Video Clips on DVD
- 11-1
Transvaginal Cystotomy Repair
- 11-2
Intentional Cystotomy with Passage of Ureteral Catheters
As with all surgeries, complications related to hysterectomy should be carefully scrutinized to allow the surgeon and patient to better understand the risks (versus benefits) of this intervention for the patient’s disease. Complications that occur can be directly related to the surgical technique, to the anesthesia, or to medical disorders in the perioperative period. The mortality rate from hysterectomy is estimated at 0.12 to 0.38 per 1000 surgeries, and is substantially higher when the hysterectomy is performed for an obstetric indication or for malignancy, or when significant co-morbidities exist.
The Maryland Women’s Health Study, a prospective cohort study of 1299 women undergoing hysterectomy for benign disease, reported that 66.8% of patients had one or more mild complications, 11.1% had one or more moderate complications, and 0.7% had a serious complication ( ). The hospital readmission rate for a reason related to the hysterectomy was 4% during the first year after surgery. The most common reasons for readmission were wound complications, surgery for adhesions, bowel obstruction, and urinary tract problems. investigated the complication rate in 37,512 women undergoing hysterectomy for benign disease in the United Kingdom and found a 3% risk of severe complications including death, thromboembolic disease, myocardial infarction, stroke, hemorrhage, visceral injury, and end-organ failure. The risk of operative complications in this study increased in women undergoing hysterectomy for fibroids and decreased with increasing age. The highest risk groups were younger women who underwent laparoscopic hysterectomy for fibroids and those with a history of serious co-morbidities.
Race also may affect surgical morbidity; an analysis of 53,159 hysterectomies in Maryland from 1986 to 1991 found that, in comparison to white women, black women having hysterectomy had an increased risk of one or more complications of surgical or medical care (19.7% vs. 13%; odds ratio [OR] 1.4, 95% confidence interval [CI] 1.3–1.5) and higher in-hospital mortality rate (OR 3.1; 95% CI 2.0–4.8) ( ). Black women were more likely to have had hysterectomies for fibroids and to undergo abdominal surgery, perhaps partly explaining the higher complication rate.
Rates of certain complications also vary by route of hysterectomy. The lowest complication rates are generally associated with simple vaginal hysterectomy, although the likelihood of complications increases somewhat if additional procedures are done to correct prolapse. Laparoscopic hysterectomy, like all laparoscopic procedures, has its own set of unique complications related to trocar insertion, energy sources, and peritoneal insufflation. The eVALuate study comprised two parallel randomized multicenter trials: one comparing laparoscopic with abdominal hysterectomy and the other comparing laparoscopic with vaginal hysterectomy for nonmalignant disease ( ). A total of 1346 patients had surgery; patients with a uterine mass greater than 12-week size and those with stage II or greater prolapse were excluded. The primary endpoints were assessments of complications. Table 11-1 shows the complication rates, with the intraoperative conversion rate excluded as a major complication, but reported separately. All six ureter injuries occurred in the laparoscopic group. The overall urinary tract (ureter plus bladder) complication rate was higher in the laparoscopic group than in the vaginal or abdominal groups (abdominal 1%, vaginal 1.2%, laparoscopic 2.3%). A minor complication, mostly postoperative fever or infection, occurred in approximately 25% of patients in each group. If one includes conversion to laparotomy as a major complication, then more major complications were found in the laparoscopic hysterectomy group compared to abdominal hysterectomy (11.1% vs. 6.2%; OR 1.91, 95% CI 1.11–3.28). If one excludes conversion to laparotomy as a complication, then the complication rates are similar between all groups. This study also confirmed the advantages of less pain, shorter hospital stay, quicker recovery, and improved quality of life in the short term with the laparoscopic and vaginal groups. Laparoscopic surgery had longer operating room times compared with vaginal or abdominal surgery.
| Complication | Abdominal Trial | Vaginal Trial | ||
|---|---|---|---|---|
| Abdominal Hysterectomy (%) | Laparoscopic Hysterectomy (%) | Vaginal Hysterectomy (%) | Laparoscopic Hysterectomy (%) | |
| At least one major complication * | 6.2 | 7.2 | 5.4 | 6.7 |
| Intraoperative conversion to laparotomy | 3.9 | 4.2 | 2.7 | |
| Major hemorrhage † | 2.4 | 4.6 | 2.9 | 5.1 |
| Bowel injury | 1 | 0.2 | 0 | 0 |
| Ureter injury | 0 | 0.9 | 0 | 0.3 |
| Bladder injury | 1 | 2.1 | 1.2 | 0.9 |
| Other ‡ | 2.1 | 2.4 | 1.8 | 3.9 |
* Excluding intraoperative conversion to laparotomy.
† Major hemorrhage was defined as blood loss requiring a blood transfusion.
