Abdominal Hysterectomy
Stephanie Ricci
General Principles
Definition
Abdominal hysterectomy is defined as the surgical removal of the uterus via a laparotomy incision. A total hysterectomy removes both the uterus and cervix. A subtotal or supracervical hysterectomy removes the uterus only. The ovaries may remain in situ for both kinds of hysterectomy. The decision to retain or excise ovaries is a complex decision to be made by the patient and her physician after extensive counseling.
Differential Diagnosis
Uterine leiomyomas
Abnormal uterine bleeding
Endometriosis
Pelvic inflammatory disease
Pelvic organ prolapse
Malignant or premalignant disease
Nonoperative Management
Alternative therapies to surgical management are highly dependent on the underlying disease. For example, symptomatic uterine fibroids can be treated with uterine fibroid embolization techniques. Endometrial ablation or intrauterine progestin delivering devices are often used to reduce menorrhagia. Similarly, medical therapy including progesterone and gonadotropin-releasing hormone agonist regimens are used to treat pelvic pain caused by endometriosis. Progestins are also used in the treatment of endometrial hyperplasia in select cases. Furthermore, the need for surgical treatment of pelvic organ prolapse can sometimes be mitigated with the use of pelvic floor strengthening exercises.
Imaging and Other Diagnostics
Depending upon the reason for hysterectomy, the use of preoperative imaging and diagnostics will differ. For surgical planning of an abdominal hysterectomy, the best tool to determine uterine size in addition to pelvic examination is pelvic ultrasound. This imaging provides an inexpensive and accurate assessment of uterine size, endometrial stripe thickness, and the adnexa. For peri- or postmenopausal women who are undergoing hysterectomy for abnormal uterine bleeding, preoperative endometrial sampling to rule out malignancy is imperative. Unless malignancy is suspected, the use of pelvic MRI prior to abdominal hysterectomy for benign disease is unlikely to provide additional information.
Preoperative Planning
It is essential to have a comprehensive discussion with the patient regarding perioperative complication risk, choice of abdominal incision, and whether the ovaries, fallopian tubes, and cervix will be removed. These decisions should be well documented both in the patient’s medical record as well as on the surgical consent form. The patient should be counseled that decisions made preoperatively are subject to change intraoperatively for patient safety.
Preoperative optimization strategies for women undergoing gynecologic surgery include medical consultation for patients with medical comorbidities and regarding perioperative medication management, pregnancy testing in all women of reproductive age, up-to-date screening with pap testing, mammography and colonoscopy, and endometrial sampling in perimenopausal/postmenopausal women with abnormal uterine bleeding. Further testing with EKG and CXR are recommended for women >50 years. Laboratory testing including complete blood count, electrolytes, creatinine, and type and screen are not required, however, may be useful in the postoperative setting.
The type of abdominal incision is based on several factors that include uterine size and the anticipation of anatomic abnormality such as extensive adhesions. If a woman has a prior vertical abdominal scar, most surgeons prefer to use this incision (Figs. 8.1.1 and 8.1.2). However, if uterine size and the absence of adhesiophylic pathology permit, a transverse abdominal incision is a good option that improves cosmesis and decreases both postoperative pain and the incidence of incisional hernias. Although earlier studies demonstrated an increase in vertical incision dehiscence rates, compared to transverse abdominal incision, more recent studies have found no difference in dehiscence rates between these two incisions.1
Figure 8.1.1. Vertical midline incision.
Figure 8.1.2. Vertical midline incision—skin incision.
The decision to remove both fallopian tubes and ovaries at the time of hysterectomy is complicated and requires a frank discussion between the patient and her surgeon. Benign indications for oophorectomy at the time of hysterectomy include endometriosis, tubo-ovarian abscess, and pelvic pain. In 2005, a nationwide study reported that unilateral or bilateral salpingo-oophorectomy was performed in 68% of women undergoing abdominal hysterectomy in the United States.2 Historically, the rationale for elective oophorectomy at the time of hysterectomy was ovarian cancer prevention in women nearing menopause. More recently, the thought has shifted to favor ovarian conservation, as new evidence suggests there are long-term health benefits associated with ovarian preservation and more risks than previously appreciated with elective oophorectomy.3 Furthermore, the incidence of ovarian cancer in the general population remains low and does not warrant elective oophorectomy at the time of hysterectomy.
