Hysterectomy

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

8. 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

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

10. 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

11. 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.

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

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

14. Types of Incisions Vertical Incision Pfannenstiel Incision

15. 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

16. 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

17. 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

18. vaginal hysterectomy Indications of vaginal hysterectomy : Some cases of uterine prolapse. Some cases of dysfunctional uterine bleeding. Some cases of cancer body

19. 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

20. 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

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

22. 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

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

24. 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. HYSTERECTOMY: Now da Vinci surgical system

25. 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

26. 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

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

28. 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 1 st raises the secretion, the 2 nd 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

29. 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

30. NURSING MANAGEMENT:

31. NURSING MANAGEMENT:

32. NURSING MANAGEMENT:

33. NURSING MANAGEMENT: