Subtotal Hysterectomy – Indications, Contraindications

Subtotal Hysterectomy/A hysterectomy is an operation to remove the uterus. This surgery may be done for different reasons, including uterine fibroids that cause pain, bleeding, or other problems. Uterine prolapse, which is a sliding of the uterus from its normal position into the vaginal canal. Cancer of the uterus, cervix, or ovaries.

A hysterectomy is a surgery to remove a woman’s uterus (also known as the womb). The uterus is where a baby grows when a woman is pregnant. During the surgery, the whole uterus is usually removed. Your doctor may also remove your fallopian tubes and ovaries. After a hysterectomy, you no longer have menstrual periods and cannot become pregnant.

Surgeons can perform hysterectomy through more than a few different methods. Some of the generally performed routes of hysterectomy are vaginal, abdominal, laparoscopic, and robotic-assisted. Vaginal hysterectomy ranks as one of the least and minimally invasive types of hysterectomies, and it has better outcomes and fewer complications compared to other types. It should be regarded as the preferred route of hysterectomy, whenever possible. The advantages of vaginal hysterectomy include less pain, rapid recovery, faster return to work, lower costs, and lower morbidity. It is usually performed for benign hysterectomies.

Types of Hysterectomy

There are four types of hysterectomies that can be performed depending on the condition and severity of the patient. These four types are

  • Vaginal hysterectomy
  • Laparoscopic hysterectomy
  • Minilaparotomy (a “short incision”) hysterectomy
  • Abdominal hysterectomy

There are various types of hysterectomy. The type you have depends on why you need the operation and how much of your womb and surrounding reproductive system can safely be left in place.

The main types of hysterectomy are
  • Total hysterectomy – the womb and cervix (neck of the womb) are removed; this is the most commonly performed operation
  • Subtotal hysterectomy – the main body of the womb is removed, leaving the cervix in place
  • Total hysterectomy with bilateral salpingo-oophorectomy – the womb, cervix, fallopian tubes (salpingectomy) and ovaries (oophorectomy) are removed
  • Radical hysterectomy – the womb and surrounding tissues are removed, including the fallopian tubes, part of the vagina, ovaries, lymph glands, and fatty tissue.
There are several approaches that can be used for a MIP hysterectomy
  • Vaginal hysterectomy – The surgeon makes a cut in the vagina and removes the uterus through this incision. The incision is closed, leaving no visible scar.
  • Laparoscopic hysterectomy – This surgery is done using a laparoscope, which is a tube with a lighted camera, and surgical tools inserted through several small cuts made in the belly or, in the case of a single site laparoscopic procedure, one small cut made in the belly button. The surgeon performs the hysterectomy from outside the body, viewing the operation on a video screen.
  • Laparoscopic-assisted vaginal hysterectomy – The surgeon uses laparoscopic tools in the belly to assist in the removal of the uterus through an incision in the vagina.
  • Robot-assisted laparoscopic hysterectomy – This procedure is similar to a laparoscopic hysterectomy, but the surgeon controls a sophisticated robotic system of surgical tools from outside the body. Advanced technology allows the surgeon to use natural wrist movements and view the hysterectomy on a three-dimensional screen.

Anatomy and Physiology

Hysterectomy can be performed in more than a few different ways. Some of the generally performed routes of hysterectomy are vaginal, abdominal, laparoscopic, and robotic-assisted. Vaginal hysterectomy is considered as one of the least and minimally invasive types of hysterectomies, and it has better outcomes and fewer complications compared to other types. It should be regarded as the preferred route of hysterectomy, whenever possible. The advantages of vaginal hysterectomy include less pain, rapid recovery, faster return to work, lower costs, and lower morbidity. It is usually performed for benign hysterectomies.

Indications of Vaginal Hysterectomy

Hysterectomy is one of the most frequently performed surgeries in the world, and some of the most common indications for hysterectomy include:

