HYSTERECTOMTY: Indications,Classification

 Classification

• Total hysterectomy
• Subtotal hysterectomy
• Abdominal hysterectomy
• Vaginal hysterectomy 
• With or without Bilateral salpingo oophorectomy
• Unilateral salpingo oophorectomy (Salpingo oophorectomy is the resection of the adnexa with the ovaries)
• It can be done incase of emergency, planned, obstetric or  gynecological indications
• It can also be laparoscopic hysterectomy, open or robotic hysterectomy. Laparoscopic and Robotic hysterectomy are the new advancements 

 Laparoscopic hysterectomy- surgery is done in 45min-2 hours and patient get discharged in the next post operative day. Maximum 1 or 2 days  hospital stay is required

Robotic hysterectomy- is not better than the laparoscopic hysterectomy. There is no advantage of doing robotic hysterectomy over a laparoscopic hysterectomy. It is far more expensive. It is technical ease in doing for the surgeon but for the patient, there is no difference between laparoscopic or robotic hysterectomy 

Indications of Hysterectomy

• Fibroid uterus is the most common indication. Almost 40-45% of surgeries done.
• Endometriosis - 15-20%
• Prolapse- 15%
• Dysfunctional uterine bleeding, pelvic inflammatory disease, chronic pelvic pain 

Prerequisites

• Consent
• Rule out pregnancy
• Pap smear ( to rule out coexistent dysplasia on the cervix)
• Arrange blood
• Take precaution for venous thrombus embolism ( patient should be given leg physiotherapy and exercises after immediate post operative)
• Antibiotics (only give induction antibiotics) within 1 hour

Complications of Hysterectomy

• Intraoperative injuries to bowel, bladder, vessels
• Injury to the ureter. In hysterectomy, injury is common while ligating the uterine artery and the most common site is at the site of crossing the uterine artery. The overall most common site is at the pelvic brim.

Postoperative Complication of Hysterectomy

• Hemorrhage- it can be immediate, can be visualized immediately or may not be visualized if it is retro peritoneal than there are signs like increase pulse rate and patient going into shock
• Reactionary hemorrhage- occurs in the first 24 hours because of slip of a ligature
• Secondary hemmorhage -  after 24 hours until 2-3 weeks. The most common cause is infection. 
• Wound infection- 4-6% cases
• Cuff cellulitis 
• Urinary retention - is due to bladder hypotonia, can be because of drugs
• Ureteric injuries- post op flank pain
• Bladder injury or vesico vaginal urethera or uretero vaginal fistula
• Prolapse of the fallopian tube through the vault
• Cuff Dehiscence

Laparoscopic Surgeries

1. Laparoscopic-assisted vaginal hysterectomy -

•  Diagnostic laparoscopy + vaginal hysterectomy or adhesolysis + vaginal hysterectomy

• Resection of the adnexa 
• Uterine resection after bladder mobilization

2. Total Laprascopic hysterectomy- removing whole uterus abdominally and suturing wall abdominally

Importance of the ovaries

Conserve ovaries as long as possible atleast till 50 years of age. If there is surgical oophorectomy before 50 years, they will be most likely having coronary artery disease by 65 years

Prophylactic oophorectomy

• Is done incases of gene mutation BRCA1 and BRCAII
• Ist degree females relatives have Ca breast or Ca ovary

Frequently Asked Questions