In contrast, there are no proven medical or surgical benefits to performing a subtotal hysterectomy if the cervix can easily be removed with the uterus. Retaining the cervix commits the patient to continued cervical cancer screening and may result in posthysterectomy bleeding. The only absolute contraindication to supracervical hysterectomy is a malignant or premalignant condition of the uterus or cervix.
Surgical Management
Women undergoing abdominal hysterectomy require venous thromboembolism (VTE) prophylaxis. Guidelines for perioperative thromboprophylaxis published by both the American College of Obstetricians and Gynecologists and the American College of Chest Physicians consistently define patients undergoing abdominal hysterectomy as at least moderate risk of VTE.4,5 Therefore, mechanical VTE prophylaxis with sequential compression devices should be used in all women undergoing abdominal hysterectomy. Consideration for pharmacologic prophylaxis with heparin should be based upon risk factors further delineated in the aforementioned guidelines. Many institutions have developed routine, perisurgical thromboprophylaxis protocols, and administer both mechanical and pharmacologic therapies for women undergoing abdominal hysterectomy.4
Prophylactic antibiotics to prevent surgical site infection are given as a single intravenous injection prior to induction of anesthesia. The greatest efficacy for antibiotic administration is within an hour prior to bacterial inoculation (i.e., abdominal incision).6 For women greater than 50 kg, a dose of 2 g cefazolin is routinely used (1 g for women with BMI <30). If bowel penetration is anticipated, metronidazole 500 mg may be given in addition to cefazolin. Alternatively, cefoxitin 2 g can be administered to cover a broader spectrum of bacteria. Women
who are penicillin-allergic require a combination of clindamycin (600 mg) and gentamicin (1.5 mg/kg; max 240 mg). For lengthy procedures, additional intraoperative doses of antibiotic are given at intervals of one or two times the half-life of the drug to maintain adequate levels throughout the operation (Table 8.1.1). For cefazolin, a second dose is necessary at 3 hours. An increased blood loss greater than 1,500 mL also warrants a second dose of antibiotic.3
Table 8.1.1 Prophylactic Antibiotic Regimens for Abdominal Hysterectomy
Antibiotic
Dose (Intravenous)
Re-Dose Time (hrs)
Cefazolin/Cefoxitin
1 or 2a g
3
Clindamycin plus gentamicin
600 mg
1.5 mg/kg (240 mg max)
3
6
Clindamycin plus quinolone
600 mg
400 mg
3
6
Clindamycin plus aztreonam
600 mg
1 g
3
3
Metronidazole plus gentamicin
500 mg
1.5 mg/kg (240 mg max)
6
6
Metronidazole plus quinolone
500 mg
400 mg
6
6
aUse 2 g dose for obese patients—i.e., weight greater than 100 kg or BMI greater than 30.
Bowel preparation is not indicated in women undergoing abdominal hysterectomy unless there is a high probability of bowel injury secondary to adhesions. In these cases, it is reasonable to consider using a parenteral antibiotic regimen that is effective in preventing infection among patients undergoing elective bowel surgery. There is no evidence that mechanical bowel preparation further reduces infection risk.3
Positioning
After the patient is brought to the operating room, preoperative prophylactic antibiotics and subcutaneous heparin are administered prior to the start of the procedure. Sequential compression devices are placed bilaterally on the patient’s lower extremities. The patient may be positioned in either the dorsal supine or lithotomy position using Allen stirrups with careful attention to pressure points to avoid neurologic injury. A “time-out” is performed in which the surgeon, anesthesia, and operating room staff confirm and agree upon the patient’s identity, indicated treatments and surgery including any procedure laterality (i.e., right salpingo-oophorectomy) followed by an examination under anesthesia. The vagina, perineum, and abdomen (from the anterior thighs to xiphoid) are then prepared with antiseptic solution and draped in a sterile fashion. In sterile fashion, a Foley catheter is placed in the bladder and drained to gravity. The surgeon then changes her gloves before moving to the abdomen.