  • Endometriosis – the growth of the uterine lining outside the uterine cavity. This inappropriate tissue growth can lead to pain and bleeding.
  • Adenomyosis – a form of endometriosis, where the uterine lining has grown into and sometimes through the uterine wall musculature. This can thicken the uterine walls and also contribute to pain and bleeding.
  • Heavy menstrual bleeding – irregular or excessive menstrual bleeding for greater than a week. It can disturb the regular quality of life and may be indicative of a more serious condition.
  • Uterine fibroids – benign growths on the uterus wall. These muscular noncancerous tumors can grow in a single form or in clusters and can cause extreme pain and bleeding.
  • Uterine prolapse – when the uterus sags down due to weakened or stretched pelvic floor muscles potentially causing the uterus to protrude out of the vagina in more severe cases.
  • Reproductive system cancer prevention – especially if there is a strong family history of reproductive system cancers (especially breast cancer in conjunction with BRCA1 or BRCA2 mutation), or as part of recovery from such cancers.
  • Gynecologic cancer – depending on the type of hysterectomy, can aid in the treatment of cancer or precancer of the endometrium, cervix, or uterus. In order to protect against or treat cancer of the ovaries, would need an oophorectomy.
  • Transgender (trans) male affirmation – aids in gender dysphoria, prevention of future gynecologic problems, and transition to obtaining new legal gender documentation.[rx]
  • Severe developmental disabilities – this treatment is controversial at best. In the United States, specific cases of sterilization due to developmental disabilities have been found by state-level Supreme Courts to violate the patient’s constitutional and common-law rights.[rx]
  • Postpartum – to remove either a severe case of placenta praevia (a placenta that has either formed over or inside the birth canal) or placenta percreta (a placenta that has grown into and through the wall of the uterus to attach itself to other organs), as well as a last resort in case of excessive obstetrical hemorrhage.[rx]
  • Chronic pelvic pain – should try to obtain pain etiology, although may have no known cause.
  • Pelvic relaxation
  • Fibroid uterus
  • Abnormal uterine bleeding
  • Pelvic pain associated with endometriosis
  • Pelvic organ prolapse
  • Benign ovarian mass
  • Gynecological cancer
  • Adenomyosis

A hysterectomy may be performed to treat

  • Abnormal uterine bleeding that is not controlled by other treatment methods
  • Severe endometriosis (uterine tissue that grows outside the uterus)
  • Uterine fibroids (benign tumors) that have increased in size, are painful or cause bleeding
  • Increased pelvic pain related to the uterus but not controlled by other treatment
  • Uterine prolapse – (uterus that has “dropped” into the vaginal canal due to weakened support muscles) that can lead to urinary incontinence or difficulty with bowel movements
  • Cervical or uterine cancer
  • Complications during childbirth (like uncontrollable bleeding)
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Contraindications of Vaginal Hysterectomy

There are no absolute contraindications, but, some of the relative contraindications to vaginal hysterectomy are:

  • Pelvic radiation
  • Large uterus
  • Prior pelvic surgeries
  • Suspected severe pelvic adhesion and anatomical distortion from PID (pelvic inflammatory disease) or endometriosis.
  • Morbid obesity
  • Nulliparity
  • Lack of uterine descent

Equipment

The instruments required for vaginal hysterectomy are the following:

  • long, heavy Mayo scissors
  • Short and long weighted vaginal speculums with an extra-long blade
  • Heaney right-angle retractors
  • Jorgenson scissors
  • long Allis clamps
  • Deaver retractors.
  • A long needle holder
  • Heany clamps
  • Single tooth tenaculum
  • Single-tooth tenaculum
  • Bovie extender,
  • Suction apparatus
  • A neurosurgery headlight

Personnel

  • Gynecologist
  • Urogynecologists
  • Anesthesiologist
  • Anesthetic technologist
  • Nurses
  • Surgical assistants

Preparation

Preparation of the patient includes the following:

  • Proper patient positioning- Vaginal hysterectomy is typically performed with the patient positioned in dorsal lithotomy with the help of either candy cane or boot-type stirrups.
  • Application of sequential compression devices or administration of anticoagulants for venous thromboembolism prophylaxis
  • Antibiotic prophylaxis- We typically use cefazolin 1 to 2 gm IV, administered within 60 min of the incision.
  • Time out (pre-procedure verification checklist) is always performed before the commencement of surgery, to confirm the correct patient, type of the operation, equipment used, and the surgeon performing the procedure, as per the standard hospital protocol.
  • The patient is examined under anesthesia for the evaluation of size, shape, mobility of the uterus; assessment of the adnexa, and other pelvic structures. Also, the degree of descent of the uterus, vaginal wall caliber, and pelvic organ prolapse, cystocele, and rectocele are assessed.
  • Betadine scrub is used for vaginal preparation before the procedure.
  • A sterile surgical drape is used to cover the patient to ensure the aseptic environment of the entire procedure.


Technique

Urinary bladder and ureteral injuries are the most common preventable complications that can occur during the hysterectomy. The technique for performing a hysterectomy is as follows:

