Ch.21 Hysterectomy

1. Ch.21Hysterectomy 부산 백병원 산부인과 R1 정은정

2. Hysterectomy most commonly performed surgical procedure in the United States. Vaginal hysterectomy continues to be the procedure of choice. No advantage to the routine use of supracervical hysterectomy. Oophorectomy at the time of hysterectomy increase in patient mortality, currently recommended that ovarian conservation be considered until at least age 65 yrs. A number of concurrent surgical procedure performed safely at the time of hysterectomy. Hysterectomy

3. Hysterectomy • Hysterectomy most commonly performed surgical procedure. • After cesarean delivery, second most frequently performed major surgical procedure in the United States.

4. Hysterectomy • 1965 : 426,000 hysterectomies performed average length of hospital day 12.2 days • 1985 : 724,000 hysterectomies performed hospital day 9.4 days • 1991 : 544,000 hysterectomies performed hospital day 4.5 days • 1998 : increased to more than 600,000 • 408,000 (75%) abdominally • 136,000 (25%) vaginally • 2005 : 824,000 hysterectomies

5. Hysterectomy • Rate of hysterectomy : 6.1~8.6 /1000 women of all ages. • Dependent on age, race, where she lives, sex of her physician. • Average age of hysterectomy : 42.7 yrs median age :40.9 yrs (remain constant since 1980s) • 75% of all hysterectomies : 20~49 yrs

6. Indication • Leiomyoma • Dysfunctional Uterine Bleeding • Intractable Dysmenorrhea • Pelvic pain • Cervical Intraepithelial Neoplasia • Genital Prolapse • Obstetrical emergency • Pelvic inflammatory disease • Endometriosis • Cancer • Benign ovarian tumor

7. Leiomyoma • Most common pelvic tumor • Consider only in patient do not desire future fertiltiy (fertility-preserving surgery: myomectomy) • Hysterectomy indication : Perform need to treat Sx • Abnormal Ut bleeding • Pelvic pressure • Pelvic pain • Rapid Ut enlargement • Ureter compression • Growth following menopause

8. Dysfunctional Uterine Bleeding • Indication for 20% of hysterectomies • Older than 35 yrs : endometrial sampling before hysterectomy • D&C • not effective means of controlling bleeding • not necessary before hysterectomy • Cannot tolerate medical therapy • Alternative therapy (Endometrial ablation or resection)

9. Intractable Dysmenorrhea • Dysmenorrhea can be treated with NSAIDs alone or combination with OCs or other hormone agent • Primary dysmenorrhea : hysterectomy is rarely required. • Second dysmenorrhea : underlying condition (leiomyomas or endometriosis) should be treated primary • Hysterectomy consider only if medical therapy fails or if patient not want preserve fertility.

10. Pelvic pain • 18% of hysterectomy : chronic pelvic pain • 78%의 환자: improvement • 22%의 환자: no improvement or exacerbation. • Hysterectomy should be performed only pain of uterine origin & not respond to nonsurgical treatment.

11. Cervical Intraepithelial Neoplasia • In past, hysterectomy was performed as primary Tx of CIN. • Maximun depth of dysplasia at the squamocolumnar junction : 5.2mm, • 99.7%의 dysplasia : within 3.8mm of the epithelial surface • Conservative treatment ( cryotherapy, laser, LEEP) can be effective. • Recurrent high-grade dysplasia : not desire to preserve fertiltiy hysterectomy appropriate Tx option. • After hysterectomy : increased risk for vaginal intraepithelial neoplsia.

12. Genital Prolapse • 15% of hysterectomy in the United States. • Unless associated condition requiring abdominal incision, vaginal hysterectomy is preferred approach. • Pelvic support defect corrected.

13. Obstetrical emergency • Postpartum hemorrhage resulting from uterine atony : most emergency hysterectomies • Uterine rupture cannot be repaired. • Pelvic abscess not respond to medial therapy • Placenta accreta or placenta increta

14. Pelvic inflammatory disease • PID pts unless not respond to intravenous antibiotic therapy : uterus, tubes, ovaries should be removed. • USG or CT guided PCD • Pts who desire future fertiltiy : unilateral adnexectomy or partial bilateral adnexectomy without hysterectomy.

