HYSTERECTOMY

A Comprehensive Assignment

1. DEFINITION

Sabiston Textbook of Surgery, p. 2799: "Hysterectomy, by definition, is surgical removal of the uterus. There are several routes in which this can be accomplished, and there are also several options for patients and surgeons regarding type of hysterectomy and, if relevant, concomitant salpingectomy and oophorectomy."

2. TYPES OF HYSTERECTOMY

A. Based on Extent of Tissue Removed

B. Based on Surgical Approach / Route

Berek & Novak's Gynecology, p. 1297

3. INDICATIONS

Benign Conditions

1. Uterine Leiomyomas (Fibroids) – Most common indication. Indicated when symptoms (abnormal uterine bleeding, pelvic pain, pressure) are present and fertility preservation is not required. ~195,000 cases/year in the US.
2. Abnormal Uterine Bleeding (AUB) – When medical therapy and endometrial ablation fail. ~195,000 cases/year.
3. Endometriosis – When medical and conservative surgical management fails. ~83,000 cases/year.
4. Pelvic Organ Prolapse – Hysterectomy combined with pelvic floor repair. ~74,000 cases/year.
5. Intractable Dysmenorrhoea – Debilitating primary or secondary dysmenorrhoea unresponsive to medical treatment.
6. Chronic Pelvic Pain – Refractory pain with uterine cause confirmed.
7. Pelvic Inflammatory Disease (PID) – Severe, recurrent, or complicated by abscess.
8. Benign Ovarian Tumours / Pelvic Mass – When an adnexal mass is associated with the uterus or requires uterine removal for complete excision.

Malignant and Pre-malignant Conditions

1. Gynaecologic Cancer – Endometrial, cervical, ovarian cancers. ~53,000 cases/year.
2. Cervical Intraepithelial Neoplasia (CIN) – High-grade lesions (CIN 3) not amenable to conservative treatment.
3. Uterine Sarcoma / Leiomyosarcoma – Aggressive malignancy requiring surgical excision.

Obstetric Emergencies

1. Postpartum Haemorrhage (PPH) – When uterine atony, placenta accreta/increta/percreta, or uterine rupture is uncontrolled — emergency peripartum hysterectomy is life-saving.
2. Placenta Accreta Spectrum – Abnormal placentation requiring planned hysterectomy at delivery.

Berek & Novak's Gynecology, Table 27-1, p. 1410

4. CAUSES (Pathological Basis)

5. PREOPERATIVE MANAGEMENT

A. Health Assessment / Workup

• Complete history and physical examination — assess comorbidities (diabetes, hypertension, cardiac/pulmonary disease, obesity, prior abdominal surgeries)
• Blood investigations: CBC, coagulation profile (PT, APTT), blood group and cross-match, RBS/FBS, urea, creatinine, LFTs
• Urinalysis and urine culture
• ECG and chest X-ray (as indicated by age and cardiopulmonary status)
• Pelvic ultrasound — confirm pathology, assess uterine size and adnexa
• Papanicolaou (Pap) smear — exclude cervical dysplasia or malignancy
• Endometrial biopsy — if AUB or suspect malignancy
• Anaesthesia consultation and fitness

B. Optimisation Before Surgery

• Glycaemic control in diabetic patients to reduce surgical site infection risk
• Anaemia correction — iron supplementation or transfusion if Hb < 8 g/dL; GnRH agonists may be used preoperatively to reduce fibroid size and blood loss
• Smoking cessation encouraged to reduce wound complications
• Nutritional assessment — optimise protein intake

C. Infection Prophylaxis

• Patient asked to bathe with chlorhexidine preoperatively to reduce skin bacterial colony count
• Prophylactic antibiotics: Cefazolin 1–2 g IV (3 g if obese) given 30–60 minutes before skin incision; redose after 3 hours or with excessive blood loss
• Bacterial vaginosis treatment if identified (reduces vaginal cuff cellulitis)
• Hair removal: Use clippers only; never shave the incision area

D. Bowel Preparation

• Mechanical bowel preparation is not routinely required for benign hysterectomy
• Enema or bowel prep may be considered if bowel surgery is anticipated (e.g., endometriosis with bowel involvement)

E. Perioperative Checklist (Surgical Safety)

1. Consent obtained and signed — including discussion of route of hysterectomy, concomitant procedures (salpingectomy, oophorectomy), risks, and alternatives
2. Deep vein thrombosis (DVT) prophylaxis ordered (compression stockings, LMWH as appropriate)
3. Patient identity, surgical site, and procedure verified
4. Allergies confirmed
5. Imaging and investigation results reviewed
6. Blood products available if high-risk for haemorrhage
7. Document that prophylactic antibiotics will be discontinued within 24 hours after surgery
8. Document plan for Foley catheter removal within 24 hours postoperatively

