or squamous adenocarcinoma in situ. Cervical conization for the last scenario is performed to ensure that occult invasive cancer is not present. Frozen-section analysis of cervical conization tissue correlates well enough with “permanent” (hematoxylin and eosin) slide analysis that if intraepithelial neoplasia with clear margins is found, the surgeon may, with reasonable certainty, perform a hysterectomy that will totally include the tumor.
Biopsy for endometrial neoplasia must also be considered in certain clinical scenarios. Generally any woman over age 35 who presents with abnormal uterine bleeding should undergo endometrial evaluation (endometrial biopsy with pipelle, D&C, or hysteroscopy with directed biopsies) before hysterectomy. However, certain clinical situations that produce an unopposed estrogen effect on the endometrium warrant preoperative endometrial evaluation at any age: chronic anovulation and secondary oligomenorrhea, unopposed estrogen therapy for menopause, and known ovarian disorders associated with endometrial neoplasia (eg, polycystic ovarian syndrome, granulosa cell tumors). Unfortunately, frozen-section analysis of endometrial curettings is neither practical nor accurate, so hysterectomy usually must wait for permanent section.
Occult cancer may also be present outside the genital tract. All patients should have their stool checked for occult blood preoperatively. In women 40 years of age or older, mammography is standard.
Preoperative Evaluation of the Pelvis
In the woman with a small, mobile uterus with mobile adnexa, little diagnostic evaluation beyond bimanual examination is indicated. However, pelvic disease may have caused disturbance of normal tissue planes that endanger the urologic and gastrointestinal tracts. The following conditions may indicate the need for more extensive evaluation of the pelvis prior to hysterectomy: (1) pelvic inflammatory disease, especially if repeated, chronic, or associated with a tubo-ovarian complex; (2) endometriosis; (3) pelvic adhesions due to other causes of pelvic inflammation (eg, appendicitis, cholecystitis, previous pelvic surgery); (4) chronic pelvic pain; (5) questionable origin of a palpable pelvic mass; and (6) clinical suspicion of cancer (eg, palpable adnexa in a postmenopausal woman).
The most commonly used preoperative adjunctive diagnostic evaluation is pelvic ultrasound, which has advantages over computed tomography (CT) scan. Ultrasound is helpful in detecting masses in the difficult-to-examine patient (eg, obese) and in confirming a pelvic mass detected on bimanual examination.
Intravenous pyelography (IVP) or CT urogram is helpful in delineating the course of the ureters through the pelvis especially in the setting of inflammatory conditions that could distort or obstruct the ureters. Also, patients with known genital developmental anomalies should have preoperative imaging to look for concomitant urologic anomalies.
Prehysterectomy evaluation of the colon (beyond screening for occult blood in the stool) is indicated in any patient with symptoms for rectal disease. In most cases, proctoscopy or flexible proctosigmoidoscopy is sufficient. In cases of severe pelvic inflammation, chronic pelvic pain, or suspected cancer, complete colonoscopy or barium enema is indicated. Preoperative diagnosis of bowel disease will aid in the selection of the incision. If necessary, a consultant gastrointestinal surgeon can be present during the operation.
Preoperative Bowel Preparation
Preoperative bowel preparation is not required prior to hysterectomy. It has been a common practice in the past to use a mechanical bowel preparation prior to hysterectomy in patients where the likelihood of bowel injury is high. However, recent data in the colorectal literature have refuted these practices. Preoperative mechanical bowel preparation is associated with increased spillage of bowel contents during elective colon resection and leads to a higher rate of anastomotic leaks and wound infections compared to no mechanical bowel preparation.
The incidence of febrile morbidity is approximately 14% in patients undergoing hysterectomy. Certain risk factors are associated with a higher likelihood of operative site infection. These factors include an abdominal surgical approach, blood loss greater than 750 mL, and no preoperative antibiotics. ACOG also recommends giving additional doses of intraoperative antibiotics during lengthy operations, given at intervals of 1 or 2 half-lives of the drug. A second dose of the prophylactic antibiotic may also be given in surgical cases with a blood loss >1500 mL. Patients diagnosed with a vaginal infection during preoperative evaluation should be treated prior to surgery.
