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Abdominal ve Vajinal Histerektomi - www.jinekolojivegebelik.com Abdominal ve Vajinal Histerektomi - www.jinekolojivegebelik.com Presentation Transcript

  • HYSTERECTOMY Abdominal Hysterectomy Vaginal Hysterectomy
  • Hysterectomy
    • Hysterectomy most commonly performed surgical procedure in the United States.
    • Vaginal hysterectomy continues to be the procedure of choice.
    • No advantage to the routine use of supracervical hysterectomy.
    • Oophorectomy at the time of hysterectomy increase in patient mortality, currently recommended that ovarian conservation be considered until at least age 65 yrs.
    • A number of concurrent surgical procedure performed safely at the time of hysterectomy.
  • Hysterectomy
    • Hysterectomy most commonly performed surgical procedure.
    • After cesarean delivery, second most frequently performed major surgical procedure in the United States.
  • Hysterectomy
    • 1965 : 426,000 hysterectomies performed average length of hospital day 12.2 days
    • 1985 : 724,000 hysterectomies performed hospital day 9.4 days
    • 1991 : 544,000 hysterectomies performed hospital day 4.5 days
    • 1998 : increased to more than 600,000
      • 408,000 (75%) abdominally
      • 136,000 (25%) vaginally
    • 2005 : 824,000 hysterectomies
  • Hysterectomy
    • Rate of hysterectomy : 6.1~8.6 /1000 women of all ages.
    • Dependent on age, race, where she lives, sex of her physician.
    • Average age of hysterectomy : 42.7 yrs median age :40.9 yrs (remain constant since 1980s)
    • 75% of all hysterectomies : 20~49 yrs
  • Indication
    • Leiomyoma
    • Dysfunctional Uterine Bleeding
    • Intractable Dysmenorrhea
    • Pelvic pain
    • Cervical Intraepithelial Neoplasia
    • Genital Prolapse
    • Obstetrical emergency
    • Pelvic inflammatory disease
    • Endometriosis
    • Cancer
    • Benign ovarian tumor
  • Leiomyoma
    • Most common pelvic tumor
    • Consider only in patient do not desire future fertiltiy (fertility-preserving surgery: myomectomy)
    • Hysterectomy indication : Perform need to treat Sx
      • Abnormal Ut bleeding
      • Pelvic pressure
      • Pelvic pain
      • Rapid Ut enlargement
      • Ureter compression
      • Growth following menopause
  • Dysfunctional Uterine Bleeding
    • Indication for 20% of hysterectomies
    • Older than 35 yrs : endometrial sampling before hysterectomy
    • D&C
      • not effective means of controlling bleeding
      • not necessary before hysterectomy
    • Cannot tolerate medical therapy
    • Alternative therapy (Endometrial ablation or resection)
  • Intractable Dysmenorrhea
    • Dysmenorrhea can be treated with NSAIDs alone or combination with OCs or other hormone agent
    • Primary dysmenorrhea : hysterectomy is rarely required.
    • Second dysmenorrhea : underlying condition (leiomyomas or endometriosis) should be treated primary
    • Hysterectomy consider only if medical therapy fails or if patient not want preserve fertility.
  • Pelvic pain
    • 18% of hysterectomy : chronic pelvic pain
      • 78% 의 환자 : improvement
      • 22% 의 환자 : no improvement or exacerbation.
    • Hysterectomy should be performed only pain of uterine origin & not respond to nonsurgical treatment.
  • Cervical Intraepithelial Neoplasia
      • In past, hysterectomy was performed as primary Tx of CIN.
      • Maximun depth of dysplasia at the squamocolumnar junction : 5.2mm,
      • 99.7% 의 dysplasia : within 3.8mm of the epithelial surface
      •  Conservative treatment ( cryotherapy, laser, LEEP) can be effective.
      • Recurrent high-grade dysplasia : not desire to preserve fertiltiy hysterectomy appropriate Tx option.
      • After hysterectomy : increased risk for vaginal intraepithelial neoplsia.
  • Genital Prolapse
    • 15% of hysterectomy in the United States.
    • Unless associated condition requiring abdominal incision, vaginal hysterectomy is preferred approach.
