Refference Study

Surgical Approach to Hysterectomy for Benign Gynaecological Disease

Lecturer: dr. Darto, SpOG Presented by : dr. Bambang Triono Cahyadi

DEPARTMENT OF OBSTETRIC AND GYNECOLOGY FK UNS/RSUD DR.MOEWARDI SURAKARTA 2012 I. Introduction

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Hysterectomy involves the removal of the uterine body and cervix, referred to as total abdominal hysterectomy, or the removal of the uterine body only at or below the level of the isthmus, referred to as supracervical hysterectomy. Hysterectomy may also be associated with removal of the ovaries and fallopian tubes (bilateral salpingooophorectomy). (Kives et al, 2010) Hysterectomy is the most common nonpregnancy-related major surgery performed on women in the United States. Reasons for choosing this operation are treatment of uterine cancer and various common noncancerous uterine conditions such as fibroids, endometriosis, prolapse that leads to disabling levels of pain, discomfort, uterine bleeding, and emotional stress. Although this procedure is highly successful in curing the disease of concern, it is a surgical alternative with the accompanying risks, morbidity, and mortality that an operative procedure carries and it leads to sterility in women who are premenopausal. The patient may be hospitalized for several days and may require 6-12 weeks of convalescence. Complications, such as excessive bleeding, infection, and injury to adjacent organs, also may occur. (Berek, 2012) II. Indication A. Benign Disease
1. Abnormal Uterine Bleeding

