CLINICAL PRESENTATION AND HISTOPATHOLOGICAL VARIENTS OF HYSTERECTOMIES PERFORMED IN SHAHEED SUHRAWARDY HOSPITAL DHAKA, AMONG 100 CASES
Hysterectomy is the removal of the uterus with or without cervix. When this is done through an abdominal incision it is called abdominal hysterectomy. When the approach is through vaginal vault it is called vaginal hysterectomy.
Nowadays, hysterectomy is one of the most common major gynecological operations performed, but the decision to perform hysterectomy has got far reacting consequences to the patient. Thus the indications, the risks and the benefits have all the weighted minutely.1
The uterus is mostly removed for organic pathology such as lolomyoma, adenomyosis, and carcinoma of the corpus and cervix of uterus and ovary. But some hysterectomies are performed even though the uterus shows no evidence of pathology as in dysfunctional uterine bleeding, genital prolepses, pelvic inflammatory disease and endometriosis.
The improved hospital care, availability of blood transfusion, advanced anesthesia, and above all, the advent of antibiotics has opened up a new era and thereby broadened the indications for hysterectomy with minimum post operative morbidity and mortality.
However, hysterectomy must never be done without proper indication, hysterectomy should be performed when the risk of preserving the uterus is greater than the risk of removal or when there is no successful medical treatment.
70% to 80% of hysterectomies are performed through abdominal route, 20% to 30% are performed through vaginal route.¹ The vaginal route has increasingly become the method of choice for hysterectomy, it is proved to be effective and safe procedure regardless of some contraindications (Nulliparity, excessive uterine size, previous pelvic surgery). Traditional vaginal hysterectomy has proved to be faster operative technique compared with laparoscopic assisted vaginal hysterectomy (LAVH).2
LAVH is gaining popularity in the recent years with the increase in skill and expertise and because of several advantages (short period of hospital stay, early convalescence, less need for postoperative analgesia). Although it is expensive but the indirect cost is much less.3
The study has been undertaken to find out the common indications of hysterectomy in our country, to study the pattern of complications and to see the correlation between clinical diagnosis, preoperative findings and histopathological findings among 1000 cases studied.
Hysterectomy: A Historical Perspective
The study of hysterectomy dates back to the middle of 19th century when it was performed. The progress until now in the techniques hysterectomy proves the remarkable improvement in the surgical art of gynecology. Abdomen was first deliberately opened to remove an ovarian cyst by Ephraim McDowell in Kentucky in 1809.4
The first abdominal hysterectomy was performed by Charles Clay in Manchester, England in 1843.4 unfortunately the diagnosis was wrong and the patient died in the immediate post operative period. The following year, Charles Clay was almost the first to claim a surviving patient, however she died postoperatively and it was not until 1853 that Ellis Burnham from Lowell, Massachusetts achieved the first successful abdominal hysterectomy although again the diagnosis was wrong4 of his next 15 cases, only 3 survived.
Lawson Taitt attempted to solve the problem of leiomyomata by castration, by means of bilateral oopherectomy. During subsequent period, the postoperative fate of the ovaries became a subject of dispute. In the early twentieth century, as ovarian physiology began to be understood, an era of ovarian conservation began. At the same time prophylactic removal of normal ovaries in the pre and post menopausal woman at the time of hysterectomy was gaining acceptance, because of difficulty diagnosing and curing ovarian cancer.
Wertheim of Vienna who established radical abdominal type of hysterectomy with selective pelvic lymphadenectomy (1898) by performing an extensive series, for carcinoma cervix.5
Vaginal hysterectomy dates back to ancient times. The procedure was performed by Soranus of Ephesus 120 years after the birth of Christ, the many reports of its use in the Middle Ages were nearly always for the extirpation of an inverted uterus. And the patients rarely survived. Vaginalhysterectomy was performed in 1813 by Lavgenback in Germany 1829 by John Collins Waraen in Boston. Both operations were unsuccessful. Fenger described the modern operation of vaginal hysterectomy in 1881. Radical vaginal hysterectomy was performed by Schauta in 1908.5
Early hysterectomy was complicated with hazards and the patients usually died of hemorrhage, peritonitis and exhaustion. The main problem of hysterectomy at the time was management of the cervical stump. Early procedures were performed without anesthesia with mortality of about 70% mainly due to sepsis, from leaving a long ligature to encourage the drainage of pus. Thomas Keith from Scotland realized the danger of the this practice and merely cauterized the cervical stump and allowed it to fall internally, thereby bringing the mortality down to about 8%.
Hysterectomy became safer with the introduction of anesthesia, antibiotics and antiseptics, blood transfusions and intravenous therapy. During the 1930s, Richardson introduced the total abdominal hysterectomy to avoid serosanguinous discharge from the cervical remnant and the risk of cervical carcinoma developing in the stump. Apart from this innovation and the transverse incision introduced by Johanns Pfannenstiel in the 1920s, there was a little advance in hysterectomy techniques until the advent of endoscopic surgery and the performance of the first laparoscopic hysterectomy by Harry Reich in Kingston, Pennsylvania in 19886. The refinement and increasing safety of Laparoscopic hysterectomy suggest that it will be used increasingly in the future, although developments in the pharmacology and photodynamic therapy and interventional radiology may reduce the traditional indications of the operation.
TYPES OF HYSTERECTOMY
This involves removal of the whole uterus including the cervix.5
In this operation the vaginal part of the cervix and a variable amount of the supravaginal cervix are not removed.
This operation includes the removal of the uterus, cervix, the top portion of the vagina and most of tissues that surrounds the cervix in the pelvic cavity. Pelvic lymph nodes may also be removed. It was usually called for in women with cervical cancer or endometrial cancer that has spread to the cervix.