    • Pelvic support defect corrected.
  • Obstetrical emergency
    • Postpartum hemorrhage resulting from uterine atony : most emergency hysterectomies
    • Uterine rupture cannot be repaired.
    • Pelvic abscess not respond to medial therapy
    • Placenta accreta or placenta increta
  • Pelvic inflammatory disease
    • PID pts unless not respond to intravenous antibiotic therapy : uterus, tubes, ovaries should be removed.
    • USG or CT guided PCD
    • Pts who desire future fertiltiy : unilateral adnexectomy or partial bilateral adnexectomy without hysterectomy.
  • Endometriosis
    • Medical and conservative surgical procedures : successful for Tx .
    • Adnexectomy be performed only in pts who not respond to conservative surgical (resection or ablation of endometriotic implants) or medical Tx .
    • Hysterectomy required unrelenting pelvic pain or dysmenorrhea.
  • Cancer
    • Cancer : meatstasis from nongynecologic sites.
    • Colorectal carcinoma pts : consider TAH with BSO due to risk of either synchronous pelvic cancers or occult metastasis.
  • Benign ovarian tumor
    • Benign ovarian tumor : persistent of symptomatic .
      • Peri or post menopause: decision whether Ut be removed
      • Group of adnexectomy with hysterectomy : increase in operative morbidity, estimated blood loss, length of hospital stay compared to Group of adnexetomy only
  • Vaginal hysterectomy versus abdominal hysterectomy
    • 75% : abdominal hysterectomy
    • No specific criteria determine route of hysterectomy
    • Ovarall complicaton rate : TVH 24.5/1000 vs, TAH 42.8/1000
    • Risk for one or more complication: TAH 1.7 times vs TVH
      • Risk for febrile morbidity : TAH 2.1 배
      • Hemorrhage requiring transfusion : TAH 1.9 배
    • If feasible TVH preferred approach
  • Supracervical hysterectomy
    • Ix : vague
    • Endometriosis c obliteration of anterior & posterior cul-de-sac
    • Cesarean hysterectomy when Cx fully dilated & difficult to identify
    • Cx can almost always be removed.
  • LAVH
    • Presence of pelvic adhesions cannot predict based on Hx or P/Ex
    • Criteria for selection of patients for LAVH vs abdominal hysterectomy : not clearly estabilsihed.
    • No advantage of LAVH over traditional vaginal hysterectomy
    • Not reduce perioperative morbidity & cost higher
  • LAVH Ix
    • Endometriosis
    • Known pelvic adhesive disease
    • Adnexal mass that require hysterectomy
    • Lack of uterine mobility
    • LAVH preferable in pt. c uterine mobility limited ☞ uncertain.
      • Supporting structures of uterus : uterosacral ligament & lower cardinal complex not transected with laparoscopic approach.
      • Transected of uteroovarian ligament, round ligament, broad ligament : not improve mobility.
  • Concurrent surgical procedures
    • Prophylactic oophorectomy : m/c surgical procedure performed concurrently with hysteretomy.
    • Oophorectomy performed prophylactically to prevent ovarian ca & eliminate potential need for further surgery for either benign or malignat disease
    • Against prophylactic oophorectomy center on need for earlier & more prolonged hormone therapy and potential increase risk of cardiovascular disease
      • HRT well tolerated & good symptomatic relief
      • But not as effective as nl ovarian fx, implication of long term HRT not fully known
  • Concurrent surgical procedures
    • Decision to proceed with Prophylactic Oophorectomy : considered carefully after patient be informed of risks & benefits
      • Risk for developing ovarian ca after hysterectomy for benign disease : lower than be expected based in its prevalence
      • At time of hysterectomy : no Hx of ovarian tumor & normal-apperaring ovaries  expected rate of ovarian ca 0.14%~0.47 % vs 1.4% (1/10)
  • Concurrent surgical procedures
    • Long term compliance c posthysterectomy estrogen therapy : low
      • After TAH with BSO : 20-40% of women take estrogen for more than 5yrs
    • ∴ Ovarian conservation until at least age 65 years confers long term survival benefits for women at average risk for ovarian ca undergoing hysterectomy for benign disease
  • Appendectomy
    • Appendectomy performed concurrently with hysteretomy to prevent appendicitis & remove disease that may be present
    • Limited value
      • Peak incidence of appedicitis : 20-40
      • Peak age for hysterectomy 10-20yrs later .