15. Endometriosis • Medical and conservative surgical procedures : successful for Tx . • Adnexectomy be performed only in pts who not respond to conservative surgical (resection or ablation of endometriotic implants) or medical Tx . • Hysterectomy required unrelenting pelvic pain or dysmenorrhea.

16. Cancer • Cancer : meatstasis from nongynecologic sites. • Colorectal carcinoma pts : consider TAH with BSO due to risk of either synchronous pelvic cancers or occult metastasis.

17. Benign ovarian tumor • Benign ovarian tumor : persistent of symptomatic . • Peri or post menopause: decision whether Ut be removed • Group of adnexectomy with hysterectomy : increase in operative morbidity, estimated blood loss, length of hospital stay compared to Group of adnexetomy only

18. Vaginal hysterectomy versus abdominal hysterectomy • 75% : abdominal hysterectomy • No specific criteria determine route of hysterectomy • Ovarall complicaton rate : TVH 24.5/1000 vs, TAH 42.8/1000 • Risk for one or more complication: TAH 1.7 times vs TVH • Risk for febrile morbidity : TAH 2.1배 • Hemorrhage requiring transfusion : TAH 1.9배 • If feasible TVH preferred approach

19. Supracervical hysterectomy • Ix : vague • Endometriosis c obliteration of anterior & posterior cul-de-sac • Cesarean hysterectomy when Cx fully dilated & difficult to identify • Cx can almost always be removed.

20. LAVH • Presence of pelvic adhesions cannot predict based on Hx or P/Ex • Criteria for selection of patients for LAVH vs abdominal hysterectomy : not clearly estabilsihed. • No advantage of LAVH over traditional vaginal hysterectomy • Not reduce perioperative morbidity & cost higher

21. LAVH Ix • Endometriosis • Known pelvic adhesive disease • Adnexal mass that require hysterectomy • Lack of uterine mobility • LAVH preferable in pt. c uterine mobility limited ☞uncertain. • Supporting structures of uterus : uterosacral ligament & lower cardinal complex not transected with laparoscopic approach. • Transected of uteroovarian ligament, round ligament, broad ligament : not improve mobility.

22. Concurrent surgical procedures • Prophylactic oophorectomy : m/c surgical procedure performed concurrently with hysteretomy. • Oophorectomy performed prophylactically to prevent ovarian ca & eliminate potential need for further surgery for either benign or malignat disease • Against prophylactic oophorectomy center on need for earlier & more prolonged hormone therapy and potential increase risk of cardiovascular disease • HRT well tolerated & good symptomatic relief • But not as effective as nl ovarian fx, implication of long term HRT not fully known

23. Concurrent surgical procedures • Decision to proceed with Prophylactic Oophorectomy : considered carefully after patient be informed of risks & benefits • Risk for developing ovarian ca after hysterectomy for benign disease : lower than be expected based in its prevalence • At time of hysterectomy : no Hx of ovarian tumor & normal-apperaring ovaries expected rate of ovarian ca 0.14%~0.47 % vs 1.4% (1/10)

24. Concurrent surgical procedures • Long term compliance c posthysterectomy estrogen therapy : low • After TAH with BSO : 20-40% of women take estrogen for more than 5yrs • ∴Ovarian conservation until at least age 65 years confers long term survival benefits for women at average risk for ovarian ca undergoing hysterectomy for benign disease

25. Appendectomy • Appendectomy performed concurrently with hysteretomy to prevent appendicitis & remove disease that may be present • Limited value • Peak incidence of appedicitis : 20-40 • Peak age for hysterectomy 10-20yrs later . • No increase in morbidity with appendectomy performed concurrently with hysteretomy but require average of 10 min of additional operating time.