A broad-spectrum antibiotic should be chosen that is effective against common (but not necessarily all) pathogens causing pelvic infection. The agent should have a low incidence of toxicity and side effects and should be easily administered and cost-effective. The proper dosage should be administered 30 minutes prior to incision to achieve therapeutic levels in tissue at the surgical site. It should not be an antibiotic reserved for serious infection. ACOG recommends intravenous (IV) cefazolin (1–2 g IV), clindamycin (600 mg IV), plus either gentamicin 1.5 mg/kg IV) or quinolone (400 mg IV) or aztreonam (1 g IV), or metronidazole (500 mg IV) plus gentamicin (1.5 mg/kg IV) or quinolone (400 mg IV) prior to vaginal or abdominal hysterectomy.
Hysterectomy is a major surgical procedure, carrying at least a moderate risk of thromboembolism. The risk of calf vein thrombosis, proximal vein thrombosis, and pulmonary embolism can be minimized with the use of graduated compression stockings perioperatively and early ambulation postoperatively. Sequential compression devices will help prevent stasis as well. Compression stockings and devices should be in use prior to administration of anesthesia for optimal effect. For patients at high risk for thromboembolic disease, a dose of 5000 U subcutaneous heparin is given preoperatively and then every 8–12 hours postoperatively while in the hospital. Risk factors include malignancy, obesity, previous radiation therapy, immobilization, estrogen use, prolonged anesthesia, radical surgery, history of thromboembolism, nephrotic syndrome, HIV, and personal or family history of hypercoagulability (inherited thrombophilia). Low-molecular-weight heparin may also be used postoperatively.
It is not necessary to preoperatively cross-match all patients undergoing hysterectomy. Women who are not at particular risk of needing a transfusion during hysterectomy should at least have blood typing and antibody screening prior to surgery. Patients undergoing peripartum hysterectomy or hysterectomy for gynecologic cancer are more likely to need blood transfusion. Patients undergoing elective hysterectomy are more likely to need a transfusion if the starting hematocrit is low (30%), if they have pelvic inflammatory disease or pelvic abscess or adhesions, or if colporrhaphy is performed at the time of vaginal hysterectomy.
Many women desire, and most insurance companies require, a second opinion prior to scheduling an elective hysterectomy. The patient must understand the diagnosis and be aware of alternative therapies (medical or conservative surgical options) and the risks and benefits of the operation. Common risks of surgery such as wound infection, cuff cellulitis, and blood loss are usually explained during preoperative counseling. The current medicolegal climate mandates the discussion of unusual complications, including the possibility of completing a vaginal or laparoscopic operation via an abdominal route and the risks of viral illness following transfusion, severe postoperative infection (including adnexal abscess), and vaginal vault prolapse.
Vaginal versus Abdominal Hysterectomy
The route of hysterectomy is chosen according to the following guidelines.
The ideal candidate for vaginal hysterectomy has a gynecoid pelvis with a wide pubic arch and a vaginal apex >2 fingerbreadths at the apex. Some descent of the uterus is helpful but not mandatory; procidentia makes for a more complicated vaginal hysterectomy because of the greater vulnerability of the prolapsed ureters.
Most gynecologists will perform vaginal hysterectomy on a uterus equivalent in size to a uterus at 12 weeks' gestation or smaller or a uterine weight of <280 g. More experienced surgeons have successfully removed uteri of up to 1200 g vaginally using bivalve and morcellation techniques.
In patients with symptoms or pelvic findings suggesting adnexal disease that may indicate adnexectomy, the abdominal route for hysterectomy is preferred. In addition, most surgeons offer patients the option of prophylactic removal of the ovaries after age 45 years old to decrease the risk of ovarian cancer, in spite of the lack of supporting evidence. Such patients may still undergo vaginal removal or laparoscopic-assisted vaginal hysterectomy if otherwise a good candidate for these routes.
Especially in older patients or those with significant history of gastrointestinal complaints, the abdominal approach offers an opportunity for complete examination of the bowel.
