Hysterectomy

2023-04-01T21:32:01Z

Ckurian:

{{Infobox surgical case reference
| anesthesia_type = General
| airway = ETT
| lines_access = Peripheral IV
| monitors = Standard
5-lead ECG
| considerations_preoperative = Type and cross patients at risk for hemorrhage
| considerations_intraoperative =
| considerations_postoperative = PONV
}}
A '''hysterectomy''' is performed for a variety of indications, including uterine cancer, postpartum hemorrhage, fibroids, abnormal uterine bleeding, and endometriosis. It is most commonly performed laparoscopically, and is increasingly an outpatient procedure.<ref>{{Cite journal|last=Morgan|first=Daniel M.|last2=Kamdar|first2=Neil S.|last3=Swenson|first3=Carolyn W.|last4=Kobernik|first4=Emily K.|last5=Sammarco|first5=Anne G.|last6=Nallamothu|first6=Brahmajee|date=2018-04|title=Nationwide trends in the utilization of and payments for hysterectomy in the United States among commercially insured women|url=http://dx.doi.org/10.1016/j.ajog.2017.12.218|journal=American Journal of Obstetrics and Gynecology|volume=218|issue=4|pages=425.e1–425.e18|doi=10.1016/j.ajog.2017.12.218|issn=0002-9378}}</ref> It is the second-most common gynecological surgical procedure after Cesarean section in the United States<ref>{{Cite web|title=Plotting the downward trend in traditional hysterectomy|url=https://ihpi.umich.edu/news/plotting-downward-trend-traditional-hysterectomy|access-date=2021-03-30|website=ihpi.umich.edu|language=en}}</ref>, and it is frequently performed alongside other procedures including bilateral salpingo-oophrectomy and pelvic/paraaortic lymph node dissection.<ref>{{Cite book|last=Jaffe|first=Richard A|url=http://public.ebookcentral.proquest.com/choice/publicfullrecord.aspx?p=3418805|title=Anesthesiologist's manual of surgical procedures|last2=Schmiesing|first2=Clifford A|last3=Golianu|first3=Brenda|date=2014|isbn=978-1-4963-0594-7|language=English|oclc=888551588}}</ref>

* Surgical procedure: The selection for surgical approach requires consideration of the patient’s age, medical history, history of prior pelvic surgery, or presence/possibility of adhesions, endometriosis, uterine size and presence of uterine prolapse. The advantage of the laparoscopic approach includes shorter recovery time, quicker return of bowel function, less pain, less bleeding and adhesion formation, as well as lower wound complication rate. THe most common procedure is the laparoscopically assisted vaginal hysterectomy (LAVH) which is begun by laparoscopy with a combination of steps performed vaginally.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|
|-
|Cardiovascular
|
* patients with advanced cardiac disease may not tolerate physiologic changes from pneumoperitoneum including higher HR, MAP, SVR, PVR and decreased venous return, preload, and CO.
|-
|Pulmonary
|Many gynecological tumors are associated with cigarette smoking, assess for preexisting lung disease.

* Assess for respiratory disease, diaphragmatic hernia which increase the risk of respiratory compromise from abdominal insufflation.
|-
|Gastrointestinal
|
* High BMI can complicate Trendelenburg positioning through decreasing diaphragmatic excursion when combined with insufflation.
|-
|Hematologic
|Patients with abnormal uterine bleeding, fibroids frequently have chronic anemia
|-
|Renal
|
* Evaluate for volume status as abdominal insufflation decreases preload
|-
|Endocrine
|
|-
|Labs
|Type and cross all patients

CBC in chronic anemia
|}

=== Patient preparation and premedication ===

** The patient should be counseled including limiting NPO duration, alcohol/smoking cessation, review of nutritional status, post pain management options, recovery plan, and possibility of urinary drain post.
*** Multimodal analgesia: Tylenol 650-1000 mg, celecoxib 200-400 mg, gabapentin 300-600 mg for post-op analgesia.
*** Scopolamine patch for PONV prophylaxis in high risk patients
*** IV midazolam for anxiolysis

=== Regional and neuraxial techniques ===

* Spinal or epidural can be considered in open approach

== Intraoperative management ==

=== Monitoring and access ===

* Standard ASA monitors
* 5-lead EKG
* Urinary catheter
*EEG if utilizing a TIVA
* 1-2 peripheral IVs (16-18 gauge)
* In hemorrhaging patients, consider arterial line and central access

=== Induction and airway management ===

* Standard induction
* In unstable patients including hemorrhaging patients, consider etomidate (BP control) and rapid sequence intubation (RSI)
*RSI is usually indicated for patients with an ectopic pregnancy
*OG tube decompression prop to laparoscopic trocar insertion

=== Positioning ===

* Dorsal lithotomy position, arms tucked
**Sciatic and femoral nerve injuries may occur in lithotomy position. Check to minimize hip abduction and external rotation. Carefully pad and secure the knees and heels
**Watch hands and fingers carefully when arms are tucked at patient’s side.
* Deep Trendelenburg position for laparoscopic approach

=== Maintenance and surgical considerations ===

* Intraoperative insufflation may cause:
** Resp: atelectasis, decrease FRC, increase PIPs, and increase CO2. May also cause endobronchial intubation
** GI: gastric content regurgitation
** Cardiac: decreased cardiac output (decreased venous return) and bradycardia from pressure-induced vagal stimulation
**Hematologic: Blood loss is usually minimal though could be significant during some procedures. Discuss with surgeon ahead of time.
**Pain: Consider a ketamine infusion for chronic pain patients

=== Emergence ===

* PONV prophylaxis, especially in young women at higher risk.
*Post-op pain control plan if surgical approach was converted to laparotomy.

== Postoperative management ==

=== Disposition ===

* PACU
* Occasionally, same-day discharge

=== Pain management ===

** Epidural, TAP block/catheters, Rectus sheath block/catheters should be considered if patients surgery was converted to an open approach
** Consider a PCA if the patient had a larger incision than anticipated
** Multimodal analgesia as discussed above

=== Potential complications ===

* PONV
* Conversion to laparotomy (3.9%)
* Urinary tract injury
* Bowel injury
* Vaginal cuff dehiscence
* Hemorrhage

== Procedure variants ==

{| class="wikitable"
|+
!
!Open
!Laparoscopic
!Robotic
Laparoscopic
|-
|Unique considerations
|
|
|
|-
|Position
|
|Dorsal lithotomy

Steep Trendelenburg
|Dorsal lithotomy
Steep Trendelenburg
|-
|Surgical time
|
|
|
|-
|EBL
|
|
|
|-
|Postoperative disposition
|
|PACU

Poss. same day discharge
|
|-
|Pain management
|Regional
|Oral narcotics vs. PCA
|
|-
|Potential complications
|
|
|
|}

== References ==

[[Category:Surgical procedures]]
<references />

* Nelson G, Altman AD, Nick A, et al: Guidelines for pre- and intra-operative care in gynecologic/ oncology surgery: enhanced recovery after surgery (ERAS) Society recommendations-Part I. ''Gynecol Oncol 2016''; 140(2):313-22.

* Gerges FJ, Kanazi GE, Jabbour-Khoury SI: Anesthesia for laparoscopy: a review. ''J Clinic Anesth 2006''; 18(1): 67-78.

[[Category:Obstetric and gynecologic surgery]]

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Hysterectomy