The indications for hysterectomy for benign disease in 2005 changed little over the past decade, with uterine leiomyomata (33%) and menstrual disorders (17%) being the most common, followed by uterine prolapse (13%) and endometriosis (9%) ( www.hcupnet.ahrq.gov , 2007). Alternatives to hysterectomy are generally available and should be discussed with the patient. However, once the decision to perform a hysterectomy has been made, the type and route of hysterectomy must be chosen, and efforts must be made to accomplish the surgery as safely as possible. Hysterectomy can be performed vaginally, abdominally, or with laparoscopic or robotic assistance. The Nationwide In-Patient Sample of the Healthcare Cost and Utilization Project reported 538,722 hysterectomies for benign disease in 2003 ( www.hcupnet.ahrq.gov , 2007; ). An analysis of these United States data showed that abdominal (total and subtotal) hysterectomy was performed in 66.1% of cases, followed by vaginal route in 21.8% of cases and laparoscopic route in 11.8% ( ). By region of the country, the South has the highest hysterectomy rate and the Northeast has the lowest. The percentage of laparoscopic procedures is similar across all regions ( ).
This chapter will review considerations in the pre- and perioperative assessment and planning of hysterectomy and will discuss the issues and evidence for choosing the best route of hysterectomy for the patient.
General Preoperative Considerations
Preoperative Health Assessment
Preoperative health assessment is critical for optimal surgical outcome. The preoperative health assessment for hysterectomy should include a complete evaluation of the patient’s health status by a complete history and physical examination. There is no routinely recommended imaging, blood tests, or other tests such as electrocardiogram (ECG). These tests should be ordered on the basis of the patient’s underlying medical problem. This choice might include ordering a serum creatinine in patients with diabetes or hypertension or an ECG in patients with a history of heart disease. In certain cases, the preoperative evaluation identifies medical conditions that are unstable enough to adversely affect the postoperative outcome, and appropriate referral for medical management can be made ( ). Individual hospitals may have their own requirements for assessment before surgical intervention that may be age-adjusted.
Careful assessment of prescription and nonprescription drugs is important. Nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, have antiplatelet effects due to inhibition of cyclooxygenase with decreased thromboxane A 2 production. These drugs should be discontinued before surgery by at least 7 days, or four to five times the drug half-life to diminish the risk of intraoperative bleeding. Vitamin E should be discontinued 10 to 14 days before surgery, also because of concern for the risks of bleeding. If iron deficiency anemia is diagnosed before surgery, intraoperative or postoperative blood product use can be minimized with preoperative treatment with iron supplementation or use of menstrual cycle suppressive therapy, such as continuous oral contraceptives or gonadotropin-releasing hormone (GnRH) agonists, that help restore normal hemoglobin levels. The use of GnRH agonists should also be considered if their use will convert an abdominal procedure to a vaginal or laparoscopic one. The potential for blood transfusion or use of blood products should be discussed with the patient and their refusal documented. If excessive blood loss is expected, intraoperative blood salvage techniques and autologous blood donation should be considered.
Women taking contraceptives or hormone replacement therapy are at increased risk for venous thromboembolic events after hysterectomy. In general, contraceptives should be stopped 4 to 6 weeks before hysterectomy, although this may be difficult in women with anemia and severe menorrhagia ( ). There are no studies on the possible reduction of thromboembolic events with discontinuation of hormone replacement therapy before hysterectomy. This decision to discontinue hormone replacement therapy should then be based on the overall risk to the patient for a venous thromboembolic event. Stress dose steroids may be necessary for patients on chronic corticosteroids. Some medications, such as β-blockers, should be continued on the day of surgery.
A recent normal Papanicolaou (Pap) smear should be documented before hysterectomy. Sampling of the endometrium or pelvic ultrasound should be considered in patients who are at risk for a malignancy, such as women with postmenopausal bleeding and polycystic ovary syndrome. Based on age alone, it is generally recommended that women over 39 years of age with persistent anovulatory bleeding have an endometrial assessment after excluding pregnancy. Some guidelines suggest this cutoff should be age 35 ( ). Pelvic pain should be thoroughly investigated before hysterectomy is considered; alternative treatments should be discussed that include a wide range of medical suppressive therapy, physical therapy, and possible assessment by pain management specialists. If a pelvic mass is palpated on pelvic examination, a transvaginal ultrasound examination should be performed. No other imaging has been shown to be superior ( ). If there is a suspicious mass on transvaginal ultrasound examination, appropriate consultation with a gynecologic oncologist is recommended before surgery. Uterine prolapse is often accompanied by other pelvic floor disorders, such as urinary and fecal incontinence. These problems need to be assessed preoperatively and, if appropriate, corrected at the time of hysterectomy.