  • Decompression of the bladder – Foley catheter is used to drain urine.
  • Injecting vasoconstricting agents – Dilute vasopressin (20 units in 100 ml of normal saline) is circumferentially injected into the proper planes of the cervicovaginal junction. The purpose of this is for hemostasis and hydrodissection.
  • A circumferential – incision is made around the cervix at the cervicovaginal intersection by using a scalpel or diathermy.
  • Dissection and deflection of the bladderanterior colpotomy – after the circumferential incision is made, the anterior aspect of the vaginal mucosa is grasped and tented up, sharp and blunt dissection is done to separate the vaginal mucosa from the cervical stroma. The peritoneum is identified, and the peritoneal cavity is entered sharply. A right angle or Deaver retractor is then placed into the peritoneal cavity and the bladder is protected.
  • Posterior cul-de-sac entry – Posterior vaginal epithelium is grasped at the previous circumferential incision with a pair of Allis clamps and tended up, the peritoneum is identified and sharply entered with Mayo scissors. Once the peritoneal cavity is opened, the vaginal mucosa is stretched or incised laterally, and a long weighted vaginal speculum is reinserted into the peritoneal cavity.
  • Uterosacral and cardinal ligament complex – Uterosacral ligaments are felt by examining with the index finger. The right-angle retractor is placed in the medial aspect of the vagina for proper exposure of this ligament, which is then clamped with Heaney clamp and cut. It is then sutured ligament, and the tail of the suture is clamped and saved for future McCall’s culdoplasty. Similarly, the cardinal ligaments are identified, clamped, cut, and suture ligated. Care be taken during clamping as the ureters are very close to the uterosacral ligaments. Clamps must be placed very close to the cervical stump. All clamps must incorporate both anterior and posterior peritoneum to prevent bleeding from collateral blood vessels.
  • Uterine vessels – The Heaney clamp is widely opened and slide off the cervix, making sure all the vasculature is incorporated into the clamp, uterine vessels are cut, and suture ligated. The author does not recommend Heaney stitch as it can cause unnecessary injury to the vascular pedicle and cause bleeding. A significant uterine descent is seen after the uterine vessel dissection.
  • Broad ligament – This is an avascular ligament, which is primarily composed of peritoneum and minor blood vessels. This ligament is clamped medially, cut, and sutured.
  • Utero-ovarian, round ligament complex, and corneal end of the Fallopian tube – The upper and the final pedicle can be clamped all together or separately. If the pedicles are too large, the round ligament can be clamped individually. As this is a large pedicle, the author recommends doubly clamping this pedicle, and two sutures are placed. First, suture tie followed by suture ligation medial to the first. Once all ligaments and vessels are cut, ligated, and secured, the uterus is delivered.
  • Evaluate all pedicles – in a clockwise fashion for adequate hemostasis.
  • Closure of the cuff and McCall’s Coloplast – As the vaginal apex is the most common site of bleeding during vaginal hysterectomy, we usually close it in the running and locking fashion to control bleeding from the vaginal edges. The author typically horizontally closes the cuff unless there is a concern for the vaginal length, in which the wound is closed in a vertical fashion.

Incorporate the uterosacral ligaments into the angle of the vaginal cuff at the time of cuff closure for the suspensory support of the vagina. This maneuver prevents future vaginal wall prolapse.

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The vagina is not usually packed as it has not shown to improve bleeding or any other outcomes. A Foley catheter is left in place until the patient is ambulatory.  Diet is advanced as tolerated.

Results

It takes time to get back to your usual self after an abdominal hysterectomy — about six weeks for most women. During that time:

  • Get plenty of rest.
  • Don’t lift anything heavy for a full six weeks after the operation.
  • Stay active after your surgery, but avoid strenuous physical activity for the first six weeks.
  • Wait six weeks to resume sexual activity.
  • Follow your doctor’s recommendations about returning to your other normal activities.


Life after a hysterectomy

A hysterectomy permanently changes some aspects of your life. For instance:

  • You’ll no longer have menstrual periods.
  • Most of the time, you’ll get relief from the symptoms that made your surgery necessary.
  • You won’t be able to become pregnant.
  • If you’re premenopausal, having your ovaries removed along with a hysterectomy starts menopause.
  • If you have a hysterectomy before menopause and you keep your ovaries, you may experience menopause at a younger than average age.
  • If you have a partial hysterectomy, your cervix remains in place, so you’re still at risk of cervical cancer. You need regular Pap tests to screen for cervical cancer.

Other parts of your life will likely return to normal or perhaps improve once you’ve recovered from your hysterectomy. For example:

  • If you had a good sex life before a hysterectomy, chances are you’ll maintain it afterward. Some women even experience more sexual pleasure after a hysterectomy. This may be due to relief from chronic pain or heavy bleeding that was caused by a uterine problem.
  • The relief of symptoms may greatly enhance your quality of life. You may have an improved sense of well-being and a chance to get on with your life.

On the other hand, you may feel a sense of loss after a hysterectomy. Premenopausal women who must have a hysterectomy to treat gynecologic cancer may experience grief and possibly depression over the loss of fertility. If sadness or negative feelings begin to interfere with your enjoyment of everyday life, talk with your doctor.