Berek & Novak's Gynecology, pp. 1417–1419

6. SURGICAL STEPS

Total Abdominal Hysterectomy (TAH) — Step-by-Step

• Dorsal supine; legs in stirrups; pelvic examination under anaesthesia to confirm findings
• Foley catheter placed to drain bladder
• Vagina cleansed with chlorhexidine-alcohol or povidone-iodine

• Choice based on: need for exposure, prior scars, body habitus, pathology size, cosmesis
• Options: Pfannenstiel (low transverse) — preferred for benign disease; vertical midline — for malignancy or large uterus needing wide exposure
• Scalpel opens skin; incision carried through subcutaneous tissue and fascia; peritoneum opened under direct vision

• Systematic examination of liver, gallbladder, kidneys, bowel, para-aortic lymph nodes, and pelvis
• Cytologic washings obtained if malignancy suspected

• Balfour, O'Connor-O'Sullivan, or Bookwalter retractor used for pelvic exposure
• Bowel packed cephalad with moist laparotomy sponges

1. Round ligament division — clamped laterally, ligated with delayed absorbable suture, and divided
2. Broad ligament incision — anterior leaf incised medially toward the internal cervical os → develops bladder flap
3. Bladder dissection — bladder sharply dissected off the cervix with Metzenbaum scissors or electrocautery and retracted inferiorly
4. Ovarian vessel division (if oophorectomy planned) — posterior broad ligament incised; ureters identified; infundibulopelvic ligament doubly clamped with Heaney/Zeppelin clamps, incised, and doubly ligated
5. Utero-ovarian vessel division (if ovaries conserved) — two Kelly/Heaney clamps across utero-ovarian ligaments; divided and ligated
6. Uterine vessel ligation — curved Heaney clamp placed at level of internal cervical os; pedicle cut and suture ligated (single suture/single clamp technique to reduce ureteral injury risk)
7. Cardinal and uterosacral ligament ligation — straight Heaney clamps applied in serial steps; pedicles cut and suture ligated bilaterally down to the level of the external cervical os
8. Colpotomy (vaginal entry) — curved clamps placed across vagina just below cervix; uterus and cervix separated from the upper vagina by cutting above the clamps
9. Uterus removed
10. Vaginal cuff closure — Heaney transfixion stitches at vaginal angles incorporating ipsilateral uterosacral ligaments for apical support; cuff closed with running, interrupted, or figure-of-eight sutures
11. Peritoneal closure and abdominal wall closure in layers

• Pneumoperitoneum with Veress needle (or open Hasson technique)
• Port placement: umbilical primary port + 3 lateral accessory ports (8 cm from midline, 8 cm above pubic symphysis, avoiding inferior epigastric vessels)
• Uterine manipulator used for traction/countertraction
• Mesosalpinx and round ligament coagulated and transected
• Bladder peritoneal flap created
• Utero-ovarian ligaments coagulated and transected
• Uterine vessels secured
• Colpotomy performed; specimen removed vaginally
• Vaginal cuff closed laparoscopically or vaginally

Berek & Novak's Gynecology, pp. 1420–1460; Sabiston Textbook of Surgery, pp. 2799–2800

7. POSTOPERATIVE MANAGEMENT

A. Immediate Postoperative (Recovery Room — First Hours)

B. Postoperative Care Within 48 Hours (Ward)

Analgesia

• NSAIDs (ibuprofen, ketorolac) — first-line for mild-to-moderate pain
• Paracetamol (acetaminophen) — regular scheduled dosing
• Opioids (morphine, tramadol) — for moderate-to-severe pain; use lowest effective dose; wean early
• Neuraxial analgesia (epidural) — for TAH; provides excellent postoperative pain control

Bladder Care

• Foley catheter removed within 24 hours of surgery (unless urogynecologic procedures were performed)
• Monitor for urinary retention after catheter removal — check post-void residuals; acceptable if < 100 mL
• Encourage early voiding; bladder irrigation not routinely needed

Diet and GI Care

• Oral fluids commenced when patient is awake and tolerating
• Advance to soft/regular diet as tolerated (usually Day 1 post-op for laparoscopic; Day 1–2 for TAH)
• Stool softeners (docusate sodium) and/or osmotic laxatives (polyethylene glycol) routinely prescribed to prevent constipation
• Antiemetics continued as needed

Mobilisation (Enhanced Recovery After Surgery — ERAS)

• Early ambulation within 6–24 hours of surgery — reduces DVT, promotes bowel function and recovery
• DVT prophylaxis: compression stockings applied; LMWH (e.g., enoxaparin) initiated as per protocol
• Encourage deep breathing exercises