Evaluation of a woman with abnormal uterine bleeding (AUB) should rule out non-gynaecologic etiologies, reproductive tract problems such as cervical polyps, endometrial neoplasia and pregnancy-related causes. Hysteroscopy is particularly useful in the diagnosis of endometrial polyps and submucosal fibroids, which can easily be missed at the time of an office biopsy or curettage. One or more medical options should be presented to women with AUB prior to considering surgical treatment. Depending on the severity of the disease, the age of the patient, her cultural beliefs, and her desire to preserve fertility, an endometrial ablation or a hysterectomy can also be considered. The surgeon or gynaecologist who is prepared to perform a hysterectomy to treat AUB must be fully knowledgeable about all the medical alternatives and surgical management options and inform the patient of her choices of treatment. In patients where medical treatment or conservative surgery has failed to reduce and improve the bleeding, hysterectomy is associated with a high level of satisfaction. (Lefebvre et al, 2012) 2. Uterine Leiomyomas
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Uterine leiomyomas are the most common gynaecological tumour and are present in 30 percent of women of reproductive age. Treatment must be individualized based on symptoms, the size and rate of growth of the uterus, and the patients desire for fertility. The indications for hysterectomy in a completely asymptomatic patient are few and include rapidly enlarging fibroids or enlarging fibroids after menopause when concerns of leiomyosarcoma are raised. A recent study shows no increase in perioperative complications in women with a uterus greater than 12-week size compared to women with a small uterus. Hysterectomy need not be recommended as prophylaxis against increased operative morbidity associated with future growth. In patients who have completed childbearing, hysterectomy is indicated as a permanent solution for leiomyomas causing substantial bleeding, anemia, or pelvic pressure. When considering hysterectomy for menorrhagia presumed related to fibroids, other causes of menorrhagia should be ruled out. Endometrial sampling, when indicated, should be performed to exclude endometrial lesions. The possibility of a coagulopathy or thyroid dysfunction should be considered.Since leiomyomas rarely cause pain, other causes of pelvic pain should be excluded. Removing a fibroid uterus should not be expected to alleviate symptoms of incontinence. GnRH agonists have been shown to shrink fibroids to 50 percent of their initial volume, with the greatest effect apparent after 12 weeks of treatment. However, the use of GnRH agonists is limited due to their cost and hypoestrogenic side effects, including a decrease in bone mineral density. Treatment should be restricted to a three- to six-month interval, following which regrowth of fibroids is expected within 12 weeks. The use of GnRH agonists along with estrogen replacement is still considered investigational. GnRH agonists may be given preoperatively to decrease the size of the fibroids, reduce symptoms, and increase the patients hemoglobin preoperatively. The advantage of myomectomy is the preservation of the uterus. The desire for children is the most common indication for myomectomy instead of hysterectomy. Most patients presenting with infertility and associated uterine fibroids are found by additional investigations to have other causes for the infertility. A higher risk of blood loss and greater operative time can be expected with myomectomy than hysterectomy, although the risk of ureteric injury may be decreased with myomectomy. There is a 15 percent recurrence rate of fibroids, and 10 percent of women undergoing a myomectomy will eventually require a hysterectomy within 10 years. In discussing the planned myomectomy, patients should be informed about the risk of
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eventually requiring a hysterectomy, dependent on intraoperative findings and course of surgery. In view of the increased morbidity of an abdominal approach for myomectomy, there are very limited indications for this operation. Hysteroscopy has been proven effective for diagnosis and management of submucous fibroids. As with other approaches for myomectomy, there appears to be a 10 to 20 percent risk of requiring further intervention within five to 10 years of resection. Myolysis refers to the technique where an attempt is made to disrupt, diminish or abolish the blood supply to the fibroids in order to deprive them of nutrients, sex hormones, and growth factors, and cause shrinkage or complete degeneration of the myomas. Several techniques have been used since 1986, including the Nd:YAG laser and bipolar or monopolar electrosurgery. These procedures work best in the presence of fewer than three fibroids, where the largest fibroid measures less than 10 centimetres in diameter, and when the patient has been pretreated with a GnRH agonist for three months prior to surgery. Treatment is more effective when performed with concomitant endometrial ablation, and is not recommended for women who wish to retain their fertility. At least three uterine ruptures in pregnancy following Uterine artery laparoscopic occlusion with clips or by transfemoral embolization to treat symptomatic fibroids was introduced during the last decade. Small series addressing the feasibility, complication rates, clinical outcome and patient satisfaction have been in general encouraging, although followup is limited. However, the durability of the treatment, the effect on hysterectomy rates, and the cost-benefit of the procedure and its impact on fertility and hormone homeostasis have not yet been established. (Lefebvre et al, 2012) 3. Endometriosis Medical treatment of endometriosis is frequently associated with metabolic and symptomatic side effects and has limited success in controlling symptoms due to adhesive disease or damaged pelvic organs. Conservative surgery, with minimal disruption of the pelvic organs, may be relevant where fertility is a consideration, but has limited effect in long-term control of symptoms as indicated by cumulative recurrence rates of 13 percent at three years and 40 percent at five years. There is Level I evidence that conservative ablative surgery is helpful for treatment of infertility in patients with minimal to mild endometriosis and control of pelvic pain in patients with minimal to moderate endometriosis.
