Hysterectomy

WHAT IS HYSTERECTOMY?

Hysterectomy (removal of the uterus) is the second most frequent major operation performed on women next only to caesarean section.It is considered as the last option for benign conditions being offered only to women above the age of 45 years and who have completed their child bearing. Over the past several decades new developments have been made in the surgical approaches to hysterectomy The term laparoscopic hysterectomy is used to define various types of hysterectomy with a laparoscopic access to the abdominal cavity.

INDICATIONS FOR HYSTERECTOMY (REMOVAL OF UTERUS)

Benign Disease
– Leiomyomas: For symptomatic fibroids, hysterectomy provides a permanent solution to menorrhagia and the pressure symptoms related to an enlarged uterus.
– Abnormal uterine bleeding not responding to medical management. Endometrial lesions must be excluded preoperatively or by frozen section intraoperatively if indicated.
– Endometriosis: in the presence of severe symptoms with failure of other treatments and when fertility is no longer desired.
– Pelvic organ prolapse: in these cases , hysterectomy should include associated pelvic organ supporting procedures.
– Pelvic pain: A multidisciplinary approach is recommended. When the pain is confined to dysmenorrhea or associated with signifi cant pelvic disease, hysterectomy may offer relief.
Pre – Invasive Disease
– Hysterectomy is usually indicated for endometrial hyperplasia with atypia.
– Cervical intraepithelial neoplasia in itself is not an indication for hysterectomy.
– Simple hysterectomy is an option for treatment of adenocarcinoma in situ of the cervix when invasive disease has been excluded.
Invasive Disease
– Hysterectomy is an accepted treatment or staging procedure for endometrial carcinoma. It may play a role in the staging or treatment of cervical, epithelial ovarian, and fallopian tube carcinoma.

TYPES OF HYSTERECTOMY

• Total Hysterectomy – Total hysterectomy which involves the removal of the uterus and cervix only; the ovaries and tubes are retained .
• Subtotal Hysterectomy – Subtotal hysterectomy where the body of the uterus is removed, but the cervix, ovaries and tubes remain.
• Total Hysterectomy With Bilateral Salpingo-oopherectomy – Total hysterectomy and bilateral salpingo-oophorectomy in which the uterus, cervix ovaries and tubes are all removed.

MODES OF HYSTERECTOMY

• Abdominal Hysterectomy – Abdominal hysterectomy is performed through a long abdominal cut which may be either horizontal incision just above the symphisispubis like for a Caesarean section, or vertical in the midline below the umbilicus (naval).
• Vaginal Hysterectomy – Vaginal hysterectomy is performed through the vagina and there are no cuts in the abdomen.
• Laparoscopically assisted vaginal Hysterectomy – Laparoscopically assisted vaginal hysterectomy The tubes and ovaries are separated laparoscopically, the vault is sutured vaginally and uterus removed through the vagina (like a vaginal hysterectomy).
• Total Laparoscopic Hysterectomy – Total Laparoscopic hysterectomy which can be done by multiport or single port depending on the size of the uterus, this involves complete separation of the uterus pedicles laparoscopically.
  It is the most advanced and least traumatic mode but requires precise surgical skills, sophisticated endoscopy equipment and for advanced anaesthesia monitoring and management good patient outcome. Total laparoscopic hysterectomy (TLH) is currently accepted as a safe, efficient and acceptable alternative to standard abdominal hysterectomy . It offers a superior view of the anatomy, facilitates meticulous hemostasis, enables the surgeon to perform adhesiolysis effectively, and reduces morbidity associated with large abdominal incisions.

PRE OPERATIVE PREPARATION

All patients need basic preoperative evaluation ,investigations and preparation.Admission is usually on the day of surgery Antibiotic prophylaxis and prophylaxis against possible thromboembolic episodes is used appropriately.

OPERATIVE PROCEDURE

TLH is performed under general anesthesia with advanced monitoring including spirometry, entropy (depth of anaesthesia), capnography, gas analysis, st analysis, in addition to routine pulse oxymetry and non invasive blood pressure monitoring.

SURGICAL STEPS

• The 10-mm port is inserted under vision avoiding damage to major vessels and viscera. The pelvis and the abdomen are inspected and any other pathology (endometriotic lesions, adhesions, ovarian pathology etc), if present, is tackled first. The course of the ureters is traced out at the start of the procedure. The size, site and the number of myomas if present are assessed. The surgery is performed through three five mm accessory ports.
• The uterovesical fold of peritoneum is identified and opened from the round ligaments on either side. The bladder is dissected down completely so that the uterine vessels on either side can be clearly seen. A window is created in the broad ligament close to the uterine vessels,the ascending branch of the uterine artery identified near the isthmus and ligated at this level close to the uterus, by transfi xation using 1-0 delayed absorbable suture material. The vasculature of the uterus is thus secured and this is evidenced by the color change in the fundus, which becomes pale.
• Bilateral cornual pedicles are then dessicated and cut either using bipolar diathermy or the harmonic ultracision. The ligated uterine pedicles are cut. The uterosacrals and cardinal ligaments are dessicated and cut.
• The vaginal vault is opened & the specimen is detached completely. If ovaries need to be removed, the infundibulopelvic ligaments are also desiccated and cut . The vaginal vault is then sutured with No. 1 delayed absorbable interrupted fi gure-of-eight sutures.
• The specimen is either delivered vaginally or retrieved by Morcellation. Peritoneal lavage is given with normal saline solution..Skin is sutured with absorbable subcuticular sutures .

RECOVERY

Perioperative pain is managed judiciously so as to keep the patient pain free and comfortable. The urinary catheter is removed as early as possible and oral liquids started after peristalsis is established, usually within six hours. The patient is discharged the following day and called for follow-up after seven days.

DISCUSSION

Given adequate training in laparoscopic surgery and with proper technique, TLH can be performed successfully in most women.

Eventhough laparoscopic hysterectomy has been the subject of many controversial comments especially when it comes to large uterus and previous cesarean sections . In skilled hands, these patients could benefit from the advantages related to minimally invasive approach such as minimal blood loss, short hospital stay, prompt recovery, obtaining a satisfactory result. Compared with abdominal hysterectomy there is compelling evidence indicating that defi nitely provides specific benefits.

Total Laparoscopic Hysterectomy should be considered instead of laparotomy in all patients needing hysterectomy off ers minimal postoperative discomfort, shorter hospital stay, rapid convalescence, and early return to normal activity

Myths about hysterectomy?

• Hysterectomy and menopause
  If the ovaries are not removed, they continue to function and provide the oestrogen that skin, hair, bones, breasts and blood vessels need. If the ovaries are removed, hormone replacement therapy (HRT) can provide the necessary oestrogen. It should however be mentioned that hysterectomy may be responsible in some women for an earlier decline in ovarian function with the development of menopausal symptoms, such as hot flushes and night sweat, up to 2 years earlier than the average age of menopause.
• Sex life deteriorates after hysterectomy
  Ninety per cent of women who have a hysterectomy find that sex is as good, if not better, than before the operation.
• Hysterectomy causes weight gain
  If there is a tendency to gain weight before hysterectomy, that tendency will persist after surgery. It is important to remember that activity level and energy requirements will be reduced during recovery after surgery, and diet should be adjusted accordingly until normal activity is resumed.
• Pap smears need to be performed after hysterectomy
  Unless the cervix has been retained, or there was an abnormal cervical smear test in the past, there is no need to continue Pap smears.