Hysterectomy, types, treatment, nursing management

1. HYSTERECTOMY
Prepared by
Dr Rajesh T Eapen
ATLAS HOSPITAL
RUWI Muscat

2. Introduction
 Hysterectomy is an operation in which the
uterus is removed.
 The cervix, ovaries and/or Fallopian tubes
might also be removed.
 It may be done abdominally or vaginally.
 Vaginal hysterectomy usually done for some
cases of uterine prolapse.

3. Epidemiology
• Hysterectomy is the second most common surgery among
women in the United States
• One in three women in U.S. had one by age 60
• Each year, more than 600,000 are done
• Over 90% are performed for benign conditions
• Over 70% also involved the surgical removal of ovaries
• Abdominal hysterectomy was more common than vaginal
hysterectomy (65% vs. 35%)
• Proportion of vaginal hysterectomies performed with
laparoscopic assistance doubled (from 13% to 28%)

4. Indications
• Fibroids 30%
• Endometriosis
• Uterine prolapse
• Cancer of the uterus, cervix, or ovaries
• Vaginal bleeding, DUB 20%
• uncontrollable PPH

5. • Pelvic inflammatory
disease
• Severe pelvic
adhesions
• Bilateral ovarian
pathology
• Adenomyosis
• Pelvic congestion
syndrome
• Intractable, recurrent
dysmenorrhea or
metrorrhagia
• Uterine anomalies
• Recurrent intrauterine
polyps
• Uterine perforation
• Mentally retarded
patient with no
hygiene control
• Pregnancy
• Placenta increta,
percreta, or acreta
• Atonic uterus
• Uterine perforation
• Ruptured uterus

6. Routes for Hysterectomy
• Abdominal Hysterectomy (AH)
– Total
– Subtotal
• Vaginal Hysterectomy (VH)
– Laparoscopically-assisted vaginal (LAVH)
– Totally laparoscopic hysterectomy
• Laparoscopic Hysterectomy
• Caesarean Hysterectomy

7. Which Route is Best?
• Abdominal Hysterectomy
– Results in greatest mean blood loss
– Has the highest incidence of febrile morbidity
– And abdominal wound infection (obviously)
– Longest hospitalisation
– And slowest to recover
• Vaginal Hysterectomy
– Is the preferred route when technically possible
• Laparoscopic Hysterectomy
– Requires training and equipment
– Longest operating time
– But shortest hospitalisation and recovery
– But has the greatest overall risk of complications
– There is debate about its cost effectiveness

9. Types of Hysterectomy
• Subtotal Hysterectomy
• Uterine body only
• Total Hysterectomy
• Uterine body and cervix (not ovaries!)
• Hysterectomy with BSO
• Uterus with bilateral salpingo oophorectomy
• Radical (or Wertheim) Hysterectomy
• Total hysterectomy with pelvic lymph nodes,
paracervical tissue and upper 1/3 vagina

10. Types of Hysterectomy -
simplified
• Partial Hysterectomy
– Removes 2/3 of
uterus
• Total Hysterectomy
– Removes uterus and
cervix
• Radical Hysterectomy
– Removes uterus,
cervix, and vagina

11. Abdominal Hysterectomy
• Patient Preparation
– For patients at risk, thromboembolism prophylaxis is
begun preoperatively, or pneumatic compression boots
are applied in the OR
– Prophylactic antibiotic agent should be given as a single
dose 30 minutes prior to the incision
• Incision choice - transverse or vertical
– Need for exploration of the upper abdomen
– Size of the uterus
– Presence of prior incisions
– Desired cosmetic results

12. Abdominal Hysterectomy - the
Procedure
• Post-Op care -
– Not necessary to leave a bladder catheter in place postoperatively
– IV fluids for the first 24 hours to ensure that the patient remains well
hydrated
– Early feeding of a regular diet can stimulate the bowel and decrease the
length of hospitalization*
– Deep breathing to prevent atelectasis
– Ambulation is encouraged
– Intermittent compression boots
– Adequate control of postoperative pain
* Fanning, J, Andrews, S. Early postoperative feeding
after major gynecologic surgery: Evidence-based
scientific medicine. Am J Obstet Gynecol 2001; 185:1.

13. Advantages of subtotal hysterectomy
1. -It is easier and quicker than total
hysterectomy
2. There is less danger of injuring the bladder.
3. Less danger of pelvic infection.
4. The cervix left to act as a support for vagina.
5. The cervix discharge lubricates the vagina

14. Advantages of total hysterectomy
1. Provides better drainage of the
operation area.
2. If the cervix is lacerated or infected, the
source of irritant discharge is removed.

