1st year Choi, Suk Joo

Chapter 22. Hysterectomy

I. Preoperative Evaluation

A. Evaluation of Pelvic Support

1. The most important observation in determining the feasiblility of avaginal hysterectomy is the demonstration of uterine mobility.
2. Pelvic support structures are elevated at the initial pelvic examination.

B. Evaluation of Pelvis

1. The bony pelvis should be evaluated.
2. The size and shape of the female pelvis contributes to increased exposure.

II. Surgical Considerations

A. Patient Positioning

1. Dorsal lithotomy position with buttocks positioned just over the table's edge.
2. Several stirrup types are available.
3. To avoid nerve injury, adequate padding should be used.
4. Marked flexion of the thigh and pressure points should be avoided.
5. Trendelenburg positioning aids with intravaginal visualization.

B. Preparation

1. A povidone-iodine solution is applied to the vagina.
2. The bladder is drained.
3. Several methods for draping

C. Instrument

1. Right-angled retractors, narrow Deaver retractors, weighted specula, Heaney needle holders and an assortment of Briesky-Navratil retractors, Heaney hysterectomy clamps etc.

D. Lighting

1. Overhead high-intensity lamps, headlight, a fiberoptic-lighted irrigation suction system.

E. Suture Material

1. Various suture materials.
2. A synthetic delayed absorbable polyglactin or polyglycolic acid suture and atraumatic needles are generally preferable.

III. The Surgical Procedure

A. Examination Under Anesthesia

1. To confirm prior findings and to assess uterine mobility and descent.
2. Vaginally or abdominally.

B. Grasping and Circumscribing the Cervix

1. The anterior and posterior lips of the cervix are grasped with a single or double toothed tenaculum. With downward traction , a circumferential incision is made.

C. Dissection of Vaginal Mucosa

1. It the initial incision is too close to the external cervical os, there is a greater amount of dissection required and associated bleeding.
2. Therefore this circumscribing incision should be made just below the bladder reflection.

D. Posterior Cul-De-Sac Entry

1. The peritoneal reflection of the postreior cul-de-sac can be identified by
stretching the vaginal mucosa.
2. Examined for pathologic alterations of the uterus or adhesive disease of the cul-de-sac.

E. Uterosacral Ligament Ligation

1. The uterosacral ligaments are clamped perpendicular to the uterus axis.
2. The pedicle is cut close to the clamp and sutured.
3. A small pedicle(0.5cm) distal to the clamp is optimal .
4. Larger pedicle becomes necrotic and the tissue sloughs -> culture medium for microorganisms.
5. This suture is held with a hemostat.

F. Entry Versus Nonentry into the Vesicovaginal Space(Cul-De-Sac)

1. Downward traction of the cervix and bladder is advanced.
2. There is no danger in delaying entry as long as the operator has ascertained that the bladder has been advanced.
3. After the bladder advance, a curved retractor is placed in the midline, holding the bladder out of the operative field.

G. Cardinal Ligament Ligation

1. With traction on the cervix, the cardinal ligaments are identified, clamped, and cut and the suture is ligated.

H. Advancement of Bladder

1. A blunt dissection technique may be used.
2. Sharp dissection may be helpful for previous surgery (e.g. cesarean delivery)

I. Uterine Artery Ligation
1. Contralateral and downward traction, the uterine vessels are identified, clamped, and cut and the suture is ligated.
2. A single suture and single clamp technique is adequate and decrease the potential risk of ureteral injury

J. Entry into the Vesicovaginal Space

1. The anterior peritoneal fold usually can be identified readily just before or after clamping and suture ligation of the uterine arteries.
2. The anterior peritoneal cavity should not be opened blindly because of the increased risk of bladder injury.

K. Delivery of the Uterus

1. A tenaculum is placed onto the uterine fundus in a successive fashion to deliver the fundus posteriorly.

L. Utero-Ovarian and Round Ligament Ligation

1. With the posterior and anterior peritoneum opened, the remainder of the broad ligament and utero-ovarian ligaments are clamped, cut, and ligated.
2. Double-ligated with a suture tie is needed.

