15 Hysterectomy

HYSTERECTOMY
By Laston Kastom, BscBMS(RH),Dip.Clin.Med
INTRODUCTION
Hysterectomy means the removal of the uterus (womb). A hysterectomy may or may not be
combined with the removal of the Fallopian tubes and one or both ovaries. Removal of a tube
and ovary is called salpingo-oophorectomy; removal of both tubes and ovaries is called bi-lateral
salpingo-oophorectomy (BSO for short). Hysterectomy is a major surgical procedure and is
performed under general anaesthesia.
INDICATIONS FOR HYSTERECTOMY
Uterine Fibroids (myomas)
These are non-cancerous tumours of different sizes that usually shrink after menopause. Fibroids
are common and normally don't need treatment unless they cause symptoms. However, larger
fibroids can press against the pelvic organs and may cause bleeding, pain during sex, anaemia,
pelvic pain, or bladder pressure. This is the most frequent reason for a hysterectomy.
Endometriosis
When the tissue lining the uterus grows outside of the uterus and onto surrounding organs, it can
cause painful periods, abnormal vaginal bleeding, scarring, adhesions, and infertility (difficulty
getting pregnant). It is the second most common reason for women to have a hysterectomy.
Uterine prolapse
The uterus moves down into the vagina because the tissues that hold the uterus in place weaken.
The condition may lead to urinary incontinence (problems holding your urine), pelvic pressure or
difficulty with bowel movements. Childbirth, obesity, persistent cough or straining, and
hormonal changes (loss of estrogen after menopause) are typical causes.
Pelvic Pain
There are many causes and symptoms (ex: painful periods and intercourse) of pelvic pain, and
not all can be successfully treated with a hysterectomy. That is why it is important to carefully
diagnose the problem and try other treatments first. Endometriosis, fibroids, adhesions,
infections or injury may be a few causes of pelvic pain.
Ruptured uterus
This is when you have tearing of the uterus so extensive that repair is not possible.
Postpartum haemorrhage
Postpartum haemorrhage may become an indication for hysterectomy when it is not responding
to treatment.
TYPES OF HYSTERECTOMIES
As mentioned before, a hysterectomy is an operation to remove the uterus. Sometimes, other
organs that surround the uterus are also removed to properly treat your condition. These organs
include the cervix, the fallopian tubes and the ovaries. Your medical history and the reason for
the operation will shape the doctor's decision as to which type of hysterectomy is best for you:
A complete or total hysterectomy removes the uterus, including the cervix. The name is
confusing because it does not remove "everything". In fact, the ovaries and fallopian tubes
remain. This is the most common type of hysterectomy.
A partial or subtotal hysterectomy only removes the upper part of the uterus and leaves the cervix
and other organs in place. This is commonly done following emergencies related to pregnancy,
making this procedure an important obstetrical emergency procedure. It causes less bleeding and
there is almost no danger to the ureters. This procedure is still possible when a uterine rupture
extends down into the cervix and vagina. In that case, the tear in the cervix and vagina is repaired
after the body of the uterus has been removed.
A radical hysterectomy removes the uterus, the cervix, the upper part of the vagina, supporting
tissues and usually the pelvic lymph nodes. This operation is usually performed to treat cancer.
In addition to the hysterectomy, you may need to have one or both ovaries removed. This is
called a salpingo-oophorectomy. It involves removing the fallopian tube and ovary on one side
(unilateral) or both sides (bilateral) of the uterus. This is done mostly in cases of cancer, infection
or adhesions. In general, the ovaries and fallopian tubes are left in place unless something is
wrong with them.
ACTUAL PROCEDURE OF SUBTOTAL HYSTERECTOMY

