HYSTERECTOMY and its alternatives

By Dr Robert Sykes

General

Aims

• Basic anatomy understanding• decided we don’t need to know the

proceedure in detail as we wont ever do it!

• What a hysterectomy is...• what types we can do and why...• Indications, and alternatives in

those circumstances

ANATOMY

HYSTERECTOMY

WE REMOVE THE

UTERUS!!!!!!

HYSTERECTOMY

In November 1843, Charles Clay performed the first hysterectomy in

Manchester, England.

In 1929, Richardson, MD, performed the first total abdominal

hysterectomy (TAH), in which the entire uterus was removed (Johns,

1997).

HYSTERECTOMY

Estimated that, by the age of 55, one in five women will have had their womb (uterus)

removed

HYSTERECTOMY•Types

– Subtotal hysterectomy– Total hysterectomy– Total hysterectomy with bilateral or

unilateral salpingo-oophorectomy– Wertheim's hysterectomy

•approach– vaginal– abdominal– laparoscopic

HYSTERECTOMYTypes

TYPES:Subtotal/total hysterectomy

• Total: body and cervix removed (common), cervix superfluous, risk of CA removed.

• Subtotal:the body of the uterus removed, leaving the cervix in place (rare).

• The woman must continue to have cervical smear tests.

• Advantages of subtotal: – less disruption to the pelvic floor,

– less damage to the urinary tract,

– fewer infections.

– cervix may play a role in sexual pleasure

TYPES: TAH & BSO

• To keep or not to keep - menopause v’s cancer risk?

• sudden menopause because of the loss of ovarian hormones

• … although TAH may speed menopause because of disruption to the ovarian blood supply.

• CA risk is 200 BSO’s to prevent one case of cancer if no other risk factors

• woman HAS to be final arbiter...

TYPES:Wertheim's hysterectomy

•a radical hysterectomy.

–body of uterus and cervix,

–part of the vagina,

–fallopian tubes,

–usually the ovaries,

–parametrium (the broad ligament)

–lymph glands and fatty tissue in the pelvis.

•Usually performed to remove cancer.

Hysterectomyapproach

• Candidates:– fibroids, – abnormal or heavy

bleeding, – chronic pelvic pain, – endometriosis, – adenomyosis – uterine prolapse, – cancer of the

reproductive organs– pelvic inflammatory

disease.

PROCEEDURE:1) expose the ligaments and

blood vessels surrounding the uterus.

2) These are separated from the uterus.

3) In the process, the blood vessels are tied off to prevent bleeding and to help in healing.

4) The uterus then is cut off at the superior portion of the vagina and removed.

5) The top of the vaginal cuff is closed with sutures, and the surgical wound is closed in layers.

TAH +/- BSO

Vaginal Hysterectomy• incision made in the

upper part of the vagina

• expose the tissue and blood vessels around the cervix and uterus.

• The tissues and vessels are cut and tied off for the uterus to be removed from the top of the vagina.

• The upper part of the vagina where the surgical incision was made then is sutured.

• Often, colporrhaphy (reconstructive surgery) is done to repair cystocele and/or rectocele.

• Potential Candidates – fibroids, – abnormal or heavy bleeding, – chronic pelvic pain, – endometriosis, – uterine prolapse, – cancer of the reproductive organs – voluntary sterilization.

Laparoscopy-assisted vaginal hysterectomy

• Using the laparoscopic surgical tools, the tissues and vessels surrounding the uterus are cut and tied off.

• The uterus then is removed through the vagina, and the top of the vaginal cuff is sutured.

• The fallopian tubes and ovaries also may be removed during this surgical procedure.

Hysterectomy

approach

WHICH IS BEST?

LAVH vs TAH(Carter, 1994).

• patients undergoing LAVH have – shorter hospitalization – more rapid recuperation, less pain at 3 and 21

days– More rapid return to normal activities at 3 and

21 days– but they spend longer time in the operating

room.

Carter JE, Ryoo J, Katz A: Laparoscopic-assisted vaginal hysterectomy: a case control comparative study with total abdominal hysterectomy. J Am Assoc Gynecol Laparosc 1994 Feb; 1(2): 116-21

LAVH vs TAH(Carter, 1994). CONT…

•Patients undergoing TAH– shorter operation time. – the hospital costs are much cheaper– patients who undergo LAVH usually

return to work earlier and thus require less time off work.

Carter JE, Ryoo J, Katz A: Laparoscopic-assisted vaginal hysterectomy: a case control comparative study with total abdominal hysterectomy. J Am Assoc Gynecol Laparosc 1994 Feb; 1(2): 116-21

But… LAVH vs VH (Lipscomb, 1997).

• surgery time for the LAVH almost double that for vaginal hysterectomy

• blood loss in LAVH significantly less cost for the LAVH group significantly greater

• SO - VH may be the first choice in suitable patients, with only 10-15% of cases unsuitable (Kovac SR 1997).

Lipscomb GH: Laparoscopic-assisted hysterectomy: is it ever indicated? Clin Obstet Gynecol 1997 Dec; 40(4): 895-902

Kovac SR: Which route for hysterectomy? Evidence-based outcomes guide selection. Postgrad Med 1997 Sep; 102(3): 153-

complications

Hysterectomy complications:

–surgical wound infection; –excessive bleeding; –injury to the bowel, bladder, or

ureter; –or urinary tract infection.

And remember

PAIN

COMPLICATIONS cont.. (Makinen et al, 2001)

• Study in Finland during 1996, – 10,110 hysterectomies, – consisting of 5875 TAH, 1801 VH, and 2434 LAVH – rate of overall complications of 17.2%, 23.3%, and

19%, respectively.

• surgeon's expertise in reducing complications is key, especially in LAVH and VH, (Makinen, 2001).

Makinen J, Johansson J, Tomas C: Morbidity of 10 110 hysterectomies by type of approach. Hum Reprod 2001 Jul; 16(7): 1473-8

• The most frequent complications were (TAH/VH/LAVH)– infections, occur in 10.5% TAH, 13% VH, and 9%

LAVH. – Ureter injuries most common with LAVH (RR 7.2 to

TAH)– bowel injuries most common with VH (RR 2.5 to

TAH). – Severe hemorrhage occurred with frequencies of

2.1% TAH, 3.1% VH, and 2.7% LAVH

COMPLICATIONS cont.. (Makinen et al, 2001)

INDICATIONS

…and its alternatives…

Usual Indications

–Fibroids/DUB–Endometriosis/adenomyosis–Pain/PID–Prolapse–Cancer–PMT

FIBROIDS• Fibroids account for 1/3 of hysterectomies and

1/5 of gynecological visits. • Estimated that 20% of women over the age of

30 have at least one fibroid. • Previously operation was done at 12/40 size• Currently, surgery not recommended

based on size alone in the absence of symptoms.

• According to Reiter et al (1992), no increased incidence in operative morbidity exists in women with a fibroid uterus larger than 12 weeks (compared to less than 12 week size).

ALTERNATIVES in DUB• tranexamic acid and mefanamic acid. • Hormone treatment eg COCP or

norethisterone is sometimes used.• Other surgery - endometrial ablation is

very good but not appropriate for women who want to have children.

• For women who want contraception = the Mirena coil,

• Iron tablets for anaemia. Plus duetary advice.

• Myomectomy - relatively small fibroids.

Endometriosis• 1/5th of hysterectomies (Lee, 1984).

– > Endometrial tissue outside the cavity – > responds to monthly hormones – > internal bleeding – > inflammation of the surrounding areas – > scar tissue – > bands of adhesions.

• Currently, no cure exists for endometriosis. • many women seek hysterectomy for pain

relief• it does not provide a definite cure

– one or both ovaries are preserved – may continue to experience problems with tissue left behind.

PROLAPSE

• approximately 15% of hysterectomies. • Stresses on the pelvic muscles and ligaments

– Main insult is childbirth– Also: straining, chronic coughing, obesity, postmenopause.

• If mild may be free of symptoms - several techniques/advice provide temporary improvement and control

• moderate-to-severe prolapse – may be symptomatic

• heaviness and pressure; stress incontinence; urinary tract infections; problems with sex (Lee, 1984).

– hysterectomy may provide a more functional and longer-lasting result

Cancer• INDICATIONS

– cervical cancer, – endometrial – Ovarian cancer – cancer of the fallopian tube (very rare).

• cervical cancer is usually treated by hysterectomy and/or radiotherapy.

• The early stages of endometrial cancer can be treated with high doses of progestogen, and radiotherapy may be undertaken with surgery.

• Ovarian cancer is almost always treated by surgery, but chemotherapy may also be used.