Rutledge has defined five classes of hysterectomy in cases of malignancy, depending on the extent of resection.5
Ø Class I
Extrafascial hysterectomy with bilateral salpingo-oophorectomy.
Ø Class II
Modified radical hysterectomy which is the original Wertheim hysterectomy. In this the medial half of the cardinal and the uterosacral ligaments are also removed as well as those pelvic lymph nodes which are enlarged.
Ø Class III
Radical hysterectomy. This is the modified Wertheim’s operation as described by Meigs. It includes complete pelvic lymph node dissection, removal of almost the whole of the cardinal and uterosecral ligaments and the upper one-third of vagina.
Ø Class IV
Extended radical hysterectomy. This includes removal of the periureteral tissues, superior vesical artery and up to three-fourths of the vagina.
Ø Class V
Partial exenterating. This is rarely performed. Here portions of the distal ureter and bladder are also dissected.
Schauta’s Operation (Radical Vaginal Hysterectomy)
Less extensive operation. So far as dissection is concerned, it is modified by adding bilateral extraperitoneal lymphadenectomy through two separate abdominal incisions to correct this deficiency in India by Mitra5. It can be combined with Laparosacopic lymphadenectomy to decrease the mobility of the procedure5.
ROUTES OF HYSTERECTOMY
This means total or subtotal hysterectomy carried out through an abdominal incision.
Here the approach is through the vaginal vault and the operation is nearly always of the total hysterectomy type. The tubes and the ovaries can be removed as well as if the need arises. This operation is technically easy for the expert, even when there is no prolapse of the uterus, provided the pelvis is relatively free from adhesions and the uterus is not larger than the size of a 10-week pregnancy. When the uterus is enlarged further by the leiomyomas, its vaginal removal is still possible if the tours are shelled out during the operation. A large uterus can also be hemisected and removed vaginally, one half at a time5.
Total versus subtotal hysterectomy
v Advantages of the subtotal over the total hysterectomy5
· The operation is technically easier and involves less risk of injury to the ureter, bladder and rectum. For the experienced operator the difference in this respect is negligible, expect in some severe cases of PID, endometriosis or of advanced ovarian cancer.
· Many now believe that it reduces the risk of the subsequent prolapse by preserving the integrity of the supporting ligaments.
· The subtotal operation does not disturb the anatomy and length of the vagina and does not leave a scar in the vault. Coitus is therefore not usually shortened in the total operation and is, capable of stretching.
· Retention of cervix helps to lubricate the vagina, because of cervical mucus. This argument may be acceptable but so far as coitus is concerned, lubrication depends on Bartholin’s glands.
· Lower urinary tract dysfunction does not occur.
v Disadvantages compared to total hysterectomy5
· The cervix remains as a potential site for cancer where incidence varying from 2-6% of all cases of cancer of the cervix. It is particularly lethal as (a) the absence of uterine body fails to contain the growth and encourages rapid spread to bladder and rectum. (b) Intracavitary radiation treatment of stump cancer is made difficult by absence of uterine cavity which accommodates the intra-uterine tube.
· Increased incidence of vault prolapsed following subtotal hysterectomy as the retained cervix act as a plunger to perform the apex of the vaginal intussusceptions.
· If the support of the vagina and the uterus are slack, prolapsed is more likely after subtotal than after total hysterectomy.5
In view of these considerations, subtotal hysterectomy is seldom practiced by gynecologists and then only for some special reason such as the presence of dense adhesions obliterating the pouch Douglas, making the total operation hazardous (endometriosis, pelvic inflammatory disease). A few gynecologists prefer it in the case of the younger woman who does not have any prolapsed, whose cervix is free from injury and infection and whose exfoliated cells have normal microscopic appearance6.
Supracervical hysterectomy preserves the cervix, a feature Dr. E. Scott, Sills and colleagues at Cornell Medical Centre in Manhattan have argued, results in fewer sexual and bladder problem after surgery. NYU pelvic surgery expert Dr. Joy Saini and associates found worse post operative sexual function in the supracervical group. Her conclusions agreed with the European researchers.7
Vaginal hysterectomy versus abdominal hysterectomy
v Advantages over Abdominal hysterectomy
· Vaginal hysterectomy is generally safer than abdominal hysterectomy and carries a very low mortality rate.
· Postoperative shock and discomfort are negligible; early ambulation decreases the need for nursing care, shorten hospital stay. There is a lesser requirement for analgesics. Pulmonary function is better.
· Lesser bowel handling and early ambulation result in earlier return of bowel function and lesser requirements for intravenous fluids.
· The operation is better tolerated by the elderly, the obese and those with associated medical disorders.
· The operation leaves no abdominal scar and involves little risk of later complications such as hernia, adhesions an intestinal obstruction, and also infection or wound dehiscence
· Associated prolapsed of the vagina can be corrected at the same time.
· Postoperative thrombosis and embolism were said to be rare in the past but occur with equal frequency under conditions of modern surgery.
v Disadvantages compared to abdominal hysterectomy5
· The excision is generally less wide than in the case of abdominal hysterectomy so the operation is not ordinarily carried out for malignant disease.
· The operation is stated to be difficult and unsafe in the presence of dense adhesions caused by pelvic inflammatory disease, endometriosis or previous pelvic surgery. Its scope depends on the skill and experience of the operator; in fact it may be much safer and easier.
· It is alleged that vault prolapsed is more likely than after abdominal hysterectomy. This is not true if the operation is well done, if all redundant peritoneum is excised and slackness of the vaginal supports is recognized and treated simultaneously.