Symptomatic or potential stress urinary incontinence can be treated vaginally (suburethral sling) or abdominally (retropubic urethropexy; see Chapter 42). The route of the hysterectomy should depend on the size of the uterus and not on the planned surgical procedure for the incontinence.
Pelvic organ prolapse can be treated via a vaginal, laparoscopic, robotic, or abdominal approach, and the choice of route is often surgeon dependent (see Chapter 42)
In patients with significant heart or lung disease, the vaginal or laparoscopic approach is preferable when possible because of a lower incidence of postoperative pulmonary complications and earlier ambulation.
Most surgeons are willing to perform a vaginal hysterectomy in patients with previous tubal ligation or caesarean section. The surgery would be more problematic in patients with a history of multiple caesarean births or complications (eg, postpartum endomyometritis) or with probable abdominal adhesions from previous laparotomy. Laparoscopic-assisted vaginal hysterectomy may be used in these situations.
The preceding guidelines may certainly be adjusted to the individual patient based on the surgeon's experience and abilities. An examination performed under anesthesia when the physician first sees the patient may help to decide on the approach. Uterine size can be assessed with transvaginal ultrasound. Laparoscopic evaluation of the adnexa will further aid in the decision. All patients anticipating vaginal hysterectomy, laparoscopic hysterectomy, or laparoscopic-assisted vaginal hysterectomy should be told that the operation may have to be completed abdominally if difficulties arise.
The technique of abdominal hysterectomy varies according to the indication for the operation, the size and placement of vital structures including the ureters (which may be distorted), and the pelvic anatomy. A standard, well-organized approach to abdominal hysterectomy is essential to avoid incidental injury. Modifications are made as necessary, always within an organized plan of operation.
The anesthetic of choice typically includes general endotracheal intubation, an inhalation agent, and an analgesic. Hysterectomies are of such duration and risk that using a mask alone is unwise. In patients with pulmonary compromise, spinal or epidural anesthesia may be used.
A sterile scrub of the abdomen and vagina is done, and a urinary catheter is placed so that the anesthesiologist can monitor urine output intraoperatively. The choice of incision is based on the suspected disease, prior surgeries/incisions, patient preference, and uterine size; in general, a midline incision extending from 2 fingerbreadths above the pubic symphysis to the umbilicus offers the greatest exposure. One modification of the low transverse incision to improve exposure is the Maylard muscle-splitting procedure or the Cherney detachment of the rectus muscles from their insertion on the pubic symphysis. For an uncomplicated hysterectomy with a small uterus, a Pfannenstiel incision is usually sufficient.
The surgeon and assistants should rinse excessive talcum powder from their gloves before making the incision to prevent granulomatous tissue reaction in the wound. Once the incision is complete, peritoneal fluid may be aspirated if the possibility of gynecologic cancer exists. The pelvic organs are then inspected and the upper abdomen palpated in a systematic fashion: right gutter, right hemidiaphragm, liver, gallbladder, pancreas, stomach (assessing the position of the indwelling gastric decompression tube if present), and spleen and right hemidiaphragm (gently, because of the risk of trauma to the spleen), left gutter, para-aortic lymph nodes, and omentum. Excessive bowel manipulation should be avoided to decrease the severity of postoperative adynamic ileus; at the least, the appendix and cecum should be inspected as well as the terminal meter of ileum. Older patients and those with gastrointestinal complaints would benefit from careful palpation and inspection of the bowel from rectum to ligament of Treitz. If desired, the wound may be protected with moist towels, a self-retaining retractor placed, and the bowel packed into the upper abdomen.
The classic extrafascial hysterectomy performed by Richardson remains the mainstay of surgical technique in abdominal hysterectomy. Choice of suture and needle is made according to surgeon experience and preference; 2-0, 0, or 1 absorbable sutures on half-curved taper needles are standard choices. The uterus is grasped either by the fundus with a Massachusetts double-toothed clamp or at the cornua with Ochsner or Kocher clamps. The round ligament is grasped proximal to the uterus; at its midportion, it is ligated by suture, and the suture is tagged with a small hemostat. The round ligament is divided about 0.5 cm proximal to the suture, thus opening the broad ligament at its apex. The anterior uterine peritoneum may be incised at the vesicouterine junction in preparation for advancement of the bladder. The peritoneum only should be incised; the potentially vascular areolar tissue should be avoided. When this procedure is repeated on the contralateral side, the anterior leaves of the broad ligament are opened; the uterine vessels first become apparent. Attention is then directed to the posterior leaf of the broad ligament.