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The ultimate goal of treatment of endometriosis is the relief of symptoms, without incurring side effects. The decision to proceed to hysterectomy is a major step. This decision should be guided by three factors: a) the presence of severe symptoms, particularly intractable pain, after other possible causes of pain have been treated or ruled out; b) the failure of other treatments or intolerance to their side effects; c) future pregnancy is no longer possible or desired. Whether to preserve the ovaries when performing a hysterectomy for endometriosis is controversial. A large retrospective study compared recurrence of symptoms after hysterectomy with or without ovarian conservation with a mean followup of 58 months. In women with ovarian conservation, 62 percent had recurrent symptoms and 31 percent required further surgery, versus 10 percent and 3.7 percent in women who had had bilateral oophorectomies. Several studies have found higher reoperation rates associated with more severe disease. Women who have recurrent symptoms after hysterectomy and castration are likely to have persistent disease, most often involving the bowel. In patients with severe disease who request definitive treatment for their symptoms, it is generally recommended that both ovaries and all visible endometriosis be removed, including bowel disease if symptomatic. Bilateral oophorectomy cannot, however, be routinely recommended when performing a hysterectomy for earlier stage endometriosis after all visible lesions have been removed and the remaining ovarian tissue appears to be normal.The effects of bilateral oophorectomy should be discussed preoperatively,along with the issue of symptom recurrence if ovaries are preserved, so that a surgical plan can be developed with the patients input. If bilateral oophorectomy is performed, immediate hormonal replacement therapy should then be given in adequate dosage without fear of exacerbation of the disease. A thorough review of medical and surgical treatments can be found in the Canadian Consensus Conference on Endometriosis. (Lefebvre et al, 2012) 4. Pelvic Relaxation Symptoms attributable to prolapse include a sensation of protrusion, pelvic pressure, urinary incontinence, rectal discomfort, and discomfort related to the irritation of externalized mucosal tissues. Mild to moderate degrees of prolapse in the absence of complaints should rarely be corrected. The primary objectives of surgical treatment for symptomatic genital prolapse are the relief of symptoms, the reconstruction of pelvic
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supports, and the restoration of normal anatomy. Removing the uterus is only part of any surgical procedure for pelvic relaxation. Concomitant correction of any cystocele or rectocele must be undertaken to restore support of the vagina. Attention to support of the vagina and obliteration of a potential enterocele will minimize the risks of posthysterectomy vault prolapse. Preoperative assessment should include careful physical examination to exclude intra-abdominal and pelvic lesions. The extent of the pelvic relaxation may then be evaluated. Urinary incontinence should be assessed. Therapeutic alternatives may include estrogen replacement, pelvic floor exercises, and pessaries. The patient should be presented with options as alternatives, understanding the limitations of medical management. The long-term use of a vaginal pessary may be associated with vaginal erosion. Such patients should be monitored carefully with regular vaginal examinations. There are no successful surgical alternatives to advanced uterine prolapse, other than hysterectomy and pelvic floor repair. Uterine suspension has been found generally ineffectual. In patients with an isolated cystocele, coincidental hysterectomy for the removal of a non-prolapsing uterus is of uncertain benefit. (Lefebvre et al, 2012) 5. Benign Adnexal Mass A thorough examination of the medical literature reveals a lack of data addressing the use of incidental hysterectomy when removing a benign adnexal mass. If a bilateral oophorectomy is indicated for a benign ovarian condition such as endometriosis, the possibility of hysterectomy should be discussed with the patient before the surgery and a management plan established. Whether there are any benefits of concomitant hysterectomy at the time of bilateral oophorectomy for conditions other than ovarian cancer, where no other indications exist, remains unknown. Options must be individualized. The added surgical risks of hysterectomy in addition to the removal of the adnexal mass include infection, ureteral trauma, and blood loss. The patients desire for future fertility, previous menstrual history, and potential implications of hormone replacement therapy are other important factors to be considered and discussed with the patient. (Lefebvre et al, 2012) 6. Chronic Pelvic Pain Pelvic pain should be carefully investigated prior to considering a hysterectomy. Investigations should include a careful gynaecologic examination, pelvic ultrasound, and evaluation of urinary, gastrointestinal, and musculoskeletal sources for pain as
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indicated by the presenting symptoms. A multidisciplinary approach should be undertaken. Psychiatric evaluation should be offered, as there is an association between psychosomatic factors and a history of sexual abuse. Medical management may include use of non-steroidal antiinflammatory drugs, oral contraceptives, danazol, high-dose progestins or GnRH analogues. Laparoscopy should be considered to document and treat identifiable causes of pain. Any underlying cause should be addressed specifically. Treatment should be individualized. There is a case for hysterectomy when an underlying disease, amenable to hysterectomy, is demonstrated and the patient has completed her family. In the patient suffering exclusively from dysmenorrhea, hysterectomy may offer relief. There is little evidence to support the indications for hysterectomy in a patient with idiopathic pelvic pain and a high likelihood that the pain will persist following surgery. (Lefebvre et al, 2012) B. Preinvasive Disease 1. Hysterectomy is usually indicated for endometrial hyperplasia with atypia 2. Cervical intraepithelial neoplasia in itself is not an indication for hysterectomy
3. Simple hysterectomy is an option for treatment of adenocarcinoma in situ of the cervix

