HYSTERECTOMY
A hysterectomy is a surgical procedure that involves removing a woman's uterus (also known as the womb), which is where a fetus would develop during pregnancy. This surgery can sometimes also involve the removal of other related structures such as the fallopian tubes (a bilateral salpingectomy), ovaries (oophorectomy), and the cervix (this is typically included unless a "supracervical" or "partial" hysterectomy is performed).
There are a few different types of hysterectomies, depending on what structures are removed:
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Total hysterectomy: This is the removal of the entire uterus, including the cervix. Most hysterectomies are total.
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Subtotal or partial hysterectomy: The upper part of the uterus is removed but the cervix is left in place.
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Radical hysterectomy: This is performed when certain cancers are present. The uterus, cervix, the tissue on both sides of the cervix, and the upper part of the vagina are removed.
A hysterectomy can be performed in a few different ways:
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Abdominal hysterectomy: This involves making a large incision in the abdomen to remove the uterus.
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Vaginal hysterectomy: This involves making an incision in the vagina to remove the uterus.
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Laparoscopic hysterectomy: This involves making several small incisions in the abdomen. A laparoscope (a thin, lighted tube with a camera on the end) is inserted into one of the incisions. The uterus is removed piece by piece through the small incisions.
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Robotic hysterectomy: This is similar to a laparoscopic procedure but it is performed with a machine controlled by the surgeon.
The procedure is often recommended when other treatment options have not worked or are not possible, and conditions that might require a hysterectomy include certain types of cancer (like uterine, ovarian or cervical cancers), endometriosis, uterine fibroids, chronic pelvic pain, and uterine prolapse.
Anesthetic Implications for Hysterectomy
Anesthesia type: General, neuraxial
Airway: ETT
Preoperative:
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The patient may be hypovolemic from blood loss or bowel prep
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The blood supply to the pelvis is largely derived from the internal ileac (hypogastric) artery
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Extensive collateral circulation to pelvic viscera organs can cause significant bleeding during pelvic dissection or obstetric hemorrhage
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Sensory innervation from the pelvic viscera (including the uterus) arises from T10-L4 spinal cord segments
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Ventilatory alterations from laparoscopy: Decreased functional residual capacity, increased airway pressures, decreased lung compliance, and right mainstem intubation
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Carbon dioxide absorption during laparoscopic cases can be associated with increased plasma catecholamines
Intraoperative:
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Prevent nerve injuries
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Monitor for blood loss
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Maintain hemodynamic stability
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Abdominal incisions have increased insensible fluid loses
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Position for abdominal hysterectomy: supine
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Position for total laparoscopic and robotic hysterectomy: Supine with steep Trendeleburg
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Position for vaginal hysterectomy: Lithotomy
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Duration for abdominal and vaginal hysterectomy: 1-3 hours
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Duration for total laparoscopic and robotic hysterectomy: 2-6 hours
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EBL for elective hysterectomy: 200-600 mL
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Injection of vasopressin into uterus can reduce blood loss
Postoperative:
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A cystoscope may be inserted to assess for bladder perforation
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PONV prophylaxis
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Pain management
Complications:
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Infection
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Bleeding
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Urinary incontinence
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Injury to nearby organs (bladder, ureters, pelvic structures)
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DVT
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PE
Sources:
Longnecker, D. E., Brown, D. L., Newman, M. F., & Zapol, W. M. (2012). Anesthesiology, 2nd ed.
Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice.
Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.).
Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult.