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HysterectomyDR. S. Kalaichandran, MBBS, MD, FRCSC,FSOGC (Canada), FRCOG
Lecturer University
of Ottawa Introduction Hysterectomy is the surgical removal of the uterus (womb). It is the second most common major surgical procedure performed on women (caesarian section being the most common). Although a relatively safe and a very common procedure with a high satisfaction rate, it is not without risks. This article is an overview of hysterectomy and meant to provide general information only. Any patient who is to undergo a hysterectomy should discuss the operation and their specific situation with their gynecologist. Historical Note The earliest “hysterectomy” was probably performed in Arabia in the eleventh century A.D. They simply ligated the prolapsed womb or part of it and either excised it or allowed it to slough off over a matter of weeks. These early procedures, where all the patients succumbed to their surgery, were performed with no knowledge of anatomy or asepsis and without the benefits of anesthesia, antibiotics, blood transfusion, surgical instruments or assistants. Langenback in Germany is credited with the first successful and planned (vaginal) hysterectomy in 1813. Tillaux coined the word “hysterectomy” in 1879. A fuller understanding of the surgical anatomy, formal surgical training and developments in the fields of anesthesia, antibiotics, transfusion medicine and surgical instrumentation over the last two centuries have made hysterectomy a very safe surgical procedure. Incidence The rate of hysterectomy varies from country to country and from province to province. Every year, about 60 thousand hysterectomies are performed in Canada. 37 percent of women in the USA will have a hysterectomy by the age of 60 years. Assuming the current rate of hysterectomy, the number of hysterectomies predicted for the year 2005 in the USA is 854 000. Indications
This, as mentioned before, was the earliest indication for hysterectomy. It remains one of the most common, if not THE most common indication for hysterectomy in the developing world. Prolapse is associated with pelvic pressure and pain and urinary and bowel symptoms.
Frequent and heavy menses, not controlled by medical therapy, is probably the most common indication for hysterectomy in the developed world.
Depending on the location or their size, fibroids may cause heavy menses, painful menses, abdominal and pelvic pain, urinary or bowel symptoms.
Endometriosis is an enigmatic disease. Patients with extensive endometriosis may have few symptoms and those with minor endometriosis may have disabling dysmenorrhoea and dysparaeunia.
Surgery is the primary modality of treatment except for late stage cervical cancer.
Types of Hysterectomy 1.Vaginal Hysterectomy (Vag. Hyst.): It is performed through the vagina and does not require an abdominal incision. About one third of all hysterectomies are performed this way, usually for benign conditions and prolapse. The cervix and uterus are removed with or without the tubes and ovaries. 2. Abdominal Hysterectomy: This requires an abdominal incision, either a low transverse or vertical. The majority of hysterectomies are done this way. It is used in cases of cancer, large uterine fibroids, endometriosis and pelvic adhesions. a) Total hysterectomy (TAH): It involves the removal of both, the uterus and the cervix. The ovaries are conserved. It is done for benign conditions and in younger women. b) Sub total Hysterectomy: Here, the uterus alone is removed leaving the cervix behind. It is a seldom performed operation. It is done electively (for benign conditions) by surgeons who believe that cervix has a role in sexual gratification in women (mainly Scandinavian and some US surgeons). It may be done as an emergency procedure when speed is of the essence as in torrential obstetric bleeding or with uterine rupture. Occasionally, one has to resort to this procedure out of necessity in cases of severe endometriosis or pelvic inflammatory disease resulting in a “frozen pelvis”. c) Total Abdominal Hysterectomy with Bilateral Salpingo Oopherectomy (TAH+BSO): The uterus with cervix and tubes and ovaries are removed in this procedure. It is indicated in peri/post menopausal women with benign disease. It is also the basic operation in cancer of the uterus, tubes and ovaries. These women should be offered hormone replacement treatment unless there is a contraindication.
a) Radical hysterectomy/Staging laparotomy. These are extensive surgical procedures in the case of cervical cancer and cancer of the ovaries and uterus respectively where, the lymph nodes and other tissues are also removed. b) Caesarian Hysterectomy: This may be an emergency procedure as a last resort to stop bleeding at C-section or an elective procedure in cancer treatment when the baby is deemed viable. Counseling for Surgery Only a fully counseled patient can give an informed consent for hysterectomy (or any other medical intervention). Counseling should cover the following: 1) The patients make-up with special reference to her age, educational, racial, psycho-social and religious beliefs. 2) The diagnosis of the gynecological disorder and other co-existing medical and surgical conditions. 3) The natural history of the above conditions. 4) The impact of these conditions on the patients health and well being. 5) Options for management –from doing nothing to medical, electrical, bio-feedback, mechanical (pessary), uterine artery occlusion and various surgical options (including referral elsewhere). 6) Risk/benefits of these options for the specific patient.
The Procedure Before an elective surgery, all medical conditions in the patient should be optimized by appropriate investigations, consultations and management. Anesthesia General anesthesia is commonly used for an abdominal hysterectomy or LAVH. In the case of a vaginal hysterectomy, spinal anesthesia is an option. Surgery Vaginal hysterectomy is performed completely through the vagina. In the absence of an associated repair operation or a complication, the patient may be discharged home in two to three days. After an uncomplicated abdominal hysterectomy patients are discharged home in three to four days. LAVH patients are discharged home in one to two days. Analgesia Post-operative pain relief may be provided by an opiate injection with a spinal anesthetic. Opiates in the form of patient controlled analgesia (PCA pumps) or intermittent injections (nurse controlled analgesia) or trans dermal patches may be used for those patients who had a general anesthetic. After 24 to 48 hours, analgesia is usually provided by oral non steroidal analgesics (Ibuprofen) and Tylenol. Avoiding urinary retention and constipation are important in post-operative pain management.
Risks of Hysterectomy Although modern day surgery and anesthesia are very safe procedures, there are potential risks. In assessing the risks, one has to consider patient factors (age, comorbidities), disease factors (cancer, extensive endometriosis), physician factors (competence) and factors related to the facility (availability and quality of the equipment, support services and personnel). Between a conscientious physician and a well informed patient it should not be too difficult to select the appropriate surgery and facility most of the time. Risk associated with Anesthesia Reaction to medication and difficulty in intubation. Risk associated with Surgery Intraoperative - hemorrhage, trauma to bladder, bowel and ureters. Immediate post - operative - hemorrhage, infection, atelectasis, myocardial infarction, deep vain thrombosis, pulmonary embolism, urinary tract infection. Late post-operative - recurrent disease (prolapse, cancer), possible bladder/bowel, sexual dysfunction. Alternatives to Hysterectomy 1) Prolapse - Kegal exercises, bio-feedback, electrical stimulation, pessaries and repair without hysterectomy (Manchester repair, colpocleisis). 2) Menorrhagia - Contraceptive pill, danazole, GnRH analogues, endometrial ablation. 3) Fibroids - Myomectomy, myolysis, GnRH analogues. 4) Endometriosis - continuous contraceptive pill, progesterone. Danazole GnRH analogues and ablation of endometriotic lesions and conservative surgery. Conclusion Not withstanding the many alternatives, hysterectomy remains the second most common major surgery on women with a very high satisfaction rate among those who undergo this surgery. Developments and refinements in gynecological surgery and associated fields have made hysterectomy a very safe procedure.
Copyright © 1999 [Dr. Kalaichandran]. All rights reserved.
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