James M. Wheeler, MD, MPH, JD
Hysterectomy is one of the top ten operations performed in the U.S. today, and has been for several decades. Hysterectomies are performed for various diseases that cause some combination of pelvic pain and abnormal bleeding, including leiomyomata uteri (fibroids), endometriosis, pelvic adhesions from various causes and (fortunately) in a minority of cases, gynecologic cancers. Prior to recommending surgery, the care provider should evaluate the woman with pain and/or abnormal bleeding, providing reasonable assurance that she is not dealing with gyn cancer. Then, if her anatomy is not seriously distorted as by fibroids or uterine polyps, a trial of medical therapy may well be in order; useful medications include oral contraceptives, progestins, nonsteroidal anti-inflammatory drugs, and sometimes other meds as well. Of course, the best way to prevent complications at hysterectomy is to provide successful medical therapy, thus avoiding surgery altogether.
If care provider and patient agree that medical therapy is either contraindicated, or turns out to be less than satisfactory in its results, then a careful review of surgical options is warranted. For abnormal bleeding alone, especially in a woman with demonstrably fairly normal anatomy on ultrasound, hysteroscopic procedures may well be sufficient to stop or significantly decrease the abnormal bleeding. In the presence of a polyp or fibroid in or near the endometrial cavity, hysteroscopic resection will stop abnormal bleeding in the vast majority of cases. In the anatomically normal uterus, endometrial ablation (with or without hysteroscopic evaluation preceding) will improve bleeding in 80% of cases. However, if there is a significant pain component to the patient’s symptomatology, definitive treatment is often in the form of removal of the uterus itself – hysterectomy.
Each woman needs a careful evaluation for which type of hysterectomy is optimal. Risks are lowest, and recovery fastest, in the woman fortunate enough to be a candidate for vaginal hysterectomy (VH). Unfortunately, only a minority of patients undergo VH in the U.S. due to concerns of intraperitoneal disease and, progressively more true every year, operator inexperience as resident physicians are less well trained than ever before.
Inserting a laparoscope is a useful adjunct to hysterectomy. Pelvic diseases such as endometriosis can be identified and treated. Uterine attachments can be severed and made hemostatic under the surgeon’s direct visualization. Robotic assistance is favored by many to tackle the toughest hysterectomies, but is not yet proven superior in most cases by properly conducted clinical trials. Laparoscopic skills do have a learning curve, and residents graduate today with basic skills of laparoscopic surgery, and continue to hone their skills with each case they perform.
The default mode of hysterectomy is abdominal TAH (total abdominal hysterectomy) via a transverse or vertical abdominal wall incision. This allows the surgeon to feel the abdominopelvic viscera, as well as allowing visual inspection like at laparoscopy. Some surgeons innovated TAH by making an even wider transverse incision of fat and skin, then a vertical incision of the rectus fascia; this “wide laparotomy” quadruples the access of the typical low transvers incision, such that a hysterectomy and a cholecystectomy can be done via the same incision (when indicated, of course). And, the patients love it when the surgeon excises redundant fat and plicates the vertical fascia as in an abdominoplasty.
The most common complications of hysterectomies are bladder infections and skin infections. Most surgeons give prophylactic antibiotics to reduce the chance of these complications, but nonetheless, 10-20% of patients will have some infectious complication. Postoperative vigilance is required to make sure a mild infection does not progress into vaginal cuff cellulitis, abscess, or even sepsis.
The most common serious complication of hysterectomy is hemorrhage, which occurs in 1-3% of cases. Those having a peripartum hysterectomy, or one for cancer or severe pelvic infection including abscess, are at greatest risk. Elective cases should have their preoperative hematocrits determined and, if low, optimized prior to commencing surgery in order to avoid unnecessary transfusion. These techniques are simple, often including iron administration orally or intravenously, induction of amenorrhea if possible, and sometimes administration of erythrocytogenic stimulants (e.g., Epogen).
Bowel injuries are uncommon, occurring in about 0.4% of cases. Laparoscopic cases have the highest risk due to the use of the trocars; vaginal cases have the lowest risk. All cases require the surgeon to maintain vigilance, and suspicion of bowel injury in any postoperative patient having fever and GI symptoms, or generally not advancing as well as expected.
Urinary injuries include the bladder most often; these must be always kept in mind as much of a hysterectomy’s dissection is around the back wall of the bladder. Fortunately, with a watchful and careful surgeon, the bladder is very forgiving of minor injuries as long as continuous drainage is provided; larger injuries heal very well after proper suture repair. Sometimes, a postoperative fistula develops between the bladder and vagina or rectum – especially if a bladder injury is unrecognized, is poorly repaired, or in damaged (e.g., radiated) tissue.
Urinary injuries also include the ureter, occurring in about 0.5% of cases. This is because the pelvic ureter is in close proximity to the female organs. Knowledge of ureteric anatomy and constant awareness of its location are prerequisite to avoid ureteral damage. If the ureter is unacceptably close to an area requiring dissection or hemostatic work, it can be mobilized with a retroperitoneal approach with minimal risk, including next to no bleeding. Identification, mobilization, and avoidance of damaging contact of the ureter are the mainstays of preventing injury to it during any kind of pelvic surgery via any kind of surgical approach, be it laparoscopic or open. If an intraoperative compromise of the ureter is suspected, it can be evaluated several ways: the administration of intravenous blue dye, cystoscopically (or via the bladder wall) looking at ureteral flux, radiographically using intravenous pyelography, or via urologic consultation and passage of ureteral stents. Even if an intraoperative identification of a ureteric injury fails, every surgeon must be alert to postoperative symptoms suggesting ureteric injury, including fever, flank pain, dysuria, generally not feeling well, and ileus. Assessing the ureters postoperatively with intravenous pyelography is far superior than allowing a patient to potentially be discharged with a smoldering ureteric injury. Shorter time to diagnosis and repair is superior, with better preservation of renal function, than diagnostic delay. Other clinicians that aid in postoperative follow-up need to be familiar with the symptoms and signs of ureteric injury as well.
Very rare complications can occur at hysterectomy including: pulmonary complications including pneumonia or atelectasis, cardiac complications including myocardial infarction, thrombosis and thromboembolism, renal failure, and drug reaction. Vigilance and early diagnosis are the mainstays of the surgeon wishing to minimize morbidity and mortality of their hysterectomy procedures.
‘Thanks for giving us a methodologic map by which we could evaluate Phase IV studies (on oral contraceptives). We really just looked at each study individually before this.’
—Food and Drug Administration staffers