26. Cholecystectomy • Gallbladder disease 4 times more common in woman • Highest incidence : 50-70 yrs (hysteretomy most often performed. ) • Thus may require both procedures. • Combined prodedure not increase febrile morbidity & length of hospital stay

27. Technique • Negative result of PAP test within the year should be obatined before hysterectomy for benign disease. • 40 yrs or older : mammography • Endometrial Bx : abnormal ut bleeding • Stool guaiac test

28. Abdominal hysterectomy

29. Preop preparation • Cleansing tap water or soap enema. • Hair removed • Pt positioning : dorsal supine position • Anesthesia • Pt’s leg stirr up & pelvic examination • Foley catheterization & vaginal cleansing with iodine solution • Leg straightened • Skin preparation

30. Surgical Technique The choice of incision • Simplicity of incision • Need for exposure • Potential need for enlarging incision • Strength of healed wound • Cosmesis of healed incision • Location of previous surgical scars • Skin  Subcutaneous tissue & fascia Fascia divided  Peritoneum

31. Surgical Technique • Abdominal Exploration • Upper abdomen & pelvis • Liver, gallbladder, stomach, kidneys, paraaortic LNs, & small bowel • Cytologic sampling if needed

32. Surgical Technique • Elevation of the Ut • Broad ligament clamps at each cornu  cross round ligament • Clamp tip close to internal os

33. Fig 22.1 Elevation of Ut

34. Surgical Technique • Round ligament Ligation & transection • Ut deviated to Lt side, stretching Rt round ligament • Proximal portion of broad ligament held clamp, distal portion of the round ligament ligated, transected

35. Fig 22-2 Round ligament Ligation & Transection

36. Surgical Technique • Round ligament Ligation & Transection • Separate anterior & posterior leaves of broad ligament • Anterior leaf : incised along vesicouterne fold  seperate peritoneal reflection of bladder & lower uterine segment

37. Fig 22-3 Round ligament Ligation & Transection

38. Surgical Technique • Ureter identification • Retroperitoneum entered by incision cephalad on posterior leaf • External iliac artery along medial aspect of psoas muscle identified • Bifurcation of common iliac a, ureter cross • Ureter left attached to medial leaf of broad ligament

39. Fig 22-4Ureter identification

40. Surgical Technique • Uteroovarian or Infundibulopelvic Ligament Ligation • I. Ovaries preserve • Window in peritoneum of posterior leaf of broad ligament under utero-ovarian ligament & fallopian tube • Tube & uteroovarian ligament clamped, cut, & ligated c both free-tie & suture ligature

41. Fig 22-5 Uteroovarian Ligament Ligation

42. Surgical Technique • II. Ovaries removed • Peritoneal opening enlarged •  extended to infundibulopelvic ligament & to uterine a • Opening  exposure of uterine a, infundibulopelvic ligament, ureter • Curved heaney or Ballentine clamp placed lateral to ovary • Infundibulopelvic ligament cut & doubly ligated

43. Fig 22-6InfundibulopelvicLigament Ligation

44. Fig 22-7 InfundibulopelvicLigament Transection

45. Surgical Technique • Bladder Mobilization • Bladder dissected from lower uterine segment & Cx • Uterine Vessel Ligation • Uterine vasculature dissect • Clamp perpendicular to uterine a at junction of Cx & Ut body • Place tip of clamp adjacent to Ut • Vessels cut, suture ligated

46. Fig 22-8 Bladder Mobilization • Fig 22-8

47. Fig 22-9Uterine Vessel Ligation

48. Surgical Technique • Incision of posterior peritoneum • Rectum mobilized from posterior Cx •  posterior peritoneum between uterosacral ligament & rectum incised • Avascular tissue plane  mobilization of rectum inferiorly

49. Fig 22-10 Incision of posterior peritoneum

50. Surgical Technique • Cardinal Ligament Ligation • Cardinal ligament divided for distance of 2 to 3 cm to uterus • Ligament cut, pedicle suture ligated • Repeated until junction of cervix & vagina