    • No increase in morbidity with appendectomy performed concurrently with hysteretomy but require average of 10 min of additional operating time.
  • Cholecystectomy
    • Gallbladder disease 4 times more common in woman
    • Highest incidence : 50-70 yrs (hysteretomy most often performed. )
    • Thus may require both procedures.
    • Combined prodedure not increase febrile morbidity & length of hospital stay
  • Technique
    • Negative result of PAP test within the year should be obatined before hysterectomy for benign disease.
    • 40 yrs or older : mammography
    • Endometrial Bx : abnormal ut bleeding
    • Stool guaiac test
  • Abdominal hysterectomy
  • Preop preparation
    • Cleansing tap water or soap enema.
    • Hair removed
    • Pt positioning : dorsal supine position
      • Anesthesia
      • Pt’s leg stirr up & pelvic examination
      • Foley catheterization & vaginal cleansing with iodine solution
      • Leg straightened
    • Skin preparation
  • Surgical Technique
    • The choice of incision
    • Simplicity of incision
    • Need for exposure
    • Potential need for enlarging incision
    • Strength of healed wound
    • Cosmesis of healed incision
    • Location of previous surgical scars
    • Skin  Subcutaneous tissue & fascia  Fascia divided
    •  Peritoneum
  • Surgical Technique
    • Abdominal Exploration
      • Upper abdomen & pelvis
      • Liver, gallbladder, stomach, kidneys, paraaortic LNs, & small bowel
      • Cytologic sampling if needed
  • Surgical Technique
    • Elevation of the Ut
      • Broad ligament clamps at each cornu  cross round ligament
      • Clamp tip close to internal os
  • Fig 22.1 Elevation of Ut
  • Surgical Technique
    • Round ligament Ligation & transection
      • Ut deviated to Lt side, stretching Rt round ligament
      • Proximal portion of broad ligament held clamp, distal portion of the round ligament ligated, transected
  • Fig 22-2 Round ligament Ligation & Transection
  • Surgical Technique
    • Round ligament Ligation & T ransection
      • Separate anterior & posterior leaves of broad ligament
      • Anterior leaf : incised along vesicouterne fold  seperate peritoneal reflection of bladder & lower uterine segment
  • Fig 22-3 Round ligament Ligation & Transection
  • Surgical Technique
    • Ureter identification
      • Retroperitoneum entered by incision cephalad on posterior leaf
      • External iliac artery along medial aspect of psoas muscle identified
      • Bifurcation of common iliac a, ureter cross
      • Ureter left attached to medial leaf of broad ligament
  • Fig 22-4 Ureter identification
  • Surgical Technique
    • Uteroovarian or Infundibulopelvic Ligament Ligation
      • I. Ovaries preserve
      • Window in peritoneum of posterior leaf of broad ligament under utero-ovarian ligament & fallopian tube
      • Tube & uteroovarian ligament clamped, cut, & ligated c both free-tie & suture ligature
  • Fig 22-5 Uteroovarian Ligament Ligation
  • Surgical Technique
      • II. Ovaries removed
      • Peritoneal opening enlarged
      •  extended to infundibulopelvic ligament & to uterine a
      • Opening  exposure of uterine a, infundibulopelvic ligament, ureter
      • Curved heaney or Ballentine clamp placed lateral to ovary
      • Infundibulopelvic ligament cut & doubly ligated
  • Fig 22-6 Infundibulopelvic Ligament Ligation
  • Fig 22-7 Infundibulopelvic Ligament Transection
  • Surgical Technique
    • Bladder Mobilization
      • Bladder dissected from lower uterine segment & Cx
    • Uterine Vessel Ligation
      • Uterine vasculature dissect
      • Clamp perpendicular to uterine a at junction of Cx & Ut body
      • Place tip of clamp adjacent to Ut
      • Vessels cut, suture ligated
    • Fig 22-8
    Fig 22-8 Bladder Mobilization
  • Fig 22-9 Uterine Vessel Ligation
  • Surgical Technique
    • Incision of posterior peritoneum
      • Rectum mobilized from posterior Cx
      •  posterior peritoneum between uterosacral ligament & rectum incised
      • Avascular tissue plane  mobilization of rectum inferiorly
  • Fig 22-10 Incision of posterior peritoneum