The posterior leaf of the broad ligament is incised beginning at the ligated round ligament. The extent of the incision is determined by the decision to preserve or remove the adnexa. If the adnexa are to be removed, the peritoneum is incised parallel to the infundibulopelvic ligament to the pelvic sidewall; the loose areolar tissue is dissected medial to the internal iliac (hypogastric) artery, which is typically 0.5 cm thick with a visually appreciable (and certainly palpable) pulse. The dissection will reveal a clear area of peritoneum under the infundibulopelvic ligament; below this area at a variable distance lays the ureter on this medial leaf of peritoneum.
The intimate proximity of the ureters to the uterus makes ureteral identification important. Whereas the ureter is usually 4–6 cm deep to the infundibulopelvic ligament at the lateral margin of the uterus, it is only 0.5–2 cm below this vascular bundle at the level of the pelvic brim. Observing the ureter through the peritoneum or palpating the characteristic “snap” of the ureter should serve only to guide dissection and should not be a substitute for identification of the entire ureter through its pelvic course. The ureter tolerates careful dissection well as long as its blood-carrying adventitia is not stripped away. The ureter can always be found and dissection begun at the pelvic brim, where the ureter passes over the bifurcation of the iliac artery. The most serious ureteral injury is the unrecognized insult. The most common ureteral injuries during hysterectomy occur during ligation of the infundibulopelvic ligament, clamping and suture ligation of the uterosacral–cardinal ligament complex, placement of vaginal angle sutures, ligation of the vesicouterine ligament, ligation of the hypogastric artery as an adjunctive measure to lessen operative blood loss, and reperitonealization of the pelvic floor.
Once the course of the ureters is well established, the adnexal component of the operation is completed. If the adnexa are to be removed, the infundibulopelvic ligament is clamped, divided, and double ligated. The ligament may then be ligated again adjacent to the uterus to avoid back bleeding; the infundibulopelvic ligament is divided and the peritoneum incised to the back of the uterine fundus, always cognizant of the proximity of the ureter. If the adnexa are to be preserved, a hole is made in the avascular portion of the posterior leaf of the broad ligament superior to the ureter. The utero-ovarian ligament and fallopian tube are doubly clamped, divided, and ligated, with care taken to avoid incorporation of ovarian tissue into the ligature.
The peritoneal incision can be extended posteriorly around the uterus between the medial portions of the uterosacral ligaments. If the incision of the posterior leaf of the broad ligament is extended over the uterosacral ligaments, there is typically significant bleeding just lateral to the insertion of the ligament at the uterus. The advantages of making an incision between the uterosacral ligaments include clear identification of the rectum and its separation from the uterus, ease of suturing the vaginal cuff, and improved mobility of the peritoneum to allow reperitonealization under less tension.
The bladder is advanced down off of the lower uterine segment prior to clamping the uterine vessels. Surgeons-in-training have more difficulty with advancement of the bladder than with other aspects of abdominal hysterectomy. The principal difficulty in mobilization of the bladder is failure to identify the proper cleavage plane between the bladder and the uterus. At the attachment of the bladder to the lower uterine segment, a median raphe is variably present; it is typically a 1-cm long longitudinal band of thick connective tissue. The raphe is attenuated in pregnant or postmenopausal patients. The raphe is divided at midportion, and loose avascular fibroareolar tissue is seen immediately between the cervix and bladder. The uterus is retracted posteriorly and superiorly, roughly at an angle of 30 degrees to the long axis of the vagina. The midpoint of the peritoneal incision of the bladder flap is gently lifted with forceps; the avascular plane of the vesicovaginal and vesicocervical areolar spaces is continuous once the median raphe is divided. Metzenbaum scissors are pointed to the uterus, and sharp dissection reveals the shiny white pubocervical fascia overlying the cervix. Properly done, the dissection is bloodless, and the plane is recognized by the ease with which the bladder falls away from the cervix. The vesicouterine space is developed 2 cm beyond the anterior vaginal fornix. Care must be exercised in any dissection laterally, because the vesicouterine ligaments (“bladder pillars”) may bleed because of the paracervical and paravaginal veins present laterally.