Wound Care

• Check abdominal incision every shift — assess for redness, swelling, discharge
• Dressing changed at 24–48 hours if soiled
• Drain removed when output < 30–50 mL/24 hours (if drain was placed)

Antibiotic Therapy

• Prophylactic antibiotics stopped within 24 hours of surgery
• If infection is confirmed (wound, UTI, pelvic), treat with targeted antibiotics per culture

Investigations (First 24–48 Hours)

• CBC — check Hb and haematocrit; transfuse if Hb < 7–8 g/dL with symptoms or < 7 g/dL
• Electrolytes and renal function if on IV fluids
• Urine output monitoring — oliguria (< 30 mL/hr) requires prompt assessment

Monitoring for Complications Within 48 Hours

Berek & Novak's Gynecology, pp. 1428–1429

8. PATIENT EDUCATION

Before Discharge (and Before Surgery)

Regarding the Procedure

• Explain what has been removed (uterus ± cervix ± ovaries/tubes) and why
• Clarify that menstruation will permanently stop after hysterectomy
• If premenopausal and ovaries were also removed, explain that surgical menopause will occur immediately — hot flushes, vaginal dryness, mood changes may occur; hormone replacement therapy (HRT) options should be discussed
• Reassure that uterine cancer or fibroid symptoms will be resolved

Activity Restrictions

• Driving: Avoid for at least 2–4 weeks or while on opioid analgesics
• Heavy lifting: No lifting > 5–10 kg for 6 weeks
• Sexual intercourse: Abstain for 6–8 weeks or until the vaginal cuff is confirmed healed at follow-up
• Return to work: Light desk work in 2–4 weeks; heavy manual work after 6–8 weeks

Physical Care at Home

• Shower daily — keep incision clean and dry; pat dry after bathing
• Report any signs of wound infection: increasing redness, swelling, warmth, discharge, or wound opening
• Vaginal discharge: Some light pinkish or brownish discharge is normal for 4–6 weeks; heavy bright red bleeding is abnormal
• Avoid baths, swimming pools, and hot tubs until cleared by physician (typically 6 weeks)
• Wear loose, comfortable clothing; avoid constrictive garments over the incision

Diet and Bowel Care

• Maintain adequate fluid intake (8 glasses of water/day)
• High-fibre diet to prevent constipation
• Stool softeners or laxatives as prescribed; do not strain during bowel movements
• Report absence of bowel movements for > 3 days

Warning Signs — When to Seek Emergency Care IMMEDIATELY

• Heavy vaginal bleeding (soaking more than one pad per hour)
• Fever > 38°C (100.4°F)
• Severe, worsening abdominal or pelvic pain
• Signs of DVT: calf redness, swelling, warmth, or pain
• Signs of PE: sudden chest pain, shortness of breath, cough with blood
• Inability to urinate or severe burning on urination
• Wound opening or foul-smelling discharge from the incision or vagina
• Nausea/vomiting that prevents eating or drinking

Follow-Up

• First post-operative visit: 4–6 weeks after discharge
• At this visit: speculum examination of vaginal cuff, activity clearance, HRT discussion if applicable, return-to-work and sexual activity clearance
• Pap smear follow-up: Not required if cervix removed; continue if subtotal/supracervical hysterectomy performed

Emotional and Psychological Support

• It is normal to feel grief, loss, or mixed emotions after hysterectomy — especially related to fertility
• Depression or anxiety should be reported to the healthcare provider
• Sexual function generally improves after hysterectomy, particularly in women with prior pelvic pain or dyspareunia
• Support groups and counselling services are available

Berek & Novak's Gynecology, pp. 1465–1466

SUMMARY

1. Definition — Surgical removal of the uterus
2. Types — Total, subtotal/supracervical, radical (by extent); Abdominal, vaginal, laparoscopic, robotic (by route)
3. Indications & Causes — 13 indications including fibroids, AUB, endometriosis, cancers, pelvic prolapse, obstetric emergencies, with the underlying pathology for each
4. Surgical Steps — Full step-by-step TAH (round ligament → bladder dissection → vascular pedicle ligation → colpotomy → cuff closure) and laparoscopic approach
5. Preoperative Management — Full workup, optimisation, prophylactic antibiotics (cefazolin 30–60 min pre-incision), surgical safety checklist
6. Postoperative Care Within 48 Hours — Vital signs monitoring, analgesia protocol, Foley removal within 24 hrs, early ambulation, DVT prophylaxis, antibiotic stop within 24 hrs, complication surveillance table
7. Patient Education — Activity restrictions, wound/vaginal care, diet, emergency warning signs, follow-up schedule (4–6 weeks), emotional support
8. Summary Table — Concise recap of all components