Alternative of Hysterectomy

Alternate treatment options will depend very much on the source of the problem. The surgeon may discuss alternative approaches to Hysterectomy:

Hysterectomy is major surgery. Sometimes a hysterectomy may be medically necessary, such as with prolonged heavy bleeding or certain types of cancer. But sometimes you can try other treatments first. These include:

  • Watchful waiting. You and your doctor may wish to wait if you have uterine fibroids, which tend to shrink after menopause.
  • Exercises. For uterine prolapse, you can try Kegel exercises (squeezing the pelvic floor muscles). Kegel exercises help restore tone to the muscles holding the uterus in place.
  • Medicine. Your doctor may give you medicine to help with endometriosis. Over-the-counter pain medicines taken during your period also may help with pain and bleeding. Hormonal birth control, such as the pill, shot, or vaginal ring, or a hormonal intrauterine device (IUD) may help with irregular or heavy vaginal bleeding or periods that last longer than usual.
  • Vaginal pessary (for uterine prolapse). A pessary is a rubber or plastic donut-shaped object, similar to a diaphragm used for birth control. The pessary is inserted into the vagina to hold the uterus in place. Uterine prolapse happens when the uterus drops or “falls out” because it loses support after childbirth or pelvic surgery.
  • Surgery. You and your doctor may choose to try a surgery that involves smaller or fewer cuts than a hysterectomy. The smaller cuts may help you heal faster with less scarring. Depending on your symptoms, these options may include:
    • Surgery to treat endometriosis. Laparoscopic surgery uses a thin, lighted tube with a small camera. The doctor puts the camera and surgery tools into your pelvic area through very small cuts. This surgery can remove scar tissue or growths from endometriosis without harming the surrounding healthy organs such as ovaries. You may still get pregnant after this surgery.
    • Surgery to help stop heavy or long-term vaginal bleeding.
      • Dilation and curettage (D&C) remove the lining of the uterus that builds up every month before your period. Often, a hysteroscopy is done at the same time. Your doctor inserts the hysteroscope (a thin telescope) into your uterus to see the inside of the uterine cavity. D&C may also remove noncancerous growths or polyps from the uterus. After the D&C, a new uterine lining will build up during your next menstrual cycle as usual. You may still get pregnant after this surgery.
      • Endometrial ablation destroys the lining of the uterus permanently. Depending on the size and condition of your uterus, your doctor may use tools that freeze, heat or use microwave energy to destroy the uterine lining. This surgery should not be used if you still want to become pregnant or if you have gone through menopause.
    • Surgery to remove uterine fibroids without removing the uterus. This is called a myomectomy. Depending on the location of your fibroids, the myomectomy can be done through the pelvic area or through the vagina and cervix. You may be able to get pregnant after this surgery. If your doctor recommends this surgery, ask your doctor if a power morcellator will be used. The FDA has warned against the use of power morcellators for most women.
    • Surgery to shrink fibroids without removing the uterus. This is called myolysis. The surgeon heats the fibroids, which causes them to shrink and die. Myolysis may be done laparoscopically (through very small cuts in the pelvic area). You may still get pregnant after myolysis.
  • Treatments to shrink fibroids without surgery. These treatments include uterine artery embolization (UAE) and magnetic resonance (MR)-guided focused ultrasound (MRUS). UAE puts tiny plastic or gel particles into the vessels supplying blood to the fibroid. Once the blood supply is blocked, the fibroid shrinks and dies. MR(f)US sends ultrasound waves to the fibroids that heat and shrink the fibroids. After UAE or MR(f)US, you will not be able to get pregnant.
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Complications

Complications during a hysterectomy are divided into: 

A. Intraoperative complications
  • Bleeding – The most common sites of bleeding during vaginal hysterectomy are uterine vessels, Utero-ovarian ligament, and vaginal cuff.
  • Ureteral injury- The incidence of ureteral injury is about 0.5 percent.
  • Bladder injury- The prevalence of bladder injury during vaginal hysterectomy is up to 1.2 percent. It increases with risk factors like prior pelvic surgeries and concomitant bladder surgery.
  • Bowel injury- The risk is approximately 0.4 percent.
  • Nerve injuries- Most commonly, the femoral nerve, peroneal, and tibial nerves are affected by the retractors or by malposition of the legs on the stirrups.
  • Conversion to laparotomy- Instances like unexpected large pelvic masses, adhesions, and Hemorrhage unable to identify and control can increase the chances of conversion to abdominal hysterectomy.
  • Adverse reactions to anesthetics
B. Postoperative complications
  • Ileus
  • Bowel obstruction.
  • Vaginal cuff dehiscence
  • Infections like vaginal cuff cellulitis and pelvic abscess
  • Fistulas-vesicovaginal, ureterovaginal, and rectovaginal fistulas
  • Prolapse of the pelvic structures like a fallopian tube.
  • Clamping and cutting the infundibulopelvic ligament.
  • Separating the uterine vessels.
  • Separating the uterosacral-cardinal ligament complex and during the closure of vaginal apex.

N.B. The details of the management of complications of hysterectomy are outside the scope of this article.

References