when invasive disease has been excluded. (Lefebvre et al, 2012) C. Invasive Disease Hysterectomy is an accepted treatment or staging procedure for endometrial carcinoma. It may play a role in the staging or treatment of cervical, epithelial ovarian, and fallopian tube carcinoma. (Lefebvre et al, 2012) D. Acute Conditions 1. Hysterectomy is indicated for intractable postpartum hemorrhage when conservative therapy has failed to control bleeding 2. Tubo-ovarian abscesses that are ruptured or do not respond to antibiotics may be treated with hysterectomy and bilateral salpingo-oophorectomy in selected cases
3. Hysterectomy may be required for cases of acute menorrhagia refractory to medical or

conservative surgical treatment (Lefebvre et al, 2012) E. Other Indications Consultation with an oncologist or geneticist is recommended when considering hysterectomy and prophylactic oophorectomy for a familial history of ovarian cancer (Lefebvre et al, 2012)
F. Surgical approach 7

The vaginal route shoe should be considered as a first choice for all benign indications. The laparoscopic approach should be considered when it reduces the need for a laparotomy (Lefebvre et al, 2012)

III. Type of Hysterectomy Depending on the reason for doing hysterectomy, different types of hysterectomies are performed. These include: A. Abdominal Hysterectomy Traditionally, abdominal hysterectomy has been used for gynaecological malignancywhen other pelvic disease is present, such as endometriosis or adhesions or if the uterus is enlarged. It remains the fallback option if the uterus cannot be removed by another approach. (Johnson et al, 2005) 1) Total abdominal hysterectomy involves removal of the uterus and cervix through an abdominal incision. 2) Supracervical or subtotal hysterectomy is removal of the uterus through an abdominal incision, while sparing the cervix. 3) Radical hysterectomy is extensive surgery that, in addition to removal of the uterus and cervix, might include removal of lymph nodes, loose areolar tissue near major blood vessels, upper vagina, and omentum.
4) Oophorectomy and salpingo-oophorectomy: Oophorectomy is the surgical

removal of the ovary and salpingo-oophorectomy is the removal of the ovary and the fallopian tube. (Kovac, 2004) B. Vaginal hysterectomy is removal of the uterus and the cervix through the vagina. Vaginal hysterectomy was originally used only for prolapse,but it is now also used for menstrual abnormalities when the uterus is of fairly normal size. Vaginal hysterectomy is regarded as less invasive than abdominal hysterectomy. (Johnson et al, 2005)
C. Laparoscopy hysterectomy

In laparoscopic hysterectomy, at least part of the operation is done laparoscopically; this method requires greater surgical expertise than the vaginal and abdominal methods. The proportion of hysterectomies performed laparoscopically has gradually increased, and, although the procedure takes longer, proponents have emphasised several advantages: the opportunity to diagnose and treat other pelvic diseases (such as endometriosis) and to carry out adnexal surgery including the removal of the ovaries;
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the ability to secure thorough intraperitoneal haemostasis at the end of the procedure; and a rapid recovery time. Three subcategories of laparoscopic hysterectomy have been described.
1)

Laparoscopic assisted vaginal hysterectomy (LAVH),

the procedure is done partly laparoscopically and partly vaginally, but the laparoscopic component does not involve uterine vessel ligation. In uterine vessel ligation 2) laparoscopic hysterectomy (LH(a)), although the uterine vessels are ligated laparoscopically, part of the operation is done vaginally. 3) In total laparoscopic hysterectomy, the entire operation (including suturing of the vaginal vault) is done laparoscopically. This method of laparoscopic hysterectomy requires the highest degree of surgical skill and is currently done only by a very small proportion of gynaecologists. It has been unclear whether total laparoscopic hysterectomy offers benefits over other forms of hