Hysterectomy

Routes of hysterectomy

• Abdominal hysterectomy
  • Total
  • Sub-total hysterectomy
• Vaginal hysterectomy
• Laparoscopic hysterectomy
  • LAVH
  • TLH
• Caesarean hysterectomy

• Laparoscopic Vs open simple hysterectomies (for benign disease), Laparoscopy has
  • Less pain
  • Shorter hospital stays (by an average of 2 days)
  • Decreased wound infections (relative risk decreased by 80%)
  • Quicker return to normal activity (2 weeks sooner)
• Compared to abdominal radical hysterectomies, total laparoscopic radical hysterectomies result in
  • Reduced operative blood loss
  • Postoperative wound infections
  • Length of hospital stay
  • Ect…….

RADICAL ABDOMINAL HYSTERECTOMY

General considerations

• Appropriate selection is critical
  • Chronologic age
  • Fitness for surgery
    • Medical contraindications to RH
      • Thromboembolism
      • Coagulopathy
      • Cardiac
      • Pulmonary
      • Renal diseases
      • Ect…….
    • Complications associated with radiation may preclude its use
      • Pelvic adhesive
      • Inflammatory disease
      • Previous genitourinary or intestinal surgery
      • Inflammatory bowel disease
      • Anatomic anomalies (pelvic kidney)
  • Obesity
  • Ovarian preservation
    • Squamous carcinoma of the cervix – ovarian metastases are so rare (<1%)
      • Can preserve ovaries
      • Oophorectomy may be indicated only when
        • Gross spread to the adnexa
        • Concomitant ovarian pathology
        • Post-menopausal
      • Reposition the ovaries outside the pelvis if postoperative RT is needed
      • Ovarian failure can be reduced to as low as 17% when this is combined with shielding during adjuvant RT
    • Adenocarcinoma of the cervix – ovarian metastases 19% ( stage I or II)
      • Recommend bilateral oophorectomy
    • Endometrial carcinoma
      • Recommend bilateral oophorectomy

• Sexual function
  • Vagina is invariably shortened after RH
  • Vaginal epithelium and caliber remain relatively unchanged
  • Irreversible atrophy & stenosis of vagina occur frequently with RT à leading to sexual dysfunction in up to 78% of patients treated with RT
  • Stage of the disease

Types of RH – Classification of the Extent of Surgery (traditional)

• Piver and colleagues proposed a classification system
• According to the extent of dissection of hysterectomies (in various stages of cervical CA) thereby identifying potential surgical complications.

Type 1

• Extrafascial / simple hysterectomy
• Removes the cervix along with the uterine corpus
• Dissection and mobilisation of the supravaginal cervix is carried out in an extra-fascial plane.
• Anterolaterally, the ureter is at risk unless some mobilisation of the bladder pillar
• Not require mobilization of the ureter or removal of a significant amount of the parametria
• The attachments of the cardinal and uterosacral ligaments need to be separately divided and ligated with removal of a small (1 cm) cuff of the vaginal vault.
• For Stage 1aCervical CA

Type 2  

• Modified radical hysterectomy / Wertheim operation
• Requires more extensive dissection than the extrafascial hysterectomy
• The central portion of the parametrial tissues is removed while minimizing disruption to the ureteral and vesical vasculature. but not beyond the line of the course of the ureter, which itself needs to be mobilised and reflected laterally.
• Medial half of the uterosacral ligaments and the cardinal ligaments are removed after ligation of  uterine artery just medial to the point at which it crosses the ureter
• Removal of a upper 1/3 of the upper vagina
• May / may not be undertaken with PND depending on the 1ry  tumour site
• For Stage 1b – with pelvic lymphadenectomy

Type 3

• Radical hysterectomy (originally described by Bonney–Meig’s)
• Remove as much parametrial tissue as possible
• The uterosacral ligaments are transected near their origin from the sacrum. The cardinal ligaments (medial two-thirds) are excised as widely as possible after the uterine artery is ligated at its origin where it branches off the hypogastric artery.
• Care should be taken to preserve the superior vesical artery
• Removal of  upper two-thirds of the vagina & pelvic and para-aortic lymphadenectomy is performed in conjunction with a type 3 radical hysterectomy
• For Macroscopic early-stage tumors (11a) –  with pelvic & para-aortic lymphadenectomy

Type 4 and more advanced procedures

• A more extensive procedure is the ‘mid-pelvic exenteration’ in which segments of adherent adjacent organs including the bladder, ureters and upper rectum are resected en bloc, and their functional continuity individually restored by colorectal anastomosis and ureteric re-implantation
• A more extensive total pelvic exenteration may be performed for recurrent disease, usually after radiotherapy, when both urinary and faecal diversions are necessary either to a colostomy and ileal conduit with urostomy or if possible by continent bladder diversion. Rectal continuity may be achieved depending on the site of the pathology and extent of radiotherapy.

Alternative Classification of Radical Hysterectomy

• A new classification proposed by Querleu and Morrow (2008) following principles laid down by the Japanese School, Okabayashi and Fuji (2001)
• This includes the concept of nerve-sparing surgery in order to try and reduce bladder and rectal dysfunction by conserving branches of the hypogastric nerves and lateral pelvic plexus
• The basic surgical principles are the same as for the traditional Wertheim and Bonney-Meig’s procedures, except that recognition of the pelvic nerve supply to the bladder and rectum is respected.
• Four types of surgical procedure are described.

Type A: Extra-fascial  hysterectomy

• The position of the ureter is determined by palpation or directly after opening the ureteric tunnels but without freeing the ureters from their surrounding tissue.
• Vaginal removal is minimal, less than 1 cm
• There is no resection of the paracolpos

Type B:

 i. Modified radical hysterectomy

• Partial resection of the uterosacral and vesico-uterine ligaments
• The ureter is unroofed and rolled laterally; the paracervix is resected at the level of the ureteric tunnel
• The neural component of the paracervix caudal to the uterine vein is not resected
• At least 10 mm of vagina is removed.

 ii. The same as B(i) with additional removal of the lateral paracervical lymph nodes.

Type C:

 i. Nerve-sparing radical hysterectomy

• Transection of the uterosacral ligament at the rectum after the separation of the hypogastric nerves and vesico-uterine ligament at the bladder following preservation of the bladder branches in the lateral part of the bladder pillar
• The ureter is completely mobilised
• At least 15–20 mm of vagina and the corresponding paracolpos are removed
• The paracervix is resected at the junction with the internal iliac vascular system

 ii.

• Radical hysterectomy without preservation of the autonomic nerves
• The paracervix is resected including the part caudal to the deep uterine veins.

Type D:

 i. Lateral extended resection

• Resection of the entire paracervix at the pelvic sidewall along with the hypogastric vessels, exposing the roots of the sciatic nerve.

 ii. The same as D(i) with resection of adjacent fascial or muscular structure.

OPERAT IVE T ECHNIQUE OF RH

• Incision
  • Depending on the individual preferences of the surgeon concerned
  • The circumstances (uterine mass, an adnexal mass or multiple extensive adhesions)
• Systematic abdominal Exploration
• Assessment of Operability
• Ligation and Section of Infundibulo-Pelvic Fold and Round Ligament
  • The round ligament is divided allowing further identification of the ureter on the posterior leaf of the broad ligament
  • Infundibulo-pelvic ligament containing gonadal vessels is identified, clamped & divided
  • All pedicles are ligated with No. 1 vicryl ties.
• Dissection of Pelvic Lymph Nodes
  • Opening the broad ligament gives access to the external iliac lymph nodes and the fatty cellular tissue that surrounds the iliac vessels
  • A block dissection of the external iliac, inter-iliac, internal iliac, common iliac and obturator nodes with surrounding fatty tissue is performed
• Dissection of Ureter (Bilateral Ureterolysis)
• Separation of Bladder
• Ligation of the Uterine Vessels
• Dissection of Ureter from the Cardinal Ligament – De-roofing
• Opening the Rectovaginal Septum
• Transection of the Uterosacral Ligaments
• Clamping and Section of the Cardinal Ligament
• Transection of Vagina
• Haemostasis and Drainage
• Reperitonisation of the Pelvis