    • Cardinal Ligament Ligation
      • Cardinal ligament divided for distance of 2 to 3 cm to uterus
      • Ligament cut, pedicle suture ligated
      • Repeated until junction of cervix & vagina
    Surgical Technique
  • Fig 22-11 Uterine Vessel Ligation
  • Surgical Technique
    • Removal of the Uterus
      • Uterus on traction cephalad
      • Tip of Cx palpated
      • Curved Heaney clamps bilaterally  incorporate uterosacral ligament & upper vagina just below Cx
      • Avoid foreshortening vagina
      • Ut removed
  • Fig 22-12 Surgical Technique
  • Surgical Technique
    • Vaginal Cuff Closure
      • Figure-of-eight suture of 0–0 absorbable material
      • Both traction & hemostasis
      • Sutures at tip of each clamp, sutured  incorporating uterosacral & cardinal ligament at angle of vagina
      • Vaginal cuff left open
      • Running-locked suture for hemostasis along cuff edge
  • F ig 22-13 Vaginal Cuff Closure
  • F ig 22-14 Vaginal Cuff left open
    • Fig 22-14
  • Surgical Technique
    • Irrigation & Hemostasis
    • Peritoneal Closure
      • Pelvic peritoneum not reapproximated
      • d/t tissue trauma & adhesion
    • Incision Closure
      • Fascia c interrupted or continuous 0-0 or 1-0 monofilament absorbable suture
      • Continuous suture necrosis ↓
  • Surgical Technique
    • Skin Closure
      • Subcutaneous sutures not used
      • (Incidence of wound infection)
      • Skin staples or subcuticular sutures
  • Intraoperative Complications
  • Intraoperative Complications
    • Ureteral Injuries
      • Most formidable complcations
      • Far more serious than injury to bladder or bowel
      • Be aware of proximity of ureter
      • Avoided by opening retroperitoneum & directly identifying ureter
  • Intraoperative Complications
    • Ureteral obstruction suspected
      • IV injection of indigo carmine
      • Ureteral patency by opening dome of bladder & positioning retrograde ureteral stents
      • Cystoscopic evaluation
  • Intraoperative Complications
    • Bladder Injury
      • Close relationship of bladder, uterus, & upper vagina
      • Opening peritoneum during dissection of bladder off cervix & upper vagina
      • Unless involvement of bladder trigone, repaired 1-2 layer closure absorbable suture (ex 3-0 polyglycolic acid)
      • Bladder drained
      • Trigone involved, surgeon trained be consulted
  • Intraoperative Complications
    • Bowel Injury
      • Small bowel : most common
      • Small defects of serosa or muscularis : single layer of continuous or interrupted 3-0 absorbable suture
      • Close defects involving lumen in two layers c 3-0 absorbable suture
      • Defect closed in direction perpendicular to the intestinal lumen
      • Large area injured, resection with reanastomosis
  • Intraoperative Complications
      • Ascending colon, repaired in a similar manner
      • Descending colon & rectosigmoid colon at significant risk for injury
      • Not involving mucosa : single running layer of 2-0 or 3-0 absorbable suture
      • Laceration involve mucosa, closed as with small bowel injuries
      • Colostomy : defect > 5 cm or spillage of bowel contents
  • Intraoperative Complications
    • Hemorrhage
      • Arterial bleeding from uterine arteries or ovarian vessels
      • Blind clamping of vessels : risk for ureteral injury
      • Bleeding controlled pressure or suture ligation
  • Postoperative Management
  • Postoperative Management
    • Bladder Drainage
      • Indwelling bladder catheter for 1st few postop hours until patient ambulate & urinate
  • Postoperative Management
    • Diet
      • only ice chips & liquids on day of surgery
      • 1st postop day, bowel sounds (+)
      • Soft diet ==> solid food
      • Early feeding safe & return of bowel function & recovery
      • Pelvic & paraaortic LN dissection, bowel surgery, extensive dissections, flatus (+)==> clear liquids
  • Postoperative Management
    • Activity
      • Early ambulation thrombophlebitis & pneumonia 
      • ambulation 1st postop day
      • On discharge, avoid lifting 20 pounds  for 6 wks, (minimize stress on fascia)