‡ Includes pulmonary complications, anesthesia, return to the operating room, wound dehiscence, and hematoma.
Medical co-morbidities are associated with mortality and complication rates after hysterectomy. found that a history of congestive heart failure or myocardial infarction, prior thrombosis, perioperative hemoglobin decrease greater than 3.1 g/dL, or preoperative hemoglobin less than 12.0 g/dL were associated with increased perioperative complications. Quality improvement efforts should attempt to modify these variables to optimize outcomes. There are some general patient safety indicators that may help identify potentially preventable complications associated with the surgical event ( Table 11-2 ). This chapter will specifically address certain surgical complications at hysterectomy: perioperative bleeding, surgical site infections, wound complications, lower urinary tract injury, fistula, bowel injury, vaginal cuff evisceration, and fallopian tube prolapse.
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Perioperative Hemorrhage
Case Presentation and Discussion: Postoperative Hemorrhage
G.W. is a 47-year-old gravida 3, para 3 obese woman with a 5-year history of severe abnormal uterine bleeding in association with uterine fibroids approximately 12-week size. She has been treated medically for the last 5 years but has continued anemia with hemoglobin of 9.8 g/dL. She has been presented with the full range of treatment options including further medical therapy, myomectomy, uterine fibroid embolization, or hysterectomy, and she desires a hysterectomy. Her pelvic examination confirms a 12- to 14-week-size mobile, anteverted uterus with a large central fundal fibroid. She has adequate vaginal capacity and mobility with her cervix descending approximately 3 cm with gentle traction. She has no other significant prolapse of her vagina or stress urinary incontinence.
A vaginal hysterectomy with morcellation was done over the course of approximately 1 hour. The uterus weighed 260 g and was sent to pathology. Both tubes and ovaries were normal and were not removed. The estimated blood loss for the surgery was 350 mL and she was transferred to the recovery room in stable condition.
Approximately 4 hours after surgery the physician is called to the bedside with a report that the patient is developing hypotension and tachycardia and that she had an increase in vaginal bleeding that now appears bright red. On physical examination, she is a somewhat pale-appearing female with a pulse of 110 bpm and a blood pressure of 100/60 mm Hg that decreases to 90/palpable when she sits up. Her abdomen is somewhat distended and bright red blood is noted from the vagina. An urgent hemoglobin is sent and is 6.8 g/dL. She is given a bolus of intravenous fluids and 4 units of blood are ordered from the blood bank.
The gynecologist, while waiting for the blood transfusion to begin, is faced with a decision between two major interventions: immediately returning to the operating room to find and correct the source of the bleeding, or immediate consultation with an interventional radiologist for consideration of embolization of the bleeding vessel. If the patient is hemodynamically unstable and operating room facilities are available, then the most prudent and efficient treatment would be to return to the operating room. Once in the operating room the gynecologist should perform a vaginal examination of the vaginal cuff to attempt to identify and ligate the bleeding vessel, probably a uterine or vaginal artery, or a branch of it. If the gynecologist is unable to identify the bleeding vessel vaginally and there are signs of bleeding within the peritoneal cavity, then a laparotomy needs to be performed to ligate the bleeding vessels.
If the patient is hemodynamically stable, especially with fluid and blood resuscitation, and if the gynecologist has facilities to perform an immediate assessment by an interventional radiologist, then it might be reasonable to perform angiography to locate and embolize the bleeding vessel. This has been reported to be successful in multiple circumstances involving hemorrhage in gynecology and obstetrics and is an excellent and viable alternative in appropriate patients who are in hospitals with adequate facilities for this.
The most common serious intraoperative complications of hysterectomy are hemorrhage and lower urinary tract injury. Although the definition of hemorrhage is somewhat arbitrary, most would consider a blood loss of greater than 1000 mL or need for a blood transfusion as acceptable criteria. Using this definition, the risk of hemorrhage at hysterectomy is approximately 1% to 3%. Bleeding after surgery can occur from any of the vascular pedicles, especially the uterine and ovarian vessels. Arterial bleeding from the vagina is usually from the uterine artery that has slipped from its ligature. This would require reoperation for suture ligation or embolization by an interventional radiologist. Venous bleeding may result in a pelvic hematoma, which can be diagnosed by pelvic examination or imaging studies. Careful observation, with or without blood transfusion, usually is adequate, but the patient should be carefully followed for signs of anemia and pelvic infection.
The systematic review performed by the Cochrane collaboration found no differences in transfusion rate between the abdominal, vaginal, or laparoscopic approaches. Subtotal (supracervical) hysterectomy appears to have reduced blood loss during surgery compared to the other approaches. The risk of intraoperative bleeding is increased in the presence of extensive endometriosis, malignancy, a uterus enlarged by fibroids (>500 g), and large pelvic masses that obscure the operative field. A hysterectomy performed for an obstetric indication is also at increased risk of excessive blood loss. Last, hysterectomy in the presence of thrombocytopenia, coagulopathy, or use of anticoagulation would likely increase the risk of excessive intra- and postoperative bleeding and transfusion.