Approach
The skin incision may be transverse or midline vertical and is determined by a variety of factors, such as the presence of a prior surgical scar, need for upper abdomen exploration, uterine size, shape, and mobility, and desired cosmetic results. If a prior incision exists, most surgeons prefer to use this incision. If the prior scar is cosmetically unacceptable, it may be excised at the beginning or end of the procedure. This is accomplished by elevating the old scar with Allis clamps and creating an elliptical incision around the old scar.
If a transverse abdominal incision is desired, consider a few options. The most commonly used transverse incision is a Pfannenstiel incision; however, this incision provides the least amount of exposure because the recti remain intact. Transverse Cherney and Maylard incisions improve exposure because the rectus muscles are transected. A Cherney incision transects the rectus muscles at their tendinous insertions into the symphysis pubis, while the Maylard incision is a true transverse transection through all layers, including the rectus muscles, and necessitates identification and suture ligation of the deep, inferior epigastric vessels.
Procedures and Techniques (Video 8.1)Incision and exploration
Using a vertical abdominal approach, a midline vertical skin incision is made from the umbilicus down to the pubic symphysis (see Figs. 8.1.1 and 8.1.2). The underlying subcutaneous tissues are then divided down to the fascia (Tech Figs. 8.1.1 and 8.1.2). The fascia is incised in the midline over the rectus diastasis and along the length of the incision (Tech Figs. 8.1.3 to 8.1.6). The underlying posterior sheath is then elevated and entered sharply with Metzenbaum scissors (Tech Figs. 8.1.7 and 8.1.8). The peritoneum is grasped with smooth pick-ups or Kelly clamps, elevated, and entered sharply with the knife to gain uncomplicated entry into the abdominal cavity (Tech Fig. 8.1.9). The incision is then extended along its entire length paying careful attention to the location of the bladder.
Tech Figure 8.1.1. Dissection through subcutaneous adipose.
Tech Figure 8.1.2. Dissection through subcutaneous adipose.
Tech Figure 8.1.3. The fascia is revealed.
Tech Figure 8.1.4. Fascia is incised in the midline.
Tech Figure 8.1.5. Underlying rectus muscles are revealed.
Tech Figure 8.1.6. The midline fascial incision is extended superiorly.
A Pfannenstiel incision is a transverse incision made at a level suitable to the surgeon. It usually measured 10 to 15 cm transversely and extends through the skin, subcutaneous fat, and to the level of the rectus fascia. The rectus fascia is then incised transversely on either side of the midline with a scalpel and extended laterally with curved Mayo scissors. Kocher clamps are then placed on the inferior aspect of the fascial incision. While pulling vertically on the Kocher clamps with one hand, the surgeon uses her opposite hand to simultaneously and bluntly dissect the anterior rectus sheath from the underlying rectus muscle. The anterior aspect of the fascial incision is similarly dissected. The rectus muscles are then separated in the midline, and the peritoneum is opened vertically.
As with a Pfannenstiel incision, the skin and fascia are divided transversely with the Cherney incision; however, the rectus muscles are divided at their tendinous insertion into the symphysis pubis with a monopolar instrument or scalpel. The recti are then retracted cephalad to improve exposure. Similarly, the Maylard incision requires a transverse incision through skin, subcutaneous tissue, and fascia. However, once the fascia is transversely incised, it is not detached from the underlying muscle. The surgeon must identify the lateral borders of the rectus muscles, then identify, clamp cut, and suture ligate the inferior epigastric vessels lying on the posterior lateral border of each muscle. After these vessels are secured, the rectus muscles are transected using a monopolar instrument.
Tech Figure 8.1.7. The underlying peritoneum is exposed.
Tech Figure 8.1.8. The underlying peritoneum is exposed.
Tech Figure 8.1.9. The peritoneum is grasped and tented up for sharp entry.
Exposure
Once the peritoneum has been opened, a self-retaining retractor is placed and the target organ is exposed and delivered (Tech Figs. 8.1.10 to 8.1.12). The type of retractor used depends on the type of incision (vertical or transverse) and surgeon preference. When positioning retractors it is important to avoid placing the lateral blades over the femoral nerve as it emerges lateral to the psoas muscle. This can lead to peripheral neuropathy and postoperative difficulty with walking. To ensure safe placement, lift the abdominal wall as the retractor is placed, then check to confirm no bowel has been trapped beneath a blade and that the blade is not pressing on the sidewall of the pelvis (Tech Fig. 8.1.13).
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