Complications

• Acceptable morbidity (<5%) in the hands of an experienced surgeon
• Predisposing factors include previous pelvic surgery or radiation, endometriosis, pelvic inflammatory disease, anatomic anomalies, obesity, and pregnancy.
• Intraoperatively
  • Haemorrhage
    • Most common
    • Range from 600 ml – 1900 ml
  • Injury to the Large Vessels
  • Ureteral injury
    • < 1% of cases
    • More frequently go unnoticed
    • Use of intravenous indigo carmine may help identify the site of injury
    • When an injured ureter needs repair, techniques such as
      • Ureteroneocystostomy
      • Ureteroureterostomy
      • Stenting
      • Retroperitoneal drainage may be required
  • Bladder & bowel injury
    • Particularly when electrocautery is used inappropriately
    • Typically, cystotomies or enterotomies can be repaired with a two-layer closure
    • However, proper repair of some injuries necessitates more involved procedures such as ureteral stenting for trigone injuries /colostomy for extensive colonic injuries
• Postoperative period (Postoperative mortality has been reduced to less than 1% in this era)
  • Early complications (occurring within the first 30 postoperative days, may vary)
    • Infectious and febrile morbidity is the most common postoperative Cx
      • Prophylactic use of broad-spectrum antibiotics reduces it
    • Postoperative bleeding
      • May require reoperation
      • Most cases are self-limited and can be treated conservatively with close observation for hemodynamic instability and blood transfusions
    • Clinically significant thromboembolic complications
      • Occur in approximately 5% of cases
      • Early diagnosis requires a high index of suspicion because clinical findings are frequently subtle or nonspecific
    • Prolonged ileus or intestinal obstruction occurs occasionally
      • Usually resolve with conservative management
    • Voiding dysfunction
      • In the immediate postoperative period is nearly universal
      • Denervation of the bladder during the operation results in transient hypertonia that is gradually replaced hypotonia
      • Bladder drainage can be achieved with suprapubic catheterization, intermittent self-catheterization, or indwelling urethral catheterization
      • For most patients, the ability to void returns within 2–3 weeks; however, voiding dysfunction may persist in approximately 5% of patients
      • In addition, a substantial number of patients develop persistent urinary incontinence postoperatively
      • Pure stress urinary incontinence, urge incontinence, and mixed incontinence have been reported, although the incidence and nature of preoperative voiding dysfunction in these patients is unknown
    • Urinary tract fistulas
      • Occurring in less than 2% of cases
      • Interruption and mobilization of the vasculature of the bladder and ureters predisposes to ischemia that lends itself to fistula formation
      • The need for postoperative radiation therapy worsens this problem
      • The diagnosis – sequential inspection of a vaginal tampon after intravesical instillation of methylene blue followed by intravenous indigo carmine to determine whether a vesicovaginal or ureterovaginal fistula exists.
      • Alternatively, an intravenous pyelogram or CT may locate the fistula
      • Vesicovaginal fistulas, particularly those that are small, may heal spontaneously with prolonged bladder drainage
      • Larger defects and those that fail to heal with conservative management need to be repaired surgically. Ureterovaginal fistulas require stenting; if a retrograde stent cannot be passed, percutaneous nephrostomy with anterograde stenting is required.
  • Late postoperative complications (arising after 30 post-op) – Occur less frequently
    • Lymphedema
      • Develops insidiously over time, making its true incidence difficult to determine
      • It occurs more frequently when pelvic lymphadenectomy is followed by radiation or groin node dissection.
    • Lymphocyst
      • Similarly, can occur as a result of extensive pelvic lymphadenectomy
      • Incidence is only 2–3%
      • Many are asymptomatic and may go undetected
      • In the event that a lymphocyst causes ureteral obstruction or presents as a pelvic mass, percutaneous drainage or reoperation with marsupialization may be necessary
    • Sexual dysfunction and surgical menopause
      • Affect quality of life

1. Shaw’s Textbook of Operative Gynaecology – 7^th  Edition
2. GLOWM web

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