 You need to resuscitate the patient first, by setting up an I.V line and infusing one or two
litres of fluids before starting the operation.
 You also need to x-match 2 pints of blood in case of severe bleeding
 Give antibiotics for prophylaxis, so you may give penicillin I.V start, or chloramphenicol
I.V start, or cefazolin 1g I.V start.
 Catheterize the bladder.
 Then administer general anaesthesia. Drape and apply antiseptics.
 Open the abdomen
 Remove the fetus and placenta if the procedure is following a ruptured uterus.
 Clean away most of the blood and liquor
 Insert a self retaining abdominal retractor if this is available
 Lift the uterus from the abdomen
 Maintain the traction with one hand or put in a traction suture
 Now identify these structures
 The corpus uteri
 The round ligaments
 Tube and ovary on both sides
 The infundibulopelvic ligaments on both sides
 The avascular area in each broad ligament
 The lower segment
 The bladder
 The rectum
 The ureters
 Identify the rupture and clamp obvious bleeding points
 Pull the uterus to the left and divide the right round ligament between clamps about 2 cm
from the uterus; this step opens the anterior peritoneal leaf of the broad ligament
 Enlarge the opening in the anterior leaf of the broad ligament with scissors in a down
direction towards the bladder.
 Lift the adnexa with one hand and push a finger of the other hand from behind through
the avascular area in the broad ligament; this step helps to define the infundibulopelvic
ligament.
 Clamp the infundubulopelvic ligament with two artery forceps and cut it. Alternatively, if
you wish to leave the adnexa in place, clamp and divide the tube and ovarian ligament
near the uterus. If the tube and ovarian ligament are very thick and vascular, the clamping
and cutting may have to be done in two steps.
 Suture or ligate the pedicles of the round ligament and infundibulopelvic ligament
 Repeat the same procedure on the left side
 Now pull the uterus well up in the midline and cut the peritoneum between the uterus and
bladder, extend the incision laterally to meet the incisions in the anterior leaves of the
broad ligament
 Push the bladder off the lower segment with your finger or a swab on a holder; two or
three centimeters is enough, pushing it down further can cause bleeding; if the rupture is
in the anterior lower segment, you have to put it on stretch with green-armytage forceps
on its edge before you can separate off the bladder.
 Now expose the posterior lower segment by pulling the uterus forward over the
symphysis pubis.
 Divide the peritoneum over the posterior lower segment at about the same level as this
was done anteriorly
 Extend the incision laterally to join the openings in the broad ligaments
 Push the lower flap of the peritoneum off the lower segment with a swab on a holder or if
this is difficult, cut it loose with scissors
 Now review the situation: on either side of the uterus you should see a bundle of loose
connective tissue which holds the uterine vessels; you may have to strip down the
peritoneum of the broad ligaments a little further to see them more clearly
 Pull the uterus to the left and clamp the uterine vessels on the right with strong curved
Kocher or artery forceps just above the level where the bladder is still attached to the
lower segment; make sure the points of the clamp are very close to the uterus and there is
no harm to include a little uterine wall
 Place the second clamp inside the first and cut the uterine vessels in between
 Suture or ligate the pedicle
 Repeat this procedure on the left
 Now amputate the uterus through the lower segment just above the level of the cut
uterine vessels; have artery forceps ready to pick up the cut edge of the lower segment
before it disappears in the depths of the pelvis.
 Clamp obvious bleeders
 If there is a downward tear in the cervix, repair this now after making sure that bladder
and ureters are well out of the way.
 Now suture the anterior wall of the lower segment to the posterior wall with figure of
eight stitches; make sure you include the angles on the left and right as these tend to
bleed; leave the centre open for drainage. At this stage the pelvis should be more or less
dry.
 Look for remaining bleeding points and ligate them
 If there is a lot oozing from one of the broad ligaments, place a rubber drain in that area
and bring it out either through the cervix into the vagina or preferably extra peritoneally
( through the abdominal wall 0
 Wash the abdomen with warm saline and close it.
POSTOPERATIVE ORDERS
 I.V fluids and blood depending on the patient’s condition
 Continue with the antibiotics for 7 to 10 days.
 Pethidine is necessary 50 to 100 mg I.M every 6 hourly for first two days
 Remove the drain after one or two days
 Continuous bladder drainage for 10-14 days if the bladder was damaged
 Nasogastric tube if the bowels are distended or peritonitis is expected

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15 Hysterectomy

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HYSTERECTOMY

By Laston Kastom, BscBMS(RH),Dip.Clin.Med

INDICATIONS FOR HYSTERECTOMY

Uterine Fibroids (myomas)

ACTUAL PROCEDURE OF SUBTOTAL HYSTERECTOMY

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