      • Sexual intercourse until 6 wks
      • Wound Care : sterile bandage for 1st 24 hours ==> daily
  • Vaginal hysterectomy
  • Vaginal hysterectomy
      • Patient examined while anesthetized
      • Uterine mobility and descent
      • Decision : vaginally vs abdominally
  • Preoperative Evaluation
    • Evaluation of Pelvic Support
      • Uterine mobility
    • Evaluation of Pelvis
      • Angle of pubic arch > 90
      • Vaginal canal : ample
      • Post vaginal fornix : wide & deep
  • Preoperative Evaluation
    • Risk factor
      • Age, parity, Wt, surgical Ix, Ut size, myoma in ant lower segment ,prev surgeries, adhesions ,location length of Cx, narrow pubic arch (<90)
  • Surgical Considerations
    • Patient Positioning: dorsal lithotomy
      • Avoid nerve injury  adequate padding
    • Vaginal Preparation : povidone-iodine solution
    • Suture Material : synthetic absorbable polyglactin or polyglycolic acid suture & atraumatic needle
  • Procedure
    • Grasping & Circumscribing Cervix
      • Anterior & posterior lips of cervix grasped with tenaculum
      • Circumferential Incision in vaginal epithelium at junction of Cx
  • Fig 22.15 Circumferential Incision in vaginal epithelium
  • Procedure
    • Dissection of Vaginal Mucosa
      • Vaginal epithelium dissected from underlying tissue & pushed bluntly
      • Circumscribing incision just below bladder reflection
      • (d/t initial incision too close to external os  greater dissection  bleeding)
      • Continue dissection in correct cleavage plane
  • Fig 22.16 Dissection of Vaginal Mucosa
  • Procedure
    • Posterior Cul-de-Sac Entry
      • Stretching vaginal mucosa & underlying connective tissue  Peritoneal reflection of PCDS identified
      • Vaginal mucosa dissected in wrong plane  hysterectomy begun extraperitoneally by clamping and cutting uterosacral & cardinal ligaments close to the Cx
  • Fig 22.17 Posterior Cul-de-Sac Entry
  • Procedure
      • Peritoneal reflection of PCDS not identified, entry into anterior peritoneum  finger hooked into PCDS to place tension on peritoneum
      • Peritoneum opened
      • Interrupted suture to approximate peritoneum & vaginal cuff for hemostasis
      • Speculum placed into PCDS
  • Fig. 22.19 Interrupted suture to approximate peritoneum & vaginal cuff for hemostasis
  • Procedure
    • Uterosacral Ligament Ligation
      • Retraction of lateral vaginal wall & countertraction Cx, uterosacral ligaments clamped
      •  Incorporating lower portion of cardinal ligaments
  • Fig. 22.19 Uterosacral Ligament Ligation
  • Procedure
      • Clamped perpendicular to uterine axis, pedicle cut close to clamp and sutured
      • Small pedicle (0.5 cm) distal to clamp: optimal
      • Uterosacral ligaments transfixed to posterolateral vaginal mucosa
  • Fig. 22.20 Uterosacral ligaments transfixed to posterolateral vaginal mucosa
  • Procedure
    • Entry vs Nonentry into Vesicovaginal Space (Cul-de-Sac)
      • Cx downward traction
      • Using Mayo scissors,or open moistened 4 * 4 gauze sponge, bladder advanced
      • Vesicovaginal peritoneal reflection easily identified at this point, vesicovaginal space entered
      • After bladder advanced, curved Deaver or heaney retractor placed in midline
  • Procedure
    • Cardinal Ligament Ligation
      • Traction on Cx continued, cardinal ligaments, clamped & cut. Suture is ligated (Fig. 22.21)
  • Fig. 22.21 Cardinal Ligament Ligation
  • Procedure
    • Advancement of Bladder
      • Bladder advanced out of operative field
      • Blunt dissection technique
  • Procedure
    • Uterine Artery Ligation
      • Uterine vessels clamped, cut, & suture ligated to incorporate anterior & posterior leaves of the visceral peritoneum
      • Single suture & single clamp technique
  • Fig. 22.22 Uterine Artery Ligation
  • Procedure
    • Entry into Vesicovaginal Space
      • Anterior peritoneal fold can identified (Fig 22.23)
      • Peritoneum grasped with forceps, tented & opened
      • Heaney or Deaver retractor placed
  • Fig 22.23 Entry into Vesicovaginal Space
  • Procedure
    • Delivery of the Uterus
      • Tenaculum placed onto uterine fundus in successive fashion to deliver fundus posteriorly (Fig 22.24)
  • Fig 22.24 Delivery of the Uterus
  • Procedure
    • Uteroovarian & Round ligament Ligation
      • Posterior and anterior peritoneum opened, remainder of broad ligament and uteroovarian ligaments clamped, cut, & ligated (Fig. 22.25)
      • Uteroovarian & round ligament complexes double ligated with suture tie  ligature medial to first suture
      • Hemostat placed on second suture to aid identification of bleeding & to assist with peritoneal closure
  • Fig. 22.25 Uteroovarian & Round ligament Ligation
  • Procedure
    • Removal of ovaries
      • Adnexa removed, round ligaments removed separately from adnexal pedicles
      • Tractions on uteroovarian pedicle
      • Ovary drawn into operative field by grasping with Babcock clamp
      • Heaney clamp placed across infundibulopelvic ligament, ovary & tube excised
      • Transfixion tie & suture ligature
    • Hemostasis
      • Retractor or tagged sponge placed into peritoneal cavity, each of pedicles visualized & inspected for hemostasis
  • Fig. 22.26 Removal of ovaries & tube by clamping infundibulopelvic ligament
  • Procedure
    • Peritoneal Closure
      • Pelvic peritoneum not provide support & reforms in 24 hr after surgery, peritoneum need not reapproximate routinely
      • Continuous absorbable 0-0 sutures begun at 12-o’clock position
      • Suture continued in pursestring fashion incorporates distal portion of left upper pedicle & left uterosacral ligament
  • Procedure
    • Peritoneal Closure
      • Tension applied to suture placed at beginning of procedure  incorporates posterior peritoneum & vaginal mucosa  high posterior reperitonealization  prevent enterocele formation
      • Rt uterosacral ligament & distal portion of Rt upper pedicle incorporated
      • Ends at point on anterior peritoneum where begun
      • Slack of pursestring peritoneal suture taken up by pulling the suture tight
  • Procedure
    • Vaginal Mucosa Closure
      • Reapproximate in vertical or horizontal manner, c interrupted or continuous sutures
      • In this case, reapproximated horizontally with interrupted absorbable sutures
      • Sutures entire thickness of vaginal epithelium 
      • Obliterate underlying dead space & anatomic approximation of vaginal epithelium  decreasing formation of granulation tissue
  • Procedure
    • Bladder Drainage
      • After completion of procedure, bladder drained
      • Bladder catheter or vaginal packing not mandatory unless anterior or posterior colporrhaphy or other reconstructive procedure
  • Fig. 22.27 Peritoneal Closure
  • Fig. 22.28 Vaginal Mucosa Closure
  • Surgical Techniques for Selected patients
    • Injection of vaginal Mucosa
      • Paracervicl and submucosal injection of 20 to 30 mL of 0.5% lidocaine with 1:200,000 epinephrine before incision of vaginal mucosa  decrease postoperative pain & facilitate identification of surgical planes
      • Areas to injected : bladder pillars, lower portion of cardinal ligament, uterosacral ligamnets & paracervical tissue
  • Surgical Techniques for Selected patients
    • Morcellation of large Uterus
      • Including hemisection or bivalving, wedge or “V” incisions, and intramyometrial coring
      • Before beginning morecellation procedure, uterine vessels ligated, peritoneal cavity entered
      • Wedge morcellation : anterior or posterior fibroids or for fibroids in broad ligaments (away from the midline)
      • Cervix amputated, myometrium grasped  Wedge-shaped portions of myometrium removed
      • Apex of wedge kept in midline, reducing bulk of myometrium
      • Repeated until uterus removed
  • Surgical Techniques for Selected patients
      • Intramyometrial coring technique, myometrium above the site of ligated vessels incised parallel to axis of uterine cavity & serosa of uterus
      • Incision continued around full circumference of myometrium in symmetric fashion beneath uterine serosa
      • Comparison of abdominal hysterectomy or vaginal hysterectomy with uterine morcellation, length of stay& perioperative complications : abdomimnal hysterectomy increase