In general it can be said that vaginal hysterectomy is preferable to abdominal hysterectomy, so long as the above technical hindrances are not present, and so long as the indication for hysterectomy is not malignant disease, however exceptions can be made. Thus early stage carcinoma of the body of the uterus in a woman who is obese and generally unfit may be better treated by vaginal hysterectomy.
v Vaginal hysterectomy in nulliparous women without prolpase8
A prospective comparative study (by Aubert Agostini, Florence Bretelle, Ludovic Cravello, Anne Sophie Maisonneuve, Valerie Roger, Bernard Blanc) in the Department of Gynecology, La Conception Hospital, and Marseille, France showed that the mean operation time was significantly higher 13.46% vs 4.44%. Vaginal hysterectomy was successfully performed in 96.2% of the parous patients.
With increasing skill and technical virtuosity it was inevitable that removal of the uterus by laparoscopic surgery would eventually be attempted and this was performed in 1988 by Harry Reich at the Nesbitt Memorial Hospital in Kingston, Pennsylvania (Reich et al 1989). The original operation was TLH (Total Laparoscopic Hysterectomy). The procedure was extremely time consuming and could take up to 6 hours and was unsuitable for routine practice.9
Studies have shown TLH required longer surgery duration (140.4 vs 115.1 min) than LAVH and TLH resulted in smaller blood loss with comparable operating time. In selected patients and with skilled hand TLH can be performed within reasonable time limits. LAVH is advantageous over TLH with reduced operating time.10
Laparoscopic surgery, although expensive, offers a speedier recovery. There is no measurable difference in the rate of complications from the conventional abdominal or vaginal surgery.11
Another study have shown that outpatient total laparoscopic hysterectomy is well tolerated, safe, and cost effective.12
Study revealed laparoscopic hysterectomy is associated with a significantly higher rate of major complications than abdominal hysterectomy. It also takes longer time but was associated with less pain, quicker recovery, and better short term quality of life.7 Complication rates were 5.5%, 3.2% intreaoperative (Bleeding from abdominal wall vessel) and 2.3% cases post operative (Infection). So, laparoscopic is a safe and useful technique for treatment of some gynecological pathology.13
Laparoscopy-Assisted Vaginal Hysterectomy (LAVH)
LAVH is of greatest benefit in those conditions in which vaginal hysterectomy is relatively contraindicated. It should be used to convert an abdominal hysterectomy to a vaginal procedure and not to convert a vaginal hysterectomy into a laparoscopic one. The latter is assisted with increased operating time, cost and pain at abdominal puncture sites in such a situation. Thus LAVH is ideally suited in cases of endometriosis, known pelvic adhesion, pelvic inflammatory disease or adnexal masses. LAVH permits laparoscopic assessment of the pelvis and division of pedicles up to the level of the uterine artery. The rest of the procedure can be safely done from below. Several types of LAVH can be performed depending upon the degree up to which is carried out laparoscopically, eg. adhesiolysis and resection of endometriosis, detachment of adnexa, bladder dissection, or uterine artery ligayion, before proceeding to the vaginal hysterectomy. Several alternative laparoscopic techniques for hysterectomy has been described which includes the following.5
oLaparoscopic supracervical Hysterectomy
Subtotal hysterectomy is done laparoscopically and the fundus is removed through an enlarged umbilical incision or via a posterior colpotomy.5
oThe CASH procedure
CASH is an acronym for classic abdominal SEMM (Serrated Edged Macro-Morellated) hysterectomy. Laparoscopic supracervical hysterectomy is followed by “coring out” of the cervical canal by a special serrated resection device, to decrease the risk of cervical cancer in the stump. Long term results are awaited.5
oLaparoscopic Doder Lein hysterectomy
After the adnexa have been detached laparoscopically, an interior colpotomy is made to draw the uterine fundus into the vaginal and complete the rest of the procedure, including the ligation of the uterine arteries vaginally as with Heaney’s technique.5
Advantage of LAVH
· An abdominal procedure is converted to a vaginal one even in the presence of complication.
· Overall morbidity is reduced.
· Hospital stay and recovery time are less than that of abdominal hysterectomy.
Disadvantage of LAVH
· Special equipment and training is required.
· Baseline cost is higher.
· Operative time is increased.
· Major complications encountered include injury to major vessels, pulmonary embolism and injury to bladder and bowel.
Three methods of Hysterectomy
A randomized prospective study of short time outcome, in the department of Obstetrics and Gynecology, Hospital of Helsingborg, Sweden, by ChristianOttosen, Goran Lingman, Lena Ottosen, concluded that traditional vaginal hysterectomy proved to be feasible and the faster operative technique compared with vagianl hysterectomy with laparoscopic assistance. The abdominal technique was somewhat faster, but time spent in theatre was not significantly shorter. Abdominal hysterectomy required on average a longer stay of one day and one additional week of convalescence compared with traditional vaginal hysterectomy. Vaginal hysterectomy should be a primary method for uterine removal.2
Studies have shown that short term clinical results (blood loss, analgesia, hospital stay, convalescence time) revealed significant differences between TAH and LAVH, but long term follow up results were similar.
