Hysterectomy

Learning objectives

A hysterectomy is the partial (cervix preserved) or total (cervix removed) surgical removal of the uterus
It may also involve the removal of the cervix, ovaries (oophorectomy), fallopian tubes (salpingectomy), and other surrounding structures
The woman can no longer get pregnant or menstruate after surgery

Classification

Total or complete hysterectomy: Removal of the uterus and cervix, preserving the ovaries
Supracervical or partial hysterectomy: Removal of just the upper part of the uterus while preserving the cervix
Total hysterectomy with bilateral salpingo-oophorectomy: Removal of the uterus, cervix, fallopian tubes, and ovaries
Radical hysterectomy with bilateral salpingo-oophorectomy: Removal of the uterus, cervix, fallopian tubes, ovaries, upper vagina, and some surrounding tissue (i.e., parametrium) and lymph nodes (cancer)

Abnormal or heavy vaginal bleeding that is not managed by other treatments
Severe pain with menstruation that is not managed by other treatments
Leiomyomas or uterine fibroids (noncancerous tumors)
Cervical or uterine cancer or abnormalities that may lead to cancer for cancer prevention
Uterine prolapse
Uterine hyperplasia, recurrent uterine polyps, endometriosis, or adenomyosis
Postpartum to remove a severe case of placenta praevia or placenta percreta
As a last resort in case of excessive postpartum hemorrhage
Chronic pelvic pain related to the uterus but not managed by other treatments

Blood clots (venous thromboembolism [VTE])
Infection
Heavy bleeding
Urinary incontinence and vaginal prolapse
Adhesion formation and bowel obstruction
Torn internal stitches
Urinary tract injury
Vaginal problems
Ovary failure
Early menopause symptoms (e.g., hot flashes, vaginal dryness, loss of libido, insomnia)
Issues related to anesthesia

Technique	Advantages	Disadvantages
Abdominal hysterectomy	Not limited by the size of the uterus Combination with reduction and incontinence surgery possible No increase in postsurgical complications compared to vaginal technique	Longest recovery period and return to normal activities Higher risk of bleeding compared to laparoscopic surgery Vaginal or laparoscopic techniques are preferred in obese patients
Vaginal hysterectomy	Shortest surgery time Short recovery period and discharge from hospital Less pain medication compared to laparoscopic technique	Limited by the size of the uterus and previous surgery Limited ability to evaluate the fallopian tubes and ovaries
Laparoscopic-assisted vaginal hysterectomy	Possible with a larger uterus, depending on the surgeon's skills Combination with reduction operations are possible	Malignancies can only be removed by this approach if they are intact Not suggested for patients with cardiopulmonary disease
Total laparoscopic hysterectomy	Short inpatient treatment duration compared to abdominal technique Possiblity to diagnose and treat other pelvic diseases Quicker return to normal activities compared to abdominal technique Less bleeding, fevers, and infections compared to abdominal technique	Increased length of surgery Requires a high degree of laparoscopic surgical skills Higher risk of bladder or ureter injury

Trendelenburg position
Transverse Pfannenstiel incision, occasionally midline incision
General anesthesia or neuraxial block
- General anesthesia
  - Muscle relaxation and controlled ventilation
  - Adjustment of ventilation parameters due to diaphragmatic splinting caused by Trendelenburg position
  - Multimodal analgesia with paracetamol, NSAIDs, opioids, and local blocks (e.g., TAP block for transverse incision, rectus sheath block for midline incisions)
- Neuraxial block
  - Add an intrathecal opioid
  - Block height to at least T4
  - Do not position the patient for surgery too soon → Trendelenburg position will increase cephalad spread
  - Manage hypotension with vasopressors
Transfusion in patients with preoperative anemia
Postoperative: Gabapentin, paracetamol, NSAIDs, opioids, patient-controlled analgesia, antiemetics, and VTE prophylaxis

Lithotomy position → take precautions to avoid nerve injuries
General anesthesia or neuraxial block
- General anesthesia
  - Spontaneous breathing or mechanical ventilation → anticipate potential respiratory changes when the patient is moved into the Trendelenburg position
  - Multimodal analgesia with paracetamol, NSAIDs, opioids, and local anesthetic infiltration
- Neuraxial block
  - Consider adding an intrathecal opioid for postoperative analgesia
  - Block height to at least T8
  - Do not position the patient for surgery too soon → lithotomy and Trendelenburg position will increase cephalad spread
  - Manage hypotension with vasopressors
  - Supplemental sedation (if required)
Less postoperative pain compared to abdominal technique
Postoperative: Paracetamol, NSAIDs, oral opioids, antiemetics, and VTE prophylaxis

Lithotomy position with steep Trendelenburg
Consider the risk of pneumoperitoneum
Large bore venous access to anticipate intraoperative cardiovascular complications or intraperitoneal injury
Uterine manipulator is inserted through the cervix → may provoke vagal stimulation and bradycardia
The uterus is removed vaginally (laparoscopic-assisted vaginal hysterectomy) or through an abdominal incision (total laparoscopic hysterectomy)
General anesthesia
- Muscle relaxation, tracheal intubation, and controlled ventilation
- Pneumoperitoneum and steep Trendelenburg position will alter lung mechanics, and CO2 can accumulate from insufflation → adjust parameters to ensure adequate ventilation
- Multimodal analgesia with paracetamol, NSAIDs, opioids, and local infiltration
Transfusion in patients with preoperative anemia
Less postoperative pain compared to abdominal technique
Postoperative: Paracetamol, NSAIDs, oral opioids, antiemetics, and VTE prophylaxis