HYSTERECTOMY (Surgery and Post Surgical Physiotherapy management)

Here is details about Hysterectomy with its post operative physiotherapy management.

1. CONTEXT

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 mainly. Vaginal Hysterectomy usually done for some cases of uterine prolapse.

3. DEFINITION Term Origin : Hyster + Ectomy Uterus Surgical Removal Hysterectomy is defined as the surgical removal of total or part of the uterus.

4. Anatomical Overview

5. INDICATIONS Fibroids 30% Endometriosis Adenomyosis Uterine prolapse Cancer of the uterus, Cervix or Ovaries Vaginal bleeding, DUB 20% Pelvic Inflammatory Disease Severe pelvic Adhesions Bilateral Ovarian Pathology Uncontrollable PPH 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 Ruptured Uterus

6. Fibroids Non-cancerous growths around the Uterus.

7. Endometriosis A disease in which tissue similar to the lining of the uterus grows outside of the Uterus, such as on the ovaries, fallopian tubes and intestines.

8. Difference Between Endometriosis & Adenomyosis ?? In endometriosis,  the endometrial tissue that normally lines the inside of the uterus  grows outside of the uterus. In adenomyosis,  the endometrial tissue that normally lines the inside of the uterus  grows into the muscular wall of the uterus.

9. Uterine prolapse H erniation of the uterus from its natural anatomical location into the vaginal canal, through the hymen, or through the introitus of the vagina. This is due to the weakening of its surrounding support structures.

10. Dysfunctional Uterine Bleeding   A bnormal uterine bleeding that results from an ovarian endocrinopathy. It may be associated with ovulatory and anovulatory cycles. 

11. Pelvic Inflammatory Disease Pelvic inflammatory disease (PID) is an infection of one or more of the upper reproductive organs, including the uterus, fallopian tubes and ovaries. Untreated can cause scar tissue and pockets of infected fluid (abscesses) to develop in the reproductive tract, which can cause permanent damage. It most often occurs when sexually transmitted bacteria spread from your vagina to your uterus, fallopian tubes or ovaries. The signs and symptoms of pelvic inflammatory disease can be subtle or mild. Some women don't experience any signs or symptoms. As a result, you might not realize you have it until you have trouble getting pregnant or you develop chronic pelvic pain. Complications from this damage might include : Ectopic pregnancy : PID is a major cause of tubal (ectopic) pregnancy. An ectopic pregnancy can occur when untreated PID has caused scar tissue to develop in the fallopian tubes. The scar tissue prevents the fertilized egg from making its way through the fallopian tube to implant in the uterus. Instead, the egg implants in the fallopian tube. Ectopic pregnancies can cause massive, life-threatening bleeding and require emergency medical attention. Infertility : Damage to your reproductive organs may cause infertility — the inability to become pregnant. The more times you've had PID, the greater your risk of infertility. Delaying treatment for PID also dramatically increases your risk of infertility. Chronic pelvic pain : Pelvic inflammatory disease can cause pelvic pain that might last for months or years. Scarring in your fallopian tubes and other pelvic organs can cause pain during intercourse and ovulation. Tubo-ovarian abscess : PID might cause an abscess — a collection of pus — to form in your reproductive tract. Most commonly, abscesses affect the fallopian tubes and ovaries, but they can also develop in the uterus or in other pelvic organs. If an abscess is left untreated, you could develop a life-threatening infection.

12. Severe Pelvic Adhesion A condition that occurs when adhesions or scarring bind adjacent organs together. Pelvic adhesions may affect other organs in or near the pelvic region such as uterus, ovaries, fallopian tubes, or bladder.

13. Postpartum Haemorrhage (PPH) Any amount of bleeding from or into the genital tract following birth of the baby up to the end of the puerperium (a period until the body comes to its non-pregnant state, usually it’s considered to be 6 weeks) which adversely affects the general condition of the patient evidenced by rise in pulse rate and falling blood pressure is called postpartum hemorrhage.

14. Pelvic Congestion Syndrome Pelvic congestion syndrome (PCS) involves chronic pelvic pain unrelated to menstruation or pregnancy. It involves problems with blood flow in your pelvic veins. Blood flows backwards, causing your veins to swell and twist. Researchers aren’t sure what causes PCS, but it’s likely that changes to your veins during pregnancy and estrogen play a role. Causes : Multiple Pregnancy (multiple time expansion during pregnancy; about 50% of expansion occurs) Menopause Symptoms : Pain in pelvic region Vericose vein in pelvis Frequent bouts of diarrhea and constipation (irritable bowel). Peeing accidentally from laughing, coughing or other movements that stress your bladder (stress incontinence). Pain when you pee (dysuria)

15. Abnormally Invasive Placentation Accreta, increta, and percreta are three variants of abnormally invasive placentation: Placenta accreta The placenta attaches too deeply and firmly into the uterus, but doesn't pass through the wall or impact the muscles Placenta increta The placenta attaches more firmly to the uterus and becomes embedded in the organ's muscle wall, but doesn't pass through the uterine wall Placenta percreta The placenta attaches itself and grows through the uterus, sometimes extending to nearby organs, such as the bladder