The uterine vessels may be skeletonized by separating the loose avascular areolar connective tissue from the vessels. The intraligamentous course of the ureter is again checked; it is typically 2–3 cm inferolateral to the insertion of the uterine vessels into the uterus. The uterine vessels are clamped with a curved crushing clamp (eg, Heaney, Zeppelin, or curved Ballantine clamp). Double clamping may be used for larger vessels. It is not necessary to place another clamp on the uterine side of the pedicle to prevent back bleeding if the uterine arteries on both sides of the uterus are clamped before either pedicle is incised. The clamp is applied at the level of the internal os, with the tip of the clamp at a right angle to the long axis of the cervix; the temptation to clamp the entire cervix and “slide off” dragging paracervical tissue into the pedicle should be avoided in order to minimize the risk of the pedicle slipping out of the clamp. The uterine vessels are then ligated by suture at the tip of the clamp. Occasionally, a second application of the curved clamp is necessary to complete ligation of the uterine vessels.
Next, the cardinal ligament is assessed. On occasion, a single application of a straight clamp (Ochsner, Kocher, or Ballantine clamp) will include the cardinal ligament to the level of its attachment at the lateral edge of the cervix and upper vagina. However, with an elongated cervix, multiple pedicles need to be taken before the upper vagina is encountered. A deep knife is often useful in dividing the cardinal ligament adjacent to the uterus, leaving a larger pedicle, which is less likely to slip out of the suture than one remaining after cutting with scissors flush to the clamp. The uterosacral ligaments are clamped at their insertion into the lower cervix, divided at their insertion, and ligated. Alternatively, they may be transected with large Mayo scissors while the vagina is entered posterolaterally. If division and suture ligation of either pedicle of the cardinal–uterosacral ligament complex fails to enter the vagina, the safest approach is to enter the vagina with the knife in the midline, either anteriorly or posteriorly, at the confluence of the vagina with cervix. Once entered, the cervix is circumferentially incised, with long Ochsner clamps used to control point bleeders and elevate the vaginal cuff. The vaginal cuff can also be cross-clamped with a curved clamp (Heaney or Zeppelins) from either side just below the cervix and amputated with Jorgenson's scissors. The cervix is inspected to ensure complete excision. If the cervix is amputated without cross-clamping the vagina, sutures are placed at each lateral vaginal angle to ligate small paravaginal vessels coursing upward through the paravaginal tissues and to provide vaginal vault support. The suture is begun inside the vagina 1 cm from the upper border, then incorporates the cardinal and uterosacral ligaments, and finally transverses the vagina again to end up within the vagina. This suture is tagged, and the procedure is repeated on the contralateral side.
Surgical management of the cuff is individualized. In the case of marked pelvic inflammation and persistent oozing, the cuff may be left open to afford retroperitoneal drainage or allow egress of a closed drain system. In most cases, closing the cuff may reduce granulation tissue and possibly minimize ascension of bacteria from the vagina. The cuff may be closed with either interrupted figure-of-eight sutures or a double running suture; the key points with either closure are inversion of the cut edges into the vagina and hemostasis. If the vagina apex is cross-clamped prior to amputating the cervix, the cuff is closed with either a Heaney suture placed at the tip of each clamp, or with a running suture over each clamp. If a defect remains at the middle of the cuff, this can be closed with interrupted or figure-of-eight sutures.
