evidence base steps hysterectomy

Brahmana Askandar Tjokroprawiro

The first abdominal hysterectomy was performed by Charles Clay in Manchester, England in 1843

Ellis Burnham from Lowell, Massachusetts achieved the first successful abdominal hysterectomy

Women should be counseled before surgery about the planned type of abdominal incision

Vaginal examnination may help determine the types of incision

There are no proven medical or surgical benefits of performing subtotal hysterectomy if the cervix can be easily removed with the corpus

Retaining the cervix commits the patient to continued cervical cancer screening

The only absolute contraindication to subtotal hysterectomy is the presence of a malignant or premalignant condition of the uterine corpus or cervix.

European Journal of Obstetrics & Gynecology and Reproductive Biology 193 (2015) 40–45

European Journal of Obstetrics & Gynecology and Reproductive Biology 193 (2015) 40–45

Although supracervical (subtotal) hysterectomy preserves the cervix, upper vagina, and pelvic attachments, it does not prevent subsequent prolapse.

Randomized trials comparing total abdominal versus supracervical hysterectomy have reported no difference in vaginal support, regardless of cervical preservation or removal

Obstet Gynecol. 2003;102(3):453.

N Engl J Med. 2002;347(17):1318.

Position in the dorsal supine or lithotomy position (preferred by some surgeons so that a second assistant can stand between the patient's legs)

Perform an examination under anesthesia (helps to confirm pelvic findings and guide the final choice of incision)

Insert Foley bladder catheter

Perform sterile preparation of the abdomen and vagina

Place surgical draping.

The skin incision may be transverse or midline vertical and is determined by a variety of factors, such as presence of prior surgical scar, need for exploration of the upper abdomen, size and mobility of the uterus, and desired cosmetic results.

If a prior incision exists, most surgeons prefer to use this incision.

If the prior scar is cosmetically unacceptable, it may be excised at the beginning or end of the procedure

Most surgeons prefer to use a self-retaining retractor for an abdominal hysterectomy

The type of self-retaining retractor used depends on surgeon preference.

When positioning retractors, it is important to avoid placing the lateral blades over a femoral nerve as it emerges lateral to the psoas muscle, since this can lead to a peripheral neuropathy

The key of successful surgery Communication with anesthesiologist Use retractor may be helpfull

Traditionally, a large Kelly clamp is placed across each uterine cornu cut suture

Electrocauter can also be used

A common error is to divide the round ligament too close to the uterus

The round ligament is best divided at its mid portion, or more laterally, and then the ligament can be easily lifted to facilitate peritoneal dissection and division.

The incision in the round ligament is then carried inferiorly through the peritoneum of the broad ligament to the level of the uterine artery, and then medially along the vesicouterine fold, separating the bladder peritoneum from the lower uterine segment

Open the retroperitoneum and visualize the ureter on the posterior leaf of the broad ligament peritoneum to prevent ureteral injury

The visualization of ureteral peristalsis confirms its identity

Elevating the infundibulopelvic ligaments prior to division creates a space between the ureter and ovarian vessels and ensures that the ureter is not included in the clamp

62.379 samples TAH : 0,4 out of 1000 Subtotal Hysterectomy : 0,3 out of 1000 Laparoscopy : 13,9 out of 1000 Vaginal Hysterectomy : 0,2 out of 1000

Obstet Gynecol. 1998;92(1):113.

Incidence : 0,02-1% Risk Factors :

History of cesarean section Large Uterus

Hum Reprod. 2011;26(7):1741-1751

Be carefull if there is history of cesarean section

Sharp dissection is recommended as the use of a blunt dissection with a sponge stick may lead to a cystostomy

Incision into the bladder caused by sharp dissection is more easily repaired than a tear from blunt dissection

The bladder must be reflected inferiorly with sharp dissection prior to dividing the uterine arteries.