16. TYPES According to the ROUTES : Abdominal Hysterectomy Vaginal Hysterectomy Laparoscopic Hysterectomy Caesarean Hysterectomy According to the Removed Part : Subtotal/Partial Hysterectomy (Removes 2/3 of uterus) Total Hysterectomy (Removes uterus and cervix) Radical Hysterectomy (Removes uterus, cervix and vagina)

17. ABDOMINAL HYSTERECTOMY An abdominal hysterectomy is an operation that removes the uterus through a cut in the lower belly, also called the abdomen. This is known as an open procedure. You may need an abdominal hysterectomy instead of other types of hysterectomy if : You have a large uterus. Your health care provider wants to check other pelvic organs for signs of disease. Your surgeon feels it's in your best interest to do the surgery as an open procedure.

18. Before the procedure : You may need tests to check for cancer and other diseases. Test results could change the surgeon's approach to the operation. Tests may include: A Pap test : also called cervical cytology, which finds irregular cervical cells or cervical cancer. Endometrial biopsy : which takes a sample of tissue from the lining of the uterus. This test may find irregular cells in the uterine lining or endometrial cancer. Pelvic ultrasound : which is an imaging test that can show the size of uterine fibroids, endometrial polyps or ovarian cysts. Blood tests : to check for any conditions that might affect surgery. Pelvic MRI : which is a scan that uses a magnetic field to create images of organs and tissues inside the body. CT of the abdomen and pelvis : which uses X-rays taken from different angles around your body to show cross-sectional images of the uterus and other pelvic structures.

19. During the procedure : You'll receive general anesthesia before the procedure. This means you will not feel pain during the surgery. The procedure itself generally lasts about 1 to 2 hours. You'll have a urinary tube, called a catheter, passed through the urethra to empty the bladder. The catheter remains in place during surgery and for a short time afterward. Your care team uses a sterile solution to clean the abdomen and vagina before surgery. You also will receive antibiotic medicine through a vein in your arm to lower your risk of infection. Next, the surgeon makes a cut in the lower abdomen. This cut is called an incision. You may have: A vertical incision :  which starts in the middle of the abdomen and extends from below the bellybutton to above the pubic bone. Sometimes this incision also needs to be extended above the bellybutton. That's determined by the size of the uterus or if other surgical procedures also are planned along with the hysterectomy. A horizontal bikini-line incision :  which lies about an inch above the pubic bone. What type of incision you'll need depends on many factors. These include the reason for the hysterectomy, the need to explore the upper abdomen, the size of the uterus and whether you have any scars from prior surgeries.

20. After the procedure : After surgery, you're moved into the recovery room and then to your hospital room. Your care team will: Check for symptoms of pain. Give you medicine to control your pain. Encourage you to get up and move around soon after surgery. Encourage you to drink fluids and eat small meals. Watch for surgical complications. You may be in the hospital for 1 to 2 days, but it could be longer. Sanitary pads can help control vaginal bleeding and discharge. You may have bloody vaginal drainage for several days to weeks after a hysterectomy. Let your care team know if you have bleeding that is as heavy as a period or bleeding that won't stop. Over time, your incision will heal. But you will have a visible scar on your lower abdomen.

21. Advantages of abdominal Hysterectomy : Scope of wide exploration of the abdominal and pelvic organs. Tubo-ovarian pathology can be tackled effectively and simultaneously. Concurrent surgical procedure (appendicectomy) may be performed when needed. Operation can be done by a relatively less experienced surgeon. Disadvantages of abdominal Hysterectomy : Difficult to perform in too obese patient. Postoperative pain and complications are slightly high. There is increased incidence of peritonitis, fever, pulmonary and vascular complications. Most hospital stay. Presence of abdominal scar. Morbidity and mortality are more compared to vaginal hysterectomy.

22. VAGINAL HYSTERECTOMY Vaginal hysterectomy is a surgical procedure to remove the uterus through the vagina. During a vaginal hysterectomy, the surgeon detaches the uterus from the ovaries, fallopian tubes and upper vagina, as well as from the blood vessels and connective tissue that support it, before removing the uterus. Vaginal hysterectomy involves a shorter time in the hospital, lower cost and faster recovery than an abdominal hysterectomy, which requires an incision in your lower abdomen. However, depending on the size and shape of your uterus or the reason for the surgery, vaginal hysterectomy might not be possible. Your doctor will talk to you about other surgical options, such as an abdominal hysterectomy.

23. During the procedure : You’ll lie on your back, in a Dorsal Lithotomy position. You might have a urinary catheter inserted to empty your bladder. A member of your surgical team will clean the surgical area with a sterile solution before surgery. To perform the hysterectomy: Your surgeon makes an incision inside your vagina to get to the uterus Using long instruments, your surgeon clamps the uterine blood vessels and separates your uterus from the connective tissue, ovaries and fallopian tubes Your uterus is removed through the vaginal opening, and absorbable stitches are used to control any bleeding inside the pelvis Except in cases of suspected uterine cancer, the surgeon might cut an enlarged uterus into smaller pieces and remove it in sections (morcellation). LITHOTOMY POSITION

24. After the procedure : After surgery, you’ll be in a recovery room for one to two hours and in the hospital overnight. Some women are able to go home the day of the surgery. You’ll take medication for pain. Your health care team will encourage you to get up and move as soon as you’re able. It’s normal to have bloody vaginal discharge for several days to weeks after a hysterectomy, so you’ll need to wear sanitary pads.