The pelvis is irrigated and hemostasis checked in a systematic fashion from one lateral pedicle to the ipsilateral round ligament pedicle to the cuff and on to the other side. Small bleeding vessels must be ligated to minimize the risk of retroperitoneal hematoma formation, which may expand or become infected. For diffuse oozing, hemostatic agents such as thrombin powder or thrombostatic absorbable sponges may be useful. There is no advantage to closing the parietal peritoneum. Retained ovaries may be suspended to minimize the risk of torsion and adherence to the vaginal cuff. The utero-ovarian ligament can be conveniently attached to the round ligament stump to suspend the ovaries above the pelvis without placing the infundibulopelvic ligament under tension.
The abnormal appendix should be removed. In cases of hysterectomy for endometriosis, appendectomy will reveal microscopic endometriotic foci in some 3% of cases.
Supracervical/subtotal hysterectomy, or removal of the uterine corpus without the cervix, made up 95% of hysterectomies prior to the 1940s. Despite Papanicolaou's introduction of his cervical smear, concern over neoplastic changes occurring in the retained cervix made total abdominal hysterectomy (TAH) the leading approach to surgery from the 1950s and on. Several studies have addressed the debate about which approach leads to decreased morbidity. Proponents of supracervical hysterectomy believe that there is less damage to sympathetic and parasympathetic innervation that might occur with paracervical dissection. Thus, bladder function and orgasm are less likely to be affected with supracervical hysterectomy. However, 2 randomized controlled trials assessing psychosocial outcome and resultant sexual function found no difference between the 2 groups. A meta-analysis failed to detect a significant difference in stress or urge incontinence after supracervical versus total hysterectomy. Another randomized, double-blind, controlled trial showed no statistically significant difference in bladder, bowel, and sexual function between women who had undergone total versus supracervical hysterectomy. It has also been proposed that by leaving the cervix, vault prolapse and vaginal shortening might be avoided. Yet, a recent study performed on cadavers found equal resistance to forces applied to the vaginal apex after supracervical and total hysterectomy.
Those in favor of TAH suggest that it decreases the risk of cervical cancer, especially in women who might not follow up for routine Pap smears. In fact, a malignant or premalignant condition of the cervix or uterine corpus is an absolute contraindication to a supracervical hysterectomy. It also eliminates the small risk of cyclical bleeding (6.8%) that can occur after supracervical hysterectomy if residual endometrium is left behind.
Supracervical hysterectomy does decrease length of surgery, blood loss, and febrile morbidity. Current indications for supracervical hysterectomy include difficulty dissecting the cervix, distorted anatomy secondary to pelvic inflammatory disease or endometriosis, and compromised medical condition.
Following ligation of the uterine vessels, the uterine fundus may be amputated from the cervix; the level of amputation should be below the internal cervical os to avoid postoperative uterine bleeding from endometrial remnants. The endocervical canal can be resected or ablated to further avoid cyclical bleeding. The cervical stump is closed with figure-of-eight sutures.
Vaginal hysterectomies are performed under general or regional anesthesia. Following administration of the anesthetic, a bimanual examination is mandatory before beginning surgery. The perineum is shaved or trimmed as necessary and a sterile wash performed. The patient is placed in a low lithotomy position and draped; the surgeon should participate in proper positioning of the patient, because excessive flexion of the hips can stretch the sciatic nerve and compress the femoral nerve and excessive extension of the knee can jeopardize the peroneal nerves. All bony prominences and soft tissues in contact with the leg stirrups should be carefully padded.
The urinary bladder may be drained by catheter, but this step is optional. The cervix is grasped with a tenaculum. As the surgeon exerts gentle traction downward on the cervix, 2 assistants maintain exposure with lateral vaginal retractors and protect the bladder with an anterior Heaney retractor. If desired, the junction of the vagina and cervix can be injected with a 1% 1:1000 epinephrine solution to minimize blood loss during incision of the cervix. Beginning posteriorly to minimize obscuring the field with blood, the surgeon circumferentially incises the cervix down to the level of the pubovesicocervical fascia. Gentle traction with the bladder retractor and downward traction of the cervix will allow exposure of the fibers of fascia between bladder and cervix, which are incised. When the bladder has been advanced up off of the cervix, attention is given to the posterior attachment of the cervix. While the assistant pulls the uterus upward, the posterior vaginal mucosa is tented away from the cervix. With the patient in the Trendelenburg position to allow as much emptying of the posterior cul-de-sac as possible, the posterior cul-de-sac is incised with a single stroke of the scissors. A retractor is placed within the opening, exposing the uterosacral ligaments. The uterosacral ligaments are grasped with Heaney clamps, making certain that the peritoneum posterior to the ligament is within the clamp. The ligament is cut and ligated with 2-0 or 0 absorbable suture and tagged with a hemostat for later manipulation of the cuff.