A curved clamp is placed perpendicular to the uterine artery at the junction of the cervix and lower uterine segment

Single / double clamps can be used

Extrafascial technique : The cervicovaginal junction at the level of the

external cervical os is palpated, and an incision is made, entering the vaginal apex

A circumferential vaginal incision is made with scissors, amputating the cervix and uterus

Intrafascial technique : Transverse incisions are made on the anterior and posterior

surfaces of the cervix, below the level of the uterine vasculature

The pubovesicocervical fascia is then dissected off the lower uterine segment and cervix with the handle of the scalpel or with gauze-covered index finger

The vagina is incised and the cervix and uterus are then resected using heavy curved scissors

Numerous techniques have been described for management of the vaginal cuff closure

Randomized trials have found no difference in postoperative infectious morbidity with an open or closed cuff technique

Am J Obstet Gynecol. 1995;173(6):1807.Int J Gynaecol Obstet. 1998;63(1):29

An alternative approach minimizes blood loss and avoids spillage of vaginal content into the peritoneal cavity

Curved Heaney clamps are placed from lateral to medial at the level of the external cervical os

The cervix is amputated with a scalpel or scissors

Using a size 0 absorbable suture, a running stitch is placed from medial to lateral on each side, oversewing the clamp

The clamps are then removed and the sutures pulled tight.

Leaving the cuff open to heal secondarily

A running suture is used for hemostasis along the cuff edge and the peritoneal defect superior to the cuff is sutured closed.

There appears to be no difference in postoperative febrile morbidity whether the vaginal cuff is closed

or remains open

The association between hysterectomy and subsequent pelvic organ prolapse is controversial

Experts agree that the vaginal apex should be suspended at the time of hysterectomy to minimize subsequent apical support loss

Common techniques for vaginal apex suspension include: intrafascial hysterectomy (to preserve the uterosacral-cardinal ligament complex) and incorporating the uterosacral ligaments into the vaginal cuff angle at the time of closure Obstet Gynecol. 1982;59(4):435

J Am Coll Surg. 1994;178(5):507Best Pract Res Clin Obstet Gynaecol. 2005;19(3):403.

Courtesy of Thomas Lyons, MD.

The lateral vaginal cuff is attached to the uterosacral ligament and tied

into place to support the vaginal cuff

The pelvis is thoroughly irrigated with warm saline or Ringer's lactate solution.

Meticulous hemostasis at all pedicles is confirmed

The bladder and ureters are inspected

It is not necessary or desirable to reapproximate the visceral or parietal peritoneum

The fascia and skin are reapproximated in standard fashion

Uptodate 2015

PERITONEAL CLOSURE

“The incidence of adhesion : Peritoneal closure (22,2%) vs No peritoneal closure (15,8%), stastistically not significant”

No Difference in :• Incisional hernia• Intestinal obstruction• Reoperation rate• Length of hospital stay

FASCIAL CLOSURE

Fascial closure should reapproximate the wound edges without undue tension or tissue ischemia

Interrupted tissue ischemia due to an uneven distribution of tension

Continuous closure distributes tension evenly along the entire length of the incision, allows better tissue perfusion, and saves time.

SUBCUTANEOUS CLOSURE

A systematic review identified eight trials evaluating subcutaneous closure for non-cesarean delivery, concluding that the low-quality evidence available was insufficient to support or refute subcutaneous closure

1. Patient positioning, examination under anesthesia, and sterile preparation

2. Incision, exploration, and adhesiolysis3. Round ligament ligation4. Broad ligament dissection5. Adnexal removal (if indicated or elected by patient)6. Perivesical and perirectal dissection7. Cervical amputation or removal (subtotal versus total

AH)8. Treatment of the vaginal cuff9. Final examination and closure

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Surgical planning for (abdominal hysterectomy) AH includes patient and surgeon decision-making regarding choice of incision, salpingo-oophorectomy, and subtotal versus total hysterectomy.

In women undergoing AH, we recommend antibiotics for surgical site infection prevention rather than no antibiotics (Grade 1A).

In women planning AH who have bacterial vaginosis, we recommend treatment for eight days, starting four days preoperatively with metronidazole rather than no treatment (Grade 1A)

To prevent ureteral injury, open the retroperitoneum and visualize the ureter

Dissecting the perivesical and perirectal spaces helps to avoid injury of ureter and bowel

Numerous techniques have been described for management of the vaginal cuff closure. High quality studies have found no difference in postoperative infectious morbidity with an

open or closed cuff technique.

In patients undergoing laparotomy who have a 2 cm or greater subcutaneous fat layer, we recommend closure of the subcutaneous layer (Grade 1A).

Careful inspection of all pedicles before abdominal closure is the best method to prevent intraoperative and postoperative hemorrhage