Informed consent for hysterectomy should be methodical; it is a process rather than a single event. Multiple factors need to be documented in the medical record, including whether the patient has completed childbearing ( Table 4-1 ). The route of hysterectomy should be discussed with the general concept that conversion from a laparoscopic or vaginal approach to laparotomy, if necessary, may be required to safely carry out the intended procedure.
Pregnancy should be ruled out in all reproductive-aged women on the day of surgery. Attention to perioperative details ( Table 4-2 ) such as prophylactic antibiotics and prevention of venous thromboembolic events are important to ensure a safe outcome. The most important perioperative management protocols involve the use and timing of prophylactic antibiotics to decrease the risk of surgical site infections and treatments or maneuvers for the prevention of venous thromboembolic events. Other factors, such as maintenance of β-blockade and glycemic control are important ( ). A careful general medical risk assessment should be done. Mahid and associates found that, in addition to factors in Table 4-2 , impaired functional status, American Society of Anesthesiologists (ASA) class 4 or 5, and hypothermia (<96° C) on arrival to the postanesthesia care unit (PACU) were statistically of clinical importance in predicting risks of morbidity and mortality. Smoking cessation should be urged in all patients ideally 6 to 8 weeks before surgery.
The time of administration of the antibiotic is critical to lowering the frequency of surgical site infection ( ; ). The antibiotic should be given preoperatively to achieve minimal inhibitory concentrations (MICs) 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- (cefazolin) 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. If the patient is allergic to cephalosporins, metronidazole 500 mg intravenously is recommended. These guidelines also recommend discontinuing prophylactic antibiotics within 24 hours after the operation. Longer procedures require re-dosing; the recommending interval for cefazolin is 3 to 5 hours and for cefoxitin 2 to 3 hours ( ).
Recent guidelines from the American Heart Association have recommended that administration of antibiotics solely to prevent endocarditis in patients undergoing a genitourinary procedure be abandoned except in the most severe circumstances ( ).
Prevention for Venous Thromboembolic Events
It is important to assess the patient for her risk of venous thromboembolic events before surgery. Conditions that place a patient at higher risk are listed in Table 4-3 .
Postoperative bed rest in the hospital or at home places the patient at increased risk of venous thromboembolic event. In general, all patients undergoing hysterectomy require a prevention strategy and, by definition, are at moderate risk ( ). In these patients, low-dose unfractionated heparin (5000 units every 12 hours) or low-molecular-weight heparin (e.g., enoxaparin 40 mg or 2500 units of dalteparin daily) or intermittent pneumatic compression device is recommended. Either form of heparin should be started 2 hours before surgery, and the compression stockings are placed on the patient in the operating room before incision. These treatment approaches should be continued until the patient is ambulatory. Patients over 40 years of age and those under 40 years of age who have risk factors (such as obesity) require a similar approach, with some modification in the unfractionated heparin (5000 units every 8 hours) or low-molecular-weight heparin (5000 units dalteparin or similar enoxaparin 40 mg daily). In patients who are over 60 years of age and have significant risk factors, such as previous venous thromboembolic event, malignancy, or hypercoagulable state, unfractionated heparin (5000 units every 8 hours) or low-molecular-weight heparin (5000 units dalteparin or enoxaparin 40 mg daily) and intermittent pneumatic compression devices should be used. Patients on oral contraceptives up to the time of hysterectomy should be considered for heparin therapy ( ). In high-risk patients, prophylaxis may be needed after discharge for several weeks.
Other Preventive Strategies
The surgical time-out is a useful process for determination of correct procedure and site. Its observation is an accepted quality parameter for surgery ( ).
The value of a mechanical bowel preparation for prevention of infectious complications of an intraoperative bowel leak or for reducing the rates of anastomotic leak if bowel surgery is performed has been challenged in a meta-analysis ( ). Therefore, it does not seem necessary to “bowel prep” all patients undergoing a hysterectomy for benign disease solely in case of an inadvertent enterotomy.