The cardinal ligament may next be clamped if the bladder is safely advanced; likewise, the uterine vessels are included in the next application of the Heaney clamps. The anterior cul-de-sac is entered by blunt and sharp dissection to the anterior vesicouterine fold of peritoneum. The anterior retractor is placed within this opening, and the bladder is gently lifted upward. The surgeon now clamps, incises, and ligates in pedicles the remaining portions of the broad ligaments bilaterally, incorporating the tissue between the anterior and posterior leaves of the broad ligament. The round ligament, utero-ovarian ligament, and fallopian tube are excised from the uterus and incorporated into these pedicles, and the uterus is removed from the field. A larger uterus may require special manipulation for delivery through the vaginal introitus (eg, bivalving the uterus in the midline, morcellation of the uterus into multiple extractable segments, or myomectomy). Rarely, in the event of a narrow introitus, an episiotomy may be performed to facilitate in the delivery of the uterus. The final suture on the utero-ovarian ligament is tagged to allow careful inspection of the tubes and ovaries. If ovarian disease is suspected or if prophylactic oophorectomy is planned, a clamp is placed above the ovary and uterine tube on the infundibulopelvic ligament for suture ligature, while traction is placed on the last stay suture. The entire ovary must be removed, because an ovarian remnant may become cystic and produce pain many years after the hysterectomy.
Once all pedicles are inspected and found to be hemostatic, some surgeons advocate closing the peritoneum with a running 2-0 absorbable suture, incorporating the cardinal and uterosacral ligament pedicles for support of the vaginal vault. Lateral vaginal angle sutures are placed from the vaginal mucosa at 2 o'clock, inside the cuff and including the uterosacral pedicle, then out through the cuff to the 4 o'clock position. If anterior or posterior colporrhaphy is planned, that operation is completed prior to complete closure of the cuff. The cuff may be closed in either a horizontal or vertical manner, grasping full vaginal thickness, by an interrupted absorbable 0 suture or a running simple suture. One small randomized controlled trial showed improved preservation of vaginal length with vertical closure. The goals of closure are obliteration of the cuff's dead space back to the peritoneum and approximation of the cut edges of the vagina to afford healing and minimize postoperative granulation tissue. Modifications of the just-described technique are made by virtually every gynecologic surgeon based on operative findings and experience. Some surgeons will close the posterior cul-de-sac to prevent development of an enterocele or will shorten the uterosacral ligaments to suspend the vaginal vault. As in abdominal hysterectomy, the cuff can be left open to promote drainage with a running locked absorbable 0 suture. Another technique to drain the closure is insertion of a T-tube above the cuff, which is associated with a demonstrable reduction in postoperative febrile morbidity.
After the operation is completed, the vagina and perineum are gently cleansed. An indwelling bladder catheter is inserted and a vaginal pack may be placed. The patient is returned slowly to the dorsal supine position.
The laparoscope can be used to aid vaginal hysterectomy by freeing abdominal adhesions (laparoscopic-assisted vaginal hysterectomy; LAVH) or to free the uterus in its entirety with removal via the vagina with the assistance of uterine manipulators (ie, V-care). Supracervical hysterectomy can also be done laparoscopically with morcellation and removal by culdotomy or through extended trocar sites. Advantages to laparoscopic hysterectomy (LH) include decreased length of hospital stay, decreased postoperative analgesia, and decreased convalescence period. There may be a lower complication rate compared to TAH, but there is no difference versus vaginal hysterectomy. Advantages of LH include the ability to inspect the peritoneal cavity and ovaries. Studies present conflicting data on whether there is a benefit of LH compared to vaginal hysterectomy in respect to hospital stay and blood loss. However, the laparoscopic approach requires significantly more operating time and a well-trained, experienced surgeon. Because of the costs for the endoscopic equipment, LH has been found to be more expensive despite the shorter hospital stay.