      • vaginal hysterectomy with uterine morcellation : safe and allows for increased number of women to undergo vaginal hysterectomy
  • McCall Culdoplasty
      • Although McCall culdoplasty thought to help decrease future enterocele formation, whether remains open to debate
      • Absorbable suture through full thickness of posterior vagina wall with highest portion of the vaginal vault
      • Posterior peritoneum, between uterosacral ligaments & right uterosacral ligament
  • Intraopearative Complications
    • Bladder Injury
      • Most common intraoperative complications
      • If bladder inadvertently entered, repair performed when injury discovered & not delayed until completion of surgery
      • Edges of wound mobilized  full extent of injury  repair without tension
      • Visualization of trigone
      • Bladder repaired with single-or double-layered closure
    • Bowel injury
      • Do not occur often
      • If rectum entered, injury repaired with single or double-layer closure  copious irrigation
  • Intraopearative Complications
    • Hemorrhage
      • Intraoperative hemorrhage : result of failure to ligate significant blood vessel, bleeding from vaginal cuff, slippage of previously placed ligature, or avulsion of tissue before clamping
      • Most intraoperative bleeding avoided with adequate exposure and good surgical technique
      • Using square knots with attention to proper knot-tying mechanisms prevent bleeding in most cases
      • Bleeding vessel identified & precisely ligated, with visualization of ureter if necessary
      • If location of ureter in question, visualize before suturing bleeding vessel
  • Intraopearative Complications
    • Bladder Drainage
      • Postop bladder drainage in spontaneous procedure complete voiding not anticipated
      • Reasons: local pain, additional vaginal reparative procedures, surgery for stress incontinence, use of vagina pack, patient anxiety
      • After TVH without additional repair, most patients can void spontaneously, catheter drainage not required
      • If patient not tolerate pain or extremely anxious  transurethral insertion of 16-Fr. Cathter after completing surgery
      • Not necessary for longer than 24 hours
  • Intraopearative Complications
    • Diet
      • Little manipulation of bowel
      • Limits some form of oral intake soon after surgery
      • Experience of nausea after surgery, combined with drowsiness from analgesics
      • Clear liquid diet  regular diet
      • Patient often best judge of what she can tolerate
  • Periopearative Complications
      • Wound infections occur after 4% to 6% of abdominal hysterectomies
  • Hemorrhage
      • 1st, bleeding from vagina within first few hrs after surgery
      • 2st, little bleeding from vagina but deteriorating vital signs( low BP and rapid PR, falling Hct level, flank or abdominal pain
      • 1st presentation : bleeding from vaginal cuff or one of pedicles
      • 2st presentation: retroperitoneal hemorrhage
      • Stabilization of vital signs appropriate fluid and blood replacement, and constant surveillance of patient’s overall condition
  • Hemorrhage
      • Bleeding 2 to 3 hours after surgery  lack of hemostasis
      • Bleeding from cuff edge
      • One or two sutures placed through mucosa
  • Hemorrhage
      • Bleeding excessive or from above cuff, or patient uncomfortable  to operating room
      • General anesthesia  vaginal operative site explored
      • Bleeding point : sutured or ligated
      • Bleeding above cuff or exteremly heavy  exploratory laparotomy
      • Ovarian vessels & uterine arteries thoroughly inspected (source of excessive vaginal bleeding )
      • Difficult to localize bleeding to specific vessel  ligation of hypogastric artery
  • Hemorrhage
      • little vaginal bleeding in whom vital signs deteriorated  Retroperitoneal hemorrhage suspected
      • Input and output
      • Hematocrit assessment, cross-matching
      • Tenderness & dullness in flank
      • Case of intraperitoneal bleeding, abdominal distention