Uterine Morcellation at the time of vaginal hysterectomy is safe and facilitates the removal of moderately enlarged and well supported uteri and is associated with decreased hospital stay and preoperative morbidity rate compared with the abdominal route.14
LAVH patient have a quick postoperative recovery with less pain at the expense of a long duration of surgery. LAVH is a feasible option in a selected group of patients who would otherwise require an abdominal hysterectomy.15
LAVH in early endometrial carcinoma- A study conducted to compare the main outcomes with abdominal hysterectomy (operative time, blood loss, blood transfusion, hospital stay, no. of lymph nodes obtained) showed that laparoscopic surgery in early endometrial carcinoma is safe in the hands of experienced operator with minimal complications.16
LAVH in early cervical cancer in FIGO stage |A| to |B|, for Exocervical mass of grossly than 2 cm, LAVH was found safe and effective alternative to conventional RH (Radical Hysterectomy). Considering the higher recurrence rate in patients with large tumor Volume, it would be better to offer LAVH to patients with small Volume disease (diameter < 2cm to Vol. < 4.2cm).17 LAVH can be a suitable substitute for abdominal hysterectomy. LAVH is expensive but it offers benefits to patients in the form of less time in the hospital, faster recovery, though at the expense of potentially longer operative time, increased risk of blood transfusion and increased risk of complication.3 LAVH is advantageous in removing uterus smaller than or equal to 500g but with uterus > 500g there is increased rate of conversion of to laparotomy.18
Complications of Laparoscopic Surgery
LAVH was the leading procedure for urethral injury and the instrument involved in electro coagulation incidence was < 1% to 2%.19
Small bowel injury was not common in LAVH (1.9/2000).20
One study revealed overall complication rate was 1.92% (34 in 1769) Unintended laparotomy occurred in 0.34% (6) cases. Out of 43 cases of complication, 12 (35.3%) complications were associated with insertion of veresse needle or trocar and creation of pneumoperitoneum, including severe emphysema, vascular injury. 5 (14.7%) intraoperative complications occurred (3-bleeding 1-bladder injury, 1-skin burn of leg). Post operative complications occurred in 17 (50%) patients (2 intraperitoneal hemorrhages, 2 bowel injuries, 4 nerve paresis and 9 febrile morbidities. Operative Gynecologic laparoscopy is associated with acceptable morbidity rate, but can not be overlooked. Complication rate seems to be higher in advanced procedures such as LAVH.21
THE RATE OF OVARIES AT HYSTERECTOMY
The ovaries deserve even more respect than the uterus because their endocrine function has such a wide spread effect on general well-being. Yet there are some who still hold the view that if the uterus is to be removed it is just as well to remove the ovaries because, the ovaries may later become the seat of euplastic diseases. The ovaries may become later cystic or painful; removal of the uterus invariably causes the ovaries to cease function within 2-3 years. These and other arguments are not always valid and the same situations are as follows: 5
oIf the ovaries are hopelessly diseased, as in the case of ovarian abscess, they may have to be sacrificed with the uterus even if the woman is young. However some normal tissue can be found if looked for.
oIf the operation is for malignant disease of the uterus, than removal of the ovaries allows a wider excision and is ordinarily indicated.
oWhen the indication for hysterectomy is ovarian tumors in a woman aged more than 45 years, both ovaries and tubes should be removed. But for unilateral stage 1A ovarian cancer in a young woman conservative surgery with preservation of normal ovary and uterus is a treatment option, provided the patient will be followed up closely and treated by definitive surgery after child birth.
oIf the ovaries appear normal then it may be justified to remove them in women over the age of 50 years on the ground that it removes the possible site of cancer. In young women, at least one ovary should be conserved.
Many attempts have been made to compute statistically the chance of a woman developing ovarian cancer after hysterectomy, with an astonishingly wide variation in the conclusions reached. The most convincing reports suggest that the risk of cancer arising in an ovary the 10 years after hysterectomy is 1.5 to 2 per 1000 cases. The chance of a benign tumor is higher, perhaps 1 in 100.5 these statistical chances are less than those to which all women of comparable age are exposed. The chances are less because only ovaries which seem to be normal are conserved at the time of hysterectomy.
If ovaries are preserved, they can become cystic and painful when they become buried in adhesions; this trouble can occur if the indication was pelvic inflammatory disease, otherwise it is rare. Intermittent ovulation pain can continue but most one sided pains do not originate from the ovary.
Contrary to the earlier belief, it is now established by hormone assays, vaginal smears, temperature charting and symptomatology that ovarian function continues normally in most women until the natural age of menopause. In some cases ovarian function does cease earlier. Some of these may be explained by a naturally occurring premature menopause, others perhaps by interference with the blood supply to the ovary following hysterectomy.5
The incidence of severe menopausal symptoms following hysterectomy in premenopausal woman is lowered from 50 to 1.5 percent if at least one ovary is conserved.5
Not only does the removal of both ovaries in premenopausal women commonly result in menopausal symptoms, it is followed during the next 3-6 years by osteoporosis more frequently and in more severe form than the natural climacteric. 20% of women subjected to a surgical menopause later develop symptom producing hypertension and atherosclerosis. There is 6-7 times increase in the risk of a women subsequently dying from coronary thrombosis if both the ovaries are removed before the age of 40 years.5
Those who practice bilateral oophorectomy routinely at the time of hysterectomy, emphasize that replacement therapy with estrogen-progestogens adequately compensates for loss of normal ovarian function. This is not entirely true. HRT does protect against osteoporosis and several other problems, there is no clear evidence that such treatment prevents subsequent coronary artery disease. Moreover such treatment carries its own hazards and difficulties which lead to poor compliance and the duration for which HRT can be safely continued is not yet clearly established.