16. Types of Incisions
Vertical Incision
Pfannenstiel
Incision

17. Abdominal Hysterectomy
• the uterus is removed through an incision
in the woman’s abdomen.
• Most invasive method
• Incision site at abdomen
• Hospital stay of 5-6 days
• Recovery time 6 weeks
• Possible retention of cervix
• Required for endometriosis and large
fibroids

18. Postoperative Complications of abdominal
hysterectomy
 Shock.
 Hemorrhage. Can cause Anemia
 Infection, Wound dehiscence
 Intestinal complications as acute gastric dilatation.
 Pulmonary complications e.g. bronchitis, pneumonia,
pulmonary collapse.
 Venous thrombosis (DVT, SVT.)
 Post operative anesthetic complications e.g. Cyanosis,
vomiting.
 Remote Complications e.g. vaginal discharge (infection),
vaginal vault prolapse, low back ach,
 Menopausal symptoms e.g. sadness, irritability. (in
younger female). Depression or Sexual Dysfunction
 Incisional hernia

19. Vaginal Hysterectomy
• the uterus is removed through the
vagina.
• Less invasive than abdominal
hysterectomy
• Incision site at inner vagina
• Hospital stay 1-3 days
• Recovery time 4-6 weeks
• Cervix cannot be preserved

20. vaginal hysterectomy
Indications of vaginal hysterectomy:
1. Some cases of uterine prolapse.
2. Some cases of dysfunctional uterine
bleeding.
3. Some cases of cancer body

21. Vaginal Hysterectomy
• A prophylactic antibiotic agent should be
given as a single dose 30 minutes prior to
the first incision for vaginal hysterectomy
– cefazolin, cefoxitin, and cefuroxime
– Metronidazole (500 mg IV) may be used in
patients with cephalosporin allergies
• A course of appropriate preoperative
antibiotics in women with bacterial vaginosis
can reduce the frequency of cuff infection

22. Vaginal Hysterectomy
• Patient positioning - dorsal lithotomy
• Bimanual pelvic examination is performed
– assess uterine mobility and descent
– confirm that no unsuspected adnexal pathology is
found
• A bladder catheter may be inserted
– some surgeons believe that a distended bladder
helps with recognition of a bladder injury and thus
do not use a catheter

23.  Advantages of vaginal hysterectomy:
1. Absence of an abdominal scar.
2. Lower incidence of intestinal complication.
3. An associated genital prolapse can be treated at the same
time.
 Disadvantages of vaginal hysterectomy:
1. It is unsafe and difficult in the presence of pelvic adhesions.
2. The ovaries can not be removed in some cases.
3. It can not be done if the size of the uterus is larger than a 14
weeks pregnant uterus.

24. Laparoscopic Hysterectomy
• the uterus is removed in sections through small
incisions using a laparoscope
• Hospital stay 1-3 days
• Recover time is 4-6 weeks
• Longer duration of procedure
• Requires greater surgical expertise
• Urinary tract injuries are more likely
• Fewer abdominal wall infections or febrile
episodes
• Less blood loss

25. Robotic Hysterectomy
• 3-dimensional
image
• Greater articulation
• Eliminate hand
tremors
• Increased accuracy
and precision

26. • Robotic Laparoscopic
Hysterectomy
– The first successful surgery
using the da Vinci surgical
system was performed in
Belgium in 1997.
– da Vinci S and da Vinci SI is
equiped with double optic
which gives the operator three-
dimensional view of the
operative field, and with
adjustable magnification,
enabling much improved vision
of the pelvis.
da Vinci surgical system

27. Risks and Side Effects
• Earlier onset of menopause
• Greater risk of cardiovascular disease
• Increased chance of osteoporosis and
bone fractures
• Uncontrolled urination
• Reduced libido
• Vaginal dryness

28. After Hysterectomy
• Most women don’t need Pap smears
• Except those who had previous CIN >2 , Ca Cervix or
Ca corpus uterus
• Oestrogen only HRT (ERT) is an option
• Except when BSO was performed for oestrogen
responsive cancer or severe endometriosis
• Symptoms control in these patients can be a real
problem
• Current research suggests that ERT has many
benefits and few risks

29. Aims of treatment – Nursing plan
 Pre-operative
Psychological preparation for the operation.
 Aims of pre-operative treatment:
1. To prepare the patient physically and mentally for the
operation.
2. Teach her the exercises that will be done post operatively.
3. To improve circulation.
4. To improve respiration.
5. To strength the abdominal muscles

30. Exercise training pre-op:
 Deep breathing exercises:
to improve alveolar ventilation. (to minimize changes in lung volume and
gas exchange) from semi-fowler position, the abdominal muscle in slack to
allow greater diaphragmatic excursion
 Rolling over in bed
to minimize trunk movement.
 Coughing
Two stage cough preceded by deep breathing (the 1st raises the secretion,
the 2nd facilitate expectoration. Patient applies pressure on the incision by
pillows or hands.
 Huffing:
accomplished by forceful expiration, If the patient unable to do coughing
 Ankle circles:
To minimize the occurrence of phlebitis and facilitate venous return.
 Abdominal muscles exercises

31. • Post-operative
Aims:
• To improve circulation.
• To improve respiration and prevent chest complications.
• To avoid muscle wasting.
• To prevent postural problems
Methods
• The same like cesarean section except arm exercises.
• Electrical stimulation to decrease pain (TENS).
• Laser to decrease pain and enhance healing

32. NURSING MANAGEMENT:

33. NURSING MANAGEMENT:

34. NURSING MANAGEMENT:

35. NURSING MANAGEMENT: