Hysterectomy — Nursing Assignment

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1. Definition

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2. Anatomy Relevant to Hysterectomy

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3. Indications

Key principle: Hysterectomy for leiomyomas should only be performed in symptomatic patients who have completed childbearing. — Berek & Novak's Gynecology, 16th ed.

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4. Types of Hysterectomy

A. By Extent of Tissue Removed

Salpingo-oophorectomy in premenopausal women at average risk for ovarian malignancy is associated with increased long-term mortality from cardiovascular disease; ovarian conservation should be strongly considered. — Berek & Novak's Gynecology

B. By Surgical Approach

Vaginal hysterectomy is the procedure of choice unless contraindicated. Abdominal hysterectomy should be reserved for cases where vaginal or laparoscopic approaches are not feasible. — Berek & Novak's Gynecology

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5. Surgical Steps (Total Abdominal Hysterectomy)

1. Laparotomy — low transverse (Pfannenstiel) or vertical midline incision
2. Exploration — identify uterus, tubes, ovaries, and any pathology
3. Divide round ligaments — bilaterally with electrocautery or suture ligation
4. Incise broad ligament — anterior leaf medially to develop the bladder flap
5. Manage adnexa — if BSO: divide infundibulopelvic ligaments after identifying ureters; if ovaries retained: divide utero-ovarian vessels
6. Bladder dissection — dissect bladder off the cervix with Metzenbaum scissors
7. Ligate uterine vessels — curved clamp placed at level of internal cervical os; pedicle cut and suture-ligated
8. Divide cardinal and uterosacral ligaments — serial clamping and ligation bilaterally
9. Colpotomy — incise vagina just below the cervix circumferentially
10. Remove specimen
11. Close vaginal cuff — running, interrupted, or figure-of-eight sutures; uterosacral ligaments incorporated for apical support

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6. Preoperative Nursing Care

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7. Intraoperative Nursing Responsibilities

• Correct patient and procedure identification (time-out/WHO checklist)
• Positioning: supine (TAH), lithotomy (VH/LH)
• Assist anaesthesia team — monitoring airway, IV access
• Maintain sterile field; handle instruments and swabs per hospital protocol
• Accurate swab, instrument, and needle count before and after surgery
• Document procedure, specimens sent (uterus to histopathology), intraoperative blood loss
• Ensure specimens are correctly labelled and sent to pathology

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8. Postoperative Complications & Nursing Management

A. Hemorrhage

• Recognition: Excessive vaginal bleeding, tachycardia, hypotension, falling hematocrit, flank/abdominal pain, abdominal distention
• Types: Vaginal cuff bleeding (more visible) vs. retroperitoneal hemorrhage (insidious)
• Nursing actions:
  • Monitor vital signs every 15–30 min; assess blood loss
  • Maintain IV access; administer IV fluids and blood products as ordered
  • Input and output monitoring
  • Prepare for return to OT if hemorrhage is uncontrolled
• Berek & Novak's Gynecology

B. Urinary Tract Complications

C. Wound Infections

• Occur in ~2% of abdominal hysterectomies; lower with laparoscopic approach
• Monitor wound site for erythema, swelling, purulent discharge, dehiscence
• Maintain aseptic wound care; report signs of infection
• Administer antibiotics as ordered

D. Vaginal Cuff Dehiscence

• Rare but serious complication — separation of vaginal cuff suture line
• Presents with sudden pelvic pain and vaginal discharge/bleeding
• Requires urgent surgical repair

E. Prolapse of Fallopian Tube

• Rare; presents as persistent vaginal discharge/bleeding post-operatively
• Refer to gynecology

F. Deep Vein Thrombosis / Pulmonary Embolism

• Hysterectomy = significant VTE risk (major pelvic surgery)
• Prevention and management: Early ambulation (key!), TED stockings, LMWH (as prescribed), adequate hydration
• Monitor for leg pain, swelling, dyspnea, chest pain

G. Constipation / Ileus

• Post-op opioid use + reduced mobility → bowel slowing
• Stool softeners (docusate sodium), osmotic laxatives (polyethylene glycol), high fiber/fluid intake, early ambulation

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9. Postoperative Nursing Care (General)

Immediate Post-op (Recovery Room)

Ward (Post-op Days 1–3)

• Ambulation: Encourage as soon as possible (reduces DVT risk, aids recovery)
• Diet: Light diet as tolerated from day of surgery (laparoscopic) or next day (TAH); progress to normal diet
• Catheter removal: Usually day 1 (laparoscopic) or day 2 (TAH); ensure patient voids within 6 hours
• Pain: Transition to oral analgesics (paracetamol, NSAIDs, tramadol)
• Wound care: Daily inspection; Pfannenstiel wound closed with sutures/staples removed at 5–7 days
• Monitor for complications (see Section 8)
• Psychological support: Address grief/adjustment related to loss of reproductive organ, premature menopause if oophorectomy done

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10. Discharge Instructions (Patient Education)

1. Rest: Avoid heavy lifting (>5 kg) and strenuous activity for 6 weeks
2. Driving: Avoid until off opioids and can perform emergency stop (~2–4 weeks post VH/LH; ~4–6 weeks post TAH)
3. Sexual activity: Avoid penetrative intercourse for 6–8 weeks until cuff heals
4. Vaginal discharge: Expect light pink/brown discharge for 4–6 weeks; report heavy/bright red bleeding
5. Bowel care: Use stool softeners/fiber; avoid straining
6. When to seek urgent help:
   • Excessive vaginal bleeding
   • Fever (>38.5°C)
   • Severe abdominal pain
   • Inability to void
   • Signs of DVT (leg swelling, pain) or PE (chest pain, dyspnea)
7. Follow-up: First outpatient visit at 4–6 weeks post-surgery
8. Menstruation: Will permanently cease post-hysterectomy
9. Menopause: If ovaries removed, surgical menopause begins immediately — hormone replacement therapy may be discussed

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11. Quality of Life Outcomes

• The majority of patients report significant improvement in pelvic pain, urinary symptoms, psychological well-being, and quality of life at 1–2 years post-hysterectomy (Maine Women's Health Study)
• Sexual function is unchanged or improved in the majority of women after hysterectomy
• ~8% of patients report persistent or new symptoms (depression, reduced libido) — nursing support and referral to psychology or sexual health services is important
• Berek & Novak's Gynecology, 16th ed.; Campbell-Walsh-Wein Urology

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12. Summary Table

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What's in Your Assignment

1. Definition — what hysterectomy is
2. Relevant Anatomy — uterus, ligaments, ureter, bladder relationships
3. Indications — fibroids, AUB, endometriosis, prolapse, cancer, chronic pelvic pain
4. Types — by extent (total, subtotal, radical, ± BSO) and by surgical route (TAH, vaginal, laparoscopic, robotic)
5. Surgical Steps — step-by-step TAH technique with diagram
6. Preoperative Nursing Care — assessment, consent, investigations, prep, DVT prophylaxis
7. Intraoperative Nursing — WHO checklist, positioning, swab counts, specimen handling
8. Postoperative Complications & Nursing Management — hemorrhage, urinary complications, wound infection, DVT, cuff dehiscence, ileus
9. Post-op Nursing Care — immediate recovery room care + ward management
10. Discharge Patient Education — activity restrictions, warning signs, follow-up
11. Quality of Life Outcomes — evidence-based patient outcomes
12. Summary Table

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• Format it as a Word document (.docx) for submission
• Add nursing diagnoses (NANDA) and care plans
• Add more on a specific section (e.g., radical hysterectomy for cervical cancer, robotic technique, or hormonal effects of oophorectomy)