It is difficult not to conclude that the practice of routine bilateral oophorectomy with hysterectomy has an insecure basis. The disadvantages far outweigh the advantages. Unless special indication, it is generally wise to conserve at least one ovary in all women who are still menstruating up to the time of hysterectomy.5
INDICATIONS FOR HYSTERECTOMY
Some common indications for hysterectomy are:
Ø Gynecological conditions
Benign lesion: 22
oDysfunctional uterine Bleeding
oPelvic inflammatory disease
oRecurrent Endometrial polyp
oEctopicpregnancy-eg. cervical pregnancy
oBenign ovarian tumor in perimenopausal age
Malignant lesions: 22
Ø Obstetrical conditions
oSevere post partum haemorrhage
oMorbid adherent placenta
oHydatidiform mole (with risk factors for choriocarcinoma)
Hysterectomy performed in common pathological conditions
In leiomyoma hysterectomy is done for symptom less cases when uterus is larger than 12-14 weeks size of pregnancy, rapidly growing tumor, there is doubt about the nature of tumor, tumor likely to complicate pregnancy. And hysterectomy is also indicated in symptomatic cases of leiomyoma e.g Menorrhagia, pressure effect, pain.5
Not every DUB is pathological, yet most women feel disordered. Recurrent DUB needs a diagnostic work-up and has to be treated frequently. 80% of cases are due to hormonal disorders, called Dysfunctional; the others are of organic cause (polyps, myoma). Diagnostic work-up based on the vaginal USG. Standard invasive diagnostic tool includes combination of hysteroscopy and curettage or guided biopsy. Medical treatment is based on hormone. If contraindicated then NSAIDS or Antifibrinolytic agents are efficacious alternatives. Organic causes are treated by hysterectomy. Relapse may necessitate destruction of the endometrium or hysterectomy.
In PID and Chronic Pelvic Infection: Sometimes both fallopian tubes and both ovaries are involved by extensive inflammatory disease, either from chronic pyogenic infection or from tuberculosis. The first line of treatment for these patients is chemotherapy, if, in spite of this, a residual painful mass exists, associated with menorrhagia, low sacral backache, possibly congestive dysmenorrhoea and dyspareunia- hysterectomy may well be considered, especially if the uterus is enlarged, edematous and in retroverted position.5
When operating on a patient with bilateral ovarian endometriosis, where the disease has spread to involved the uterus and rectovaginal septum, it is advisable to perform total hysterectomy in addition to appropriate surgery for the ovarian disease. Now a day fewer hysterectomies are performed for the endometriosis. Early diagnosis judicious choice of therapies, willingness to employ repeat courses of pharmacologic agents or repeated laparoscopies offer considerable benefit to the patient both for pain control and fertility restoration.42
If symptoms are present in adenomyosis the primary line of treatment is by operation. Hysterectomy is usually necessary because it has no capsule. Adenomyosis poorly responds to medical therapy.
Endometrial polyps are usually treated by curettage but not always satisfactory because aoe or more polyps may elude the poly forceps. Hysteroscopy guided polypectomy is gold standard. Rarely hysterectomy is required if there is associated significant endometrial pathology.5
Benign ovarian tumors are treated by conservative surgery but in women above 45 years of age, it is customary to remove both the ovaries and the uterus in apprehension of some unforeseen malignancy in the other ovary. For malignant ovarian tumor, radical surgery is performed, consisting of total abdominal hysterectomy, bilateral salpingo-oophorectomy, infracolic omentectomy, appendicectomy (some text book) and bowel resection if needed.5
Invasive carcinoma confined to the cervix without obvious parametrial involvement (within FIGO 1a 1b 11a) is treated by radical hysterectomy combined with an appropriate lymphadenectomy. For advance and failed radiotherapy cases, ultraradical surgery such as exenteration is sometimes practiced. In large 1A1 where invasion is <3 mm, if there is no LSVI, conization or an extrafascial total abdominal hysterectomy (Type 1 hysterectoym) may be sufficient. Stage 1B and 11A radical (Type III) hysterectomy is performed.5
In CIN hysterectomy is indicated if a smear remains or becomes positive after conservative surgery, the patient is more than 40 years, likely to default from follow up, when microinvasion is found on biopsy, and sometimes in CIN III and carcinoma in situ if the woman not desirous for child. It should be preceded by colposcopy nad biopsy.5
In endometrial carcinoma, the first line of treatment in Stage I and stage II disease (confined to uterine body and cervix) is surgery i.e. In stage III disease surgery consists of type I hysterectomy with partial omentectomy, biopsies from suspected tissue, debulking of tumor. In all stages adjuvant radiotherapy is needed. Stage IV disease is treated by surgery, radiotherapy, hormone therapy or chemotherapy usually in combination.5
In obstetrics caesarian hysterectomy is required for certain rare cases of concealed accidental haemorrhage. In chronic inversion of the uterus a hysterectomy is sometimes required.5
Hysterectomy for septic abortion or perforation sometimes in illegal abortion the uterus may be perforated and the patient may develop spreading peritonitis, or septicemia. In certain very rare cases, particularly when there has been no response to intensive antibiotic therapy it may be necessary to remove the uterus.5
In gestational trophoblastic disease hysterectomyramained an option for good surgical candidates not desirous of future pregnancy and for older women (who are more likely to develop malignant sequele), Hysterectomy reduce the likelihood of metastatic disease, for gestational trophoblastic disease from 20% to 35%, but it does not eliminate the need for careful follow up and BHCG testing. Hysterectomy is recommended for placental site trophoblastic tumor.23
TECHNIQUE OF TOTAL ABDOMINAL HYSTERCTOMY
Type of anesthesia depends on the physical condition of the patient, indication of hysterectomy, choice of surgeon, patient and anesthesiologist. It is not necessary that general anesthesia should be the only option. It can be done by under regional anesthesia.24
Two types of incisions are commonly used
· Vertical incision (lower midline or paramedian incision)
· Pfannenstiel’s incision
Exploration of the upper abdomen and packing off the intestine
The operator inserts the right hand into the upper abdomen. The right kidney, liver, gall bladder, pancreas, stomach, left kidney and para-aortic lymph nodes are palpated in sequence and abnormalities are noted.