25. Advantages of Vaginal Hysterectomy : Absence of an abdominal scar. Lower incidence of intestinal complications. An associated genital prolapse can be treated at the same time. Can be efficiently done in obese patient. Postoperative pain and complications are less. Less morbidity and mortality. Less hospital stay. Less infective than Abdominal Hysterectomy 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. Most experience and skill are needed on the part of the surgeon. Difficult in cases with restricted uterine mobility, limited vaginal space and associated adnexal pathology (Adnexal tumors are growths of cells that form on the organs and connective tissues around the uterus.)

26. LAPAROSCOPIC HYSTERECTOMY Laparoscopic hysterectomy is a vaginal hysterectomy performed with the aid of a laparoscope, a thin, flexible tube containing a video camera. Thin tubes are inserted through tiny incisions in the abdomen near the navel. The uterus is then removed in sections through the laparoscope tube or through the vagina. ADVANTAGES : Less painful Less bleeding Less risk of infection Quicker to return to work Normal activities than women who have an abdominal hysterectomy.

27. CAESEREAN HYSTERECTOMY This is a procedure that combines the delivery of your baby or babies by c-section with a surgery that removes your uterus and usually your fallopian tubes and cervix. The ovaries are not removed.

28. TYPES ACCORDING TO REMOVED PARTS

29. SUBTOTAL HYSTERECTOMY A subtotal hysterectomy surgery involves removing the upper part of the uterus and leaving the cervix in place. This operation is not performed commonly due to post-surgery risk of cervical cancer in and regular cervical screening (a smear test) will be needed to rule out the cancer. ADVANTAGES : It’s 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 support for vagina. The cervix discharge lubricates the vagina.

30. TOTAL HYSTERECTOMY A total hysterectomy surgery involves removing the uterus and the cervix, leaving the ovaries and fallopian tubes in place. ADVANTAGES : Provides better drainage of the operation. If the cervix is lacerated of infected, the source of irritant discharge is removed.

31. RADICAL HYSTERECTOMY A radical hysterectomy surgery involves removing the whole uterus, tissue or cells on the sides of the uterus (parametrium), the cervix, pelvic lymph nodes and the top part of the vagina. This operation is mainly performed when gynecological cancer is present. In a few cases, the ovaries and fallopian tubes may also be removed depending on the patient’s condition, though removal of ovaries and fallopian tubes is not essentially a part of a radical hysterectomy. ADVANTAGES : This procedure is usually performed to treat some cancers of the cervix when other treatments such as chemotherapy and radiotherapy aren't suitable or haven't worked.

32. CONTRAINDICATIONS Uterus as like more than 20 weeks pregnant uterus size. Adnexal pathology. Limited vaginal space. Restricted vaginal mobility. Cervix flushed with mobility. Previous history of Fistula (VVF/RVF) repair. (Vesico-Vaginal Fistula) (Recto-Vaginal Fistula)

33. POSTOPERATIVE COMPLICATIONS Postoperative complications are mainly seen in Abdominal Hysterectomy. Those are: Shock. Haemorrhage. Can cause anaemia. Infection. Intestinal complications as acute gastric dilatation. Pulmonary complications as bronchitis, pneumonia, pulmonary collapse. Venous thrombosis. Postoperative anesthetic complications as cyanosis, vomiting. Remote complications as vaginal discharge (infection), vaginal vault prolapse, low back ache. Menopausal symptoms as sadness, irritability, depression or sexual dysfunction. Incisional Hernia.

34. PT. MANAGEMENT Short term Goals : Patient education Pain reduction Improve the strength of abdominal muscles Improve respiratory efficiency Bed Mobility Long term Goals : Maintain the strength of abdominal muscles Maintain the strength of pelvic floor muscles Make patient functionally independent

35. Pre-Operative Physiotherapy : Patient Education- Education regarding route of surgery, prognosis, post-surgical complications, the importance of physiotherapy To prevent respiratory complications- Active Cycle Breathing Technique (ACBT), Supported coughing To increase the strength of pelvic floor muscles -  Pelvic Floor Exercises. To increase strength in abdominals - Pelvic tilting in crook lying Mobility - Early ambulation , Bed mobility

36. Post-Operative Physiotherapy : Week 1 : Advice on scar management Pelvic floor strengthening exercises Pain control modalities Elevation exercises Advice about the most comfortable positioning Simple mobility exercises such as walking Tranverse abdominis strengthening exercises Lower limb strengthening and range of movement exercises Week 2-6 : Progressing all strengthening exercises Upper limb strengthening and range of movement exercises Progressing transverse abdominis exercises Carrying out pelvic floor exercises in more functional positions Including more functional activities relating to your hobbies or work Pacing advice