M. Removal of the Ovaries

1. When the adnexa are removed, the round ligaments should be removed separately.
2. Clamp across the infundibulopelvic ligament and the ovary and tube are excised.

N. Hemostasis

1. A retractor or tagged sponge is placed into the peritoneal cavity and each of the pedicles is visualized and inspected for hemostasis.

O. Peritoneal Closure

1. Because the pelvic peritoneum does not provide support and reforms in 24 hours after surgery the peritoneum need not be reapproximated routinely.
2. A continuous absorbable 0 suture is begun at the 12 o'clock position in a pursue-string fashion.

P. Vaginal Mucosa Closure

1. Vertical of horizontal manner.
2. The sutures are placed through the entire thickness of the vaginal epithelium.

Q. Bladder Drainage

1. After completion of the procedure, the bladder is drained.

IV. Surgical Techniques for Selected Patients

A. Injection of Vaginal Mucosa

1. The use of paracervical and submucosal injection of 20-30ml of 0.5% lidocaine with 1:20,000 epinephrine prior to incision of the vaginal mucosa
2. Decrease postoperative pain and facilitate identification of surgical planes.
3. There is no need to inject the cervix

B. Morcellation of the Large Uterus

1. Hemisection or bivalving, wedge or "V" incisions or intramyometrial coring.

V. McCall Culdoplasty

A. Decrease future enterocele formation.

B. Absorbable suture is placed through the full thickness of the posterior vaginal wall at the point of the highest portion of the vaginal vault.
Left uterosacral ligament pedicle is grasped and sutured.
Posterior peritoneum is sutured between the uterosacral ligaments.
The suture is completed by passing the needle from the inside to the outside at the same point at which it was begun.
The suture is tied, thereby approximating the uterosacral ligaments and the posterior peritoneum.

VI. Schuchardt's incision

A. When vaginal exposure is difficult, the Schuchardt's incision may be utilized.
B. To decrease the blood loss, lidocain-epinephrine injection.
C. The incision follows a curved line from the 4 o'clock position at the hymenal margin to a point halfway between the anus and the ischial tuberosity.

VII. Intraoperative Complication

A. Bladder Injury

1. One of the most common intraoperative complication.
2. If the bladder is inadvertently entered, repair should be performed when the injury is discovered and not delayed until completion of surgery
3. Assessment of the injury including the visualization of the trigone.
4. Single or double layered closure with a small-caliber absorbable suture.
5. Methylene blue or a dye sterile milk formula can be instilled into the bladder to ensure that the repair is adequate.

B. Bowel Injury

1. Most often associated with the performance of a posterior colporrhaphy and are usually confined to rectum.
2. If the rectum is entered, the injury is repaired with a single or double layer closure
3. Followed by copious irrigation.
4. Postoperatively, the patient should be given a stool softener and a low- residue diet.

C. Hemorrhage

1. Intraoperative hemorrhage invariably is the result of failure to securely ligate a significant blood vessel, bleeding from the vaginal cuff, slippage of a previously placed ligation or avulsion of tissure prior to clamping.
2. Using square knots with attention to proper knot-tying mechanism.
3. Avoid the ureteral damage.

VIII. Perioperative Care

A. Bladder Drainage

1. Postoperative bladder drainage should be employed.
2. Reasons

1) Significant local pain.
2) Additional vaginal reparative procedures.
3) Surgery for stress incontinence.
4) The use of a vaginal pack.
5) The patient anxiety.

3. Most patient can void spontaneously therefore catheter drainage is not required.
4. If the patient does not tolerate pain well postoperatively or is extremely anxious the transurethral insertion of a 16 Fr catheter is warranted.
5. Not neccessary for longer than 24 hours.

B. Diet.

1. A clear liquid diet is suitable during the first 24hours postoperatively
2. On the first full postoperatively day, a regular diet can usually be consumed.