The intestines are packed off to clear the pelvic cavity for the surgery by trendelenburg or head down position or using laparatomy pack. Retractor to retract the abdominal wall and bladder are used. A self retaining Balfour retractor and a Doyen’s retractor are used.24
Clamping the round and infundibulo pelvic ligament:
The uterus is pulled over to one side so that the tube and the ovary of the opposite side are stretched and well exposed. Placement of the first clamp will depend upon whether the ovaries and tubes are to be preserved or not.5
· If it is decided that tubes and ovaries are to be preserved, than clamps are placed over the ovarian ligament, fallopian tube and round ligament close to the cornu of the uterus. They are then divided in between clamps and ligated. The procedure is repeated on the other side.
· If salpingo-oophorectomy is to performed these clamps are placed on the infundibulo pelvic ligament and the round ligament clamped separately. Lateral clamps on the pedicles is now replaced by putting transfixation sutures.24
Division of the Broad ligament
The uterus is pulled firmly to the left side by the assistant and with dissecting forceps and scissor, starting from the cut round ligament, then surgeon divides the peritoneum which forms the anterior leaf of the broad ligament downwards and inwards towards uterovesical pouch. Same procedure is carried out on the opposite side.
Division of the peritoneum of the uterovesical pouch
The uterus is then pulled upwards and backwards and then the loose peritoneum of the uterovesical pouch on the anterior wall of the uterus is incised by a transverse curved incision with scissors from the round ligament of one side to the round ligament of the opposite side.24
Separation of the bladder
Tracing down the sheet of the pelvic fascia, which passes from the round ligament and detaching this from the cervix, the upper prolongation of the bladder pillar is separated from the cervix, when this has been done the bladder and even the ureter may be stripped quite easily away from the cervix. The bladder attached to the cervix is then freed in the midline and the bladder with lower flap of peritoneum is now pushed down by swab taken on a sponge forceps. The peritoneum on the posterior surface of the cervix is transversely incised to raise a posterior peritoneal flap.24
Clamping the uterine vessels
After separation of the broad ligaments the uterine vessels can be seen or if not seen can be felt pulsating. Clamps are applied to them on each side to the uterus, parallel to the cervix and points inclined inwards near the junction of the body with the cervix. The uterine pedicles are then divided. The lateral clamps are then replaced by transfixation sutures.
Dividing the parametrical tissue
A clamp is placed parallel to the vervix taking the paracervical tissue at a level below the pedicle containing the uterine vessels. The point of clamp must be placed by sight and with great care well away from the bladder and ureters. The ureter should be identified in the uterine canal of the parametrium by palpation between the finger and the thumb of the right hand. It can be rolled between the finger and thumb as a firm thick incompressible cord. As it escapes from grip of the finger and thumb, it gives a characteristic snap which is distinctly audible if carefully listened for and which can be appreciated by the ear of the surgeon and his assistants.24
Opening the vagina forwards and expose he uterosacral ligament
A cervical clamp is placed on the vaginal angle including the uteroscral ligament and the mackenrodt’s ligament then the tissues cut with scissors. The uretus is drawn up with the left hand and the vagina is identified making sure that the bladder is reflected to a safe level. A knife is now plunged into the anterior fornix. By the help of scissors, the incision is extended laterally on each side as far as the tips of the clamp holding the uterosacral ligaments. The posterior fornix is now incised under direct vision and the uterus removed. The entire circumference of the vagina is now visible.24
Ligate the lateral cervical pedicles
The two pedicles, one enclosing the parametrial tissue laterals to the cervix below the level of the uterine artery and another enclosing the uterosacral ligaments is then tied.
Closing the vagina
The vaginal edge should be grasped with tissue forceps to identify it. An interrupted suture is used at each end to enclose lateral vaginal angles as it is here the most troublesome bleeding can occur. By means of mattress or interrupted sutures, the vaginal vault is closed. But we can leave the vault open so that any blood or serous fluid can drain and not form a nidus for infection.
Closing the visceral peritoneum
Reperitonization is completed by suturing the bladder’s peritoneum to the culde-sac peritoneum with 1 zero chromic catgut suture. The suture is initiated on the left angel as a purse string suture. The suture is continued towards right, attaching the central part of the peritoneum to the apex of the vault to obliterate the space. At the right angle, a similar purse string suture is given ensuring that the vascular pedicles remain beneath the peritoneum and approximation of the bladder and cul-de-sac peritoneum. Special attention is paid to suturing the round ligament together with the pedicle containing the fallopian tube and the ovarian ligament to the lateral part of vagina. In this way the raw surface is reduced in size. Pedicles offer support to the vaginal vault. Now, visceral peritoneum is not closed and has no adverse effects.
Closing the abdominal cavity
A final check is made to be sure that there is no bleeding from the operation field and the abdominal packs are removed and counted. The parietal peritoneum is then closed by 1 zero chromic catgut by continuous suture. The rectus is then closed by continuous Dexon (1/0) suture. Fat stitches are then given in the form of interrupted sutures to obliterate the potential space. The skin is then closed by interrupted four point sutures with silk (1/0) or intradermal stitches with (1/0 Dexon/ vicryl22)
Variations in surgical technique
The principles of the operation are the same, variations in surgical techniques may be necessary in the following circumstances: eg.
· Very large Myoma
· Associated Pelvic Inflammatory Disease
· Broad Ligament Myoma
· Cervical Myoma
Difficulties Encountered in the Operation
· A good exposure is necessary so hat a long incision must be made if the patient is fatty.
· The trendelenburg’s position is helpful though not always essential. The better the anesthetic, the less is the need for trendelenburg’s position.
· Complete haemostasis should be obtained in the region of the appendages.
· The operation is hazardous unless the bladder and the course of the ureter are accurately defined and mobilized. There is a risk of injury to the venous plexus in the lateral wall of the vagina.