  • Hemorrhage
      • Patient’s condition stabilizes rapidly with IV fluids
      • First , transfusion  follow serial hematocirt & vital signs
      • Retroperitoneal bleeding tamponade and stop, forming hematoma  eventually resorbed
        • Risk : hematoma later infected, necessitating surgical drainage
      • Patient’s condition stable  radiologic embolization
  • Hemorrhage
      • Another option to perform abdominal exploratory surgery while patient’s condition stable
      • This approach adds morbidity of a second procedure but avoids the possibility of patient’s condition deteriorating with continued delay or formation of a pelvic abscess
      • Adequate exposure  peritoneum over hematoma opened, blood evacuated
      • Bleeding vessels identified & ligated
  • Urinary Tract Complications
    • Urinary Retention
      • Urinary retention after hysterectomy uncommon
      • Catheter not placed after surgery, retention relieved initially with insertion of Foley catheter for 12 to 24 hrs
      • Most patients are able to void after catheter removed 1 day later
      • If trouble voiding & urethral spasm  skeletal muscle relaxant
  • Urinary Tract Complications
    • Ureteral Injury
      • Flank pain soon after vaginal hysterectomy, ureteral obstruction suspected
      • Incidence of ureteral injury : lower with vaginal hysterectomy than with avdominal hysterectomy
      • CT urogram and a urinalysis
      • Near ureterovesical junction
      • Passage of catheter thorough ureter under cystoscopic guidance
      • If catheter not passed through ureter  abdominal exploration and repair ureter at site of obstruction
  • Urinary Tract Complications
    • Vesicovaginal Fistula
      • Most often after total abdominal hysterectomy
      • Identification of proper plane between bladder and cervix, sharp dissection of bladder, care in clamping suturing vaginal cuff (0.2 %)
      • postoperative vesicovaginal fistula ; watery vaginal discharge 10 to 14 days after surgery (1 st 48 to 72 hours after surgery)
      • Methylene blue or indigo carmine dye  20 minutes, tampon d stain blue if ureterovaginal fistula(+)
  • Urinary Tract Complications
      • Vesicovaginal fistula: foley catheter inserted for prolonged drainage
      • Up to 15% of fistulas close spontaneously with 4 to 6 weeks of continuous bladder drainage
      • Closure not occurred by 6 weeks  operative correction
      • 3 to 4 monthes from time of diagnosis  reduction of inflammation and improve vascular supply
      • Four-layered closure:
        • Bladder mucosa
        • Seromuscular layer
        • Endopelvic fascia
        • Vaginal epithelium
  • Urinary Tract Complications
      • Incidental cystotomy at time of hysterectomy: more common( than vesicovaginal fistula)
      • Repaired correctly, rarely development of fistula
  • Prolapse of fallopian tube
      • Granulation tissue persist after attempts to cauterize or pain  remove
      • Fallopian tube prolapse should be suspected
  • Discharge Instructions
    • Avoid strenuous activity for first 2 wks, increase activity level gradually
    • Avoid heavy lifting, douching, or sexual intercourse Bathe as needed using shower or tub baths
    • Follow regular diet
    • Avoid straining for bowel movement or urination
    • Call physician  excessive vaginal bleeding or fever
    • Schedule return appointment
  • Psychosomatic Aspects
    • Decision to proceed with hysterectomy made jointly by patient & her physician
    • Potential risk of anesthesia & surgery loss of menstruation ability to procreate  loss of femininity ,sexual satisfaction , interpersonal problem her spouse
    • Preop counseling essential
  • Depression
    • Increase incidence of psychiatric Sx after hysterectomy
    • Twice after pelvic operation compared with other surgery
  • Sexuality
    • Incidence of sexual dysfunction after hysterectomy : 10% ~ 40%
    • Hysterectomy not cause psychiatric sequelae or diminished sexual functioning in most patients
    • Best predictor of postoperative sexual functioning : patient’s preoperative sexual satisfaction