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Abdominal ve Vajinal Histerektomi - www.jinekolojivegebelik.com

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Abdominal ve Vajinal Histerektomi - www.jinekolojivegebelik.com

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Abdominal ve Vajinal Histerektomi - www.jinekolojivegebelik.com

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

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