· If clamps are placed blindly on the bleeding points the risk of damage to the ureter is considerable.
· The method of opening the vagina by cutting through the utero-sacral ligaments.
· In endometriosis, sigmoid colon may be adherent to the peritoneum of the posterior surface of the vagina, so sigmoid colon must be mobilized before utero-sacral ligament is divided.
· Reactionary haemorrhage after total hysterectomy result from either incomplete ligature of the vessels in the cut edge of the vagina or from parametrial tissue slipping away fromligatures. Such complications are preventable if correct technique is employed.24
Dangers of hysterectomy
· If adhesions present with the uterus and small or large bowel, it is wise never to start the hysterectomy until the normal anatomy has been restored. If serosa or seromascularis of the bowel has been torn or damaged should be immediately repaired by fine high polymer sutures mounted in a traumatic needle.
· During the process of separating the uretus from its vascular bed veins may be torn and it is essential to ligate these vessels individually at the time of injury; otherwise a dangerous hematoma may develop and spread into the loose areolar tissue of the broad ligament. All main vessels, ovarian and uterine must be firmly secured by double ligature.24
· No pedicles should ever be clamped until the ureter has been exactly defined by inspection or palpation.
· Injury to the bladder during hysterectomy should not occur if carefully performed.
· All pedicles should be extraperitoneal so that no raw area is left unprotected, on which small bowel may become adherent and become a case of post operative intestinal obstructions.
· The blood supply of the conserved ovary must not be restricted by ligature or suture, as this is liable to cause an ovarian failure.24
The operation is often designated as Ward Mayo’s Operation, named after Mayo (1915) and ward (1919) – both from US. It is the most popular procedure for uterovaginal prolapse except where preservation of reproductive capability is required. The operation of vaginal hysterectomy consist of removing the uterus by the vaginal route and subsequently closing the space previously occupied by the uterus with a shelf of tissue derived from the lateral attachments of the uterus.5
Now a day’s vaginal hysterectomy are usually done under spinal anesthesia, or epidural anesthesia and may be done under general anesthesia depending on the patients condition and choice of anesthesiologist.
- Preoperative preparation of the patient
The patient is placed in the Lithotomy position; the vagina and vulva are disinfected and surrounded with sterile towels and legs with leggings. Bladder is emptied by metal catheter. Vaginal examination is done to assess the type and degree of prolapsed. A Sim’s speculum is introduced to expose the cervix, which is then pulled downwards and backwards by an assistant. Infiltration with a saline of adrenaline solution (1:400,000) is recommended.24
- Vaginal incision and demarcation of lateral vaginal flaps
A midline or inverted V incision is made in the anterior vaginal wall. From the cervical end of this incision two lateral incisions are made, each placed at right angles to the original incision and completed as circumcision of the cervix. When there is also a hernia of the pouch of Douglas, the incision must include more redundant vaginal wall from the posterior fornix. The vaginal flap thus demarcated is separated from24 the bladder in the vesicovaginal space, while near the urethra the flaps are dissection. If the line of cleavage in vesicovaginal space is properly negotiated, bleeding is minimum and dissection is easy.
- Freeing the bladder upwards to expose the uterovesical pouch, which is opened
The vesicocervical ligament is now held up and cut through with Mayo’s scissors and the bladder is stripped back in the usual way until the uterovesical peritoneal fold can be seen. The bladder is retracted upwards with a Landons retractor, the peritoneum is picked up with toothed forceps and divided on each side as far as laterally as it is possible, a stay suture is placed on the peritoneal edge near the bladder.24
- Excision of redundant vaginal flaps
Lateral vaginal flaps are now excised, both vaginal wall and vaginal fascia being removed. Branches of Azygos vaginal artery are underpinned and ligatured. If large cystocele, a series of interrupted Lembert’s reefing sutures can be introduced.
- Method of dealing with the pouch of Douglas
The assistant now pulls the cervix upwards and forwards and the surgeon displays the pouch of Douglas by dissecting down and exerting traction on the vaginal flap of the posterior fornix in a downward direction. The peritoneum of the pouch Douglas is now cut opened and the incision is extended laterally as far as the pillars of the uterosecral ligaments.24
Clamping and section of the main pedicles
- First clamp
Includes uterosacral ligaments, Mackenrodt’s ligament and descending cervical artery. The tissues are cut as close to the cervix and replaced by catgut No-1. Similar procedures are followed on the either side.
- Second clamp
Includes uterine artery and the base of the broad ligament. The structures are cut as close to the uterus and replaced by ligature (catgut No 1). Same procedure on the other side.
The fundus is now brought out through the anterior pouch by a pair of Allis tissue forceps.
- Third clamp
Includes round ligament, fallopian tube, mesosalpinx and the ligament of the ovary. The structures are cut and replaced by transfixing suture (catgut No 1). Same procedure are followed on the other side, Uterus is removed
· Correction of the enterocele is to be done at this stage.
· Peritoneum is closed by a pursestring suture.
· The sutures of the upper most pedicles on either side are tied. The excess sutures of the uterine artery pedicles on either side are cut. The suture of the lower most pedicles is possed through the vault crosswise and is held temporarily.
· The pubocervical fascia is approximated and fixed to the uppermost tied pedicles to close the hiatus.
· Redundant vaginal flaps are excised and margins are sutured by interrupted suture with chromic catgut “0”.
· Crosswise passed sutures of the lowermost pedicles are tied, fixed to the vault.
· Vaginal packing done.
· Self retaining Foley’s catheter is introduced.
TECHNIQUE OF LAPAROSCOPIC HYSTERECTOMY
The aim of laparoscopic hysterectomy is to convert abdominal hysterectomy into vaginal hysterectomy, because of the obvious advantages of vaginal hysterectomy. Patients who can be treated by vaginal hysterectomy don’t need LAVH.