Complications with LH include hemorrhage and bowel or urinary tract damage. Conversion to abdominal hysterectomy may occur, especially in cases with large leiomyomas obstructing access to upper pedicles.
Perioperative deaths may be due to cardiac arrest, coronary occlusion, or respiratory paralysis. Postoperative deaths are usually the result of hemorrhage, infection, pulmonary embolus, or intercurrent disease. A recent study of the morbidity of more than 10,000 hysterectomies found the mortality rate to be <0.1% with equal rates in the abdominal, laparoscopic, and vaginal groups. Mortality rates increase with age and medical complications for both vaginal and abdominal hysterectomies.
The bladder may be injured in 1–2% of all hysterectomies. Consequences are slight if the injury is to the dome of the bladder—which is usually the case away from the trigone. Ureteral injury occurs in 0.7–1.7% of abdominal hysterectomies and 0–0.1% of vaginal hysterectomies. The essential point is to recognize urologic injuries and correct them intraoperatively, avoiding the serious postoperative complications that occur from urinary extravasation.
Damage to the bowel occurs in 0.2–0.5% of all hysterectomies. A preoperative mechanical bowel preparation has not been shown to decreased morbidity after bowel resections; however, bowel preparation is preferred for laparoscopic hysterectomy to assist with bowel decompression. Small bowel injuries, assuming no obstruction, can be closed in a single layer or multiple layers depending on surgeon preference. The injury should be closed perpendicular to the long axis of the bowel. If multiple-layer closure is used, an interrupted or running layer of 3-0 silk or absorbable sutures is used to reapproximate the mucosa followed by interrupted 2-0 absorbable or silk sutures in the serosa. Bowel resection and anastomosis may be required for larger injuries. Large bowel injuries are repaired in the same fashion as small bowel injuries. Lack of a mechanical bowel preparation is not an indication for a colostomy. Large injuries may require bowel resection and reanastomosis. After the repair, the pelvis is copiously irrigated and a drain is used by some surgeons.
The most serious postoperative complication is hemorrhage (0.2–2% of patients). Bleeding usually originates at the lateral vaginal angles and is amenable to vaginal resuturing in most cases. Blood products are replaced as needed.
Infection remains the most common complication following hysterectomy. Even with immaculate technique and careful patient selection, the gynecologic surgeon can still expect a 10% rate of postoperative febrile morbidity. A postoperative temperature of 38°C (100.4°F) or higher on 2 consecutive determinations 6 hours apart must be investigated by (1) careful interview of the patient for localizing symptoms (eg, productive cough, intravenous line pain), (2) thorough physical examination (including pelvic examination for inspection and palpation of the cuff), and (3) appropriate laboratory studies (eg, urinalysis, chest x-ray, gram-stained smear of sputum, or complete blood count). Antibiotics are begun only if a focus of infection is identified or highly suspected. Broad-spectrum antibiotics covering anticipated pathogens are prescribed; single-agent semisynthetic penicillins (eg, piperacillin) and cephalosporins (eg, cefoxitin) offer sufficient coverage. In the presence of sepsis, multiagent comprehensive coverage (eg, penicillin, an aminoglycoside, and an anaerobic agent such as clindamycin or metronidazole) must be prescribed.
Granulation of the vaginal vault is part of the normal healing process and is evident on speculum examination in over half of cases. The granulation is rarely troublesome; light cauterization with silver nitrate sticks or electrocautery eliminates the granulation tissue promptly in most cases. Many suggestions have been made on ways to minimize granulation, including management of the cuff (open vs. closed), choice of suture (plain gut vs. chromic vs. newer synthetics), and drainage techniques. The most important common denominator is close apposition of the cut vaginal edges, which can be accomplished with any of the techniques.
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