In situations in which excessive bleeding at hysterectomy is anticipated or expected, the patient’s blood should be cross-matched and available in the blood bank. Appropriate blood products should be available in the presence of coagulopathy. A CellSaver® (Haemonetics Corp., Braintree, MA) for autologous blood transfusion and thrombin products to enhance hemostasis should be available during surgery. Specialists in areas such as vascular surgery, anesthesia, and interventional radiology could be alerted preoperatively in case they will be needed.
Fever and Perioperative Infections
Fever
The most common postoperative complication of hysterectomy is febrile morbidity which occurs in 10% to 20% of women. Fevers after hysterectomy can occur for the following reasons: (1) an operative site infection such as a vaginal cuff cellulitis, pelvic abscess, or abdominal wound infection; (2) an infection remote from the operative site, such as pneumonia or pyelonephritis; or (3) the fever may be unexplained and resolve without consequence (50% of all posthysterectomy fevers). Recent evidence suggests that most unexplained postoperative fevers are not due to pulmonary atelectasis, but are the result of an increase in interleukins and cytokines. Regardless of the cause, a postoperative fever after hysterectomy increases the hospital stay an average of 1 to 2 days. Fevers that persist and are associated with clinical signs, symptoms, and laboratory findings suggestive of a surgical site infection require appropriate treatment with antibiotics.
Infections with an associated abscess or fluid collection, such as an abdominal wound infection or pelvic abscess, require surgical drainage. In the case of the posthysterectomy pelvic abscess, drainage can sometimes be accomplished transvaginally; however CT (computed tomography)-guided drainage or surgical exploration is sometimes required. Pelvic abscesses also require a course of intravenous broad-spectrum antibiotics followed by 10 to 14 days of oral antibiotics after the fevers resolve. Vaginal cuff cellulitis is diagnosed in patients who have persistent postoperative fever, vaginal cuff induration, and purulent discharge, without evidence of abscess. Antibiotics are usually adequate therapy. Abdominal wound infections often do not require antibiotics unless there is an associated skin cellulitis. Urinary tract infections are relatively common after hysterectomy; however, they are rarely a source of fever unless the upper urinary tract is involved.
Surgical Site Infections
Although data vary widely, most case series cite surgical site infection rates of 3% to 5% after abdominal hysterectomy, and this rate can increase up to 12% in obese women. Patient-related factors that increase the risk for surgical site infections include obesity, advanced age, medical conditions, cancer diagnosis, malnutrition, smoking, alteration of cervicovaginal flora, and immunosuppression ( ; ). Operative risk factors include length of surgery, length of postoperative stay, increased blood loss, and tissue trauma. Factors that predispose obese women to surgical site infections include decreased vascularity of subcutaneous tissues, increased intra-abdominal pressure causing increased tension on the wound closure, more bacterial growth on skin, higher prevalence of diabetes and poor gylcemic control, longer operations, and decreased tissue concentrations of prophylactic antibiotics ( ). The route of hysterectomy is also important: the most recent Cochran Review ( ) reports that vaginal hysterectomy has fewer febrile episodes or infections than abdominal hysterectomy (OR 0.42), and laparoscopic hysterectomy has fewer wound or abdominal wall infections than abdominal hysterectomy (OR 0.31).
A number of strategies can be used in the perioperative period to lower the risk of surgical site infections, particularly in obese patients ( Table 11-3 ). The use of prophylactic antibiotics to decrease the risk of surgical site infections is one of the most important perioperative techniques to lower morbidity rate after hysterectomy. The time of administration of the antibiotic is critical to lowering the frequency of surgical site infection. The antibiotics should be given preoperatively to achieve minimal inhibitory concentrations (MIC) in the skin and tissues by the time the incision is made. This typically means an intravenous injection within 60 minutes of incision with a first- (cephalexin) or second- (cefoxitin) generation cephalosporin. These antibiotics were chosen because the likely site infection pathogens for hysterectomies are gram-negative bacilli, enterococci, group B streptococci, and anaerobes. Several alternative regimens are suggested by American College of Obstetricians and Gynecologists ( ) if the patient is allergic to penicillin or cephalosporins ( Table 11-4 ). Longer procedures require re-dosing; the recommended interval for cephalexin is 3 to 5 hours and cefoxitin is 2 to 3 hours ( ). A recent large multicenter collaborative study confirms these observations of a consistent relationship between the timing of antimicrobial prophylaxis and surgical site infection risk, with a trend toward lower risk occurring when prophylactic antibiotics with cephalosporins and other antibiotics with short infusion times are given within 30 minutes prior to incision ( ).
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