Total Laparoscopic Hysterectomy (TLH)
In total laparoscopic hysterectomy all the steps of hysterectomy including vaginal closure is done laparoscopic ally.
Laparoscopic Assisted Vaginal Hysterectomy (LAVH)
In LAVH initial steps of hysterectomy are performed laparoscopically and rest of the surgery is completed vaginally.
Steps of LAVH
- Patient Selection
Since the surgical skill and expertise vary between gynecological surgeons, so based on training and experience, each gynecologist must decide which are the cases for vaginal hysterectomy or laparoscopically assisted vaginal hysterectomy (LAVH).
Patients with endometriosis, pelvic adhesions, and limited vaginal access are good candidates for LAVH.
- Pre-operative Preparation
Patients are evaluated as for any major abdominal surgery. No special bowel preparation is given except a laxative in the previous night. Prophylactic antibiotics are given.
For laparoscopic assisted vaginal hysterectomy only a limited number of instruments are required.
- 5mm grasper
- 5mm bipolar forceps
- Hook and curved scissors
- Unipolar Needle/L shaped electrode
- Uterine elevator
Posting of the patient is same as for standard laparoscopic surgery. But the leg positioning has to be changed to lithotomy during the vaginal part of the surgery.
- An Indwelling catheter is introduced in the bladder
§ A good uterine manipulator is inserted in the uterus. A spackman cannula is sufficient for uterus less than 8 week size. Clermont model uterine elevator (Karl Storz) is very useful for larger uterus. It cans antevert or retrovert the uterus. It gives excellent bulging of the anterior and posterior fornices.
§ One 10mm trocar at infraumbilical fold and two 5mm trocars lateral to the interior epigastric vessels are introduced. A higher position is used for the secondary trocars if uterus is enlarged.
§ Pelvic organs are thoroughly inspected. Ureters are identified on both sides. Routine dissection of ureter is not necessary. Any adhesions obscuring the view are lysed.
§ Round ligament is grasped with an atraumatic grasper and kept stretched by simultaneous pushing of uterus with manipulator to opposite side. Round ligament is coagulated with bipolar in the middle, Coagulation is continued till it is white and no more bubbles come out (Fig. 8-1).
§ It is divided in the center in small snips with scissors till a bleeding spot is visible (Fig. 8-2). At this point scissors is removed and further bipolar coagulation is done. This sequence till round ligament is completely divided.
If adnexal removal is contemplated the tube and ovary is pulled to the opposite with a grasper introduced through the contralateral port. The infundibulopelvic ligament is then coagulated close to the ovary and divided with the scissors at first incising the peritoneum followed by further coagulation (Fig. 8-3). Alternate coagulation and division in small steps till it reaches the already divided round ligament.
§ If the adnexa is retained the ovarian ligament and fallopian tube are coagulated and divided in small steps as described above (Fig. 8-4).
§ The posterior half of broad ligament on both sides is divided with curved scissors and any cozing area is coagulated. The direction of division is towards the uterosacral attachments.
§ The loose uterovesical fold of peritoneum is now identified. The uterovesical fold is then divided from left side, starting from the divided round ligament using a sharp curved scissors (Fig. 8-5). Passing the scissors from the right side to centre completes it. The division of uterovesical peritoneum should be below the line of attachment of the peritoneum to the uterus, to avoid bloody dissection. There is a safe distance of 2-2.5 cm from this point to the dome of bladder.
§ The divided uterovesical fold is picked up with a grasper and bladder is pushed down with a suction irrigator in the centre (Fig. 8-6). The vesicocervical ligaments can be divided with scissors before pushing down with the suction irrigator.
§ The bladder pillars are then identified, coagulated close to cervix and then divided before completely pushing down the bladder (Fig. 8-7).
§ Next task is to identify how far the bladder has to be pushed down. If a Clermont model uterine elevator is used, its anterior fornix bulger helps to identify the limit for bladder dissection. An alternative is to use a sponge on holder to push the anterior formix (Fig. 8-8).
§ Now the posterior fornix is bulged using the sponge on holder and incised with a unipolar needle till the sponge is visible (Fig 8-9). The anterior fornix is now divided after bulging with a sponge. Some gas leak is inevitable at this point but the high flow rate of gas maintains the pneumoperiteneum. If gas leak is too much, the vaginal opening can be closed with a mop around the uterine elevator. Clermont uterine elevator has circular for preventing the gas leak.
§ The camera, light source and insufflators are switched off and surgery is continued vaginally. The stopcock of primary trocar should be closed now, to prevent blood and fluid entering the insufflators through the tubing. Patient’s leg support is changed to lithotomy position. Uterine elevator is removed and cervix is held with a volsellum. Vaginal speculums are introduced into the already opened fornices. The uterosacrals and cardinal ligaments are clamped, cut and legated. The uterine vessels are then clamped, cut and legated. Uterus is removed after clamping any further attachments. Vaginal is closed with few sutures.
§ Pneumoperiteneum is reestablished and the peritoneal cavity is carefully inspected with the laparosope and irrigated copiously with Ringer lactate soln. Any bleeding point is coagulated with bipolar.
PREOPERATIVE PREPARATION OF PATIENTS FOR HYSTERECTOMY
A thorough pre-operative assessment of the patient is very important. As most of the abdominal hysterectomies are performed selectively there is enough time for thorough examination of the patient especially if the patient is elderly, hypertensive or suffering from cardiovascular disease or diabetes.
A full history regarding the chief and the associated complaints should be taken. Past history of any illness should be taken in details. The obstetric history should be carefully taken since hysterectomy will make her unable to take more children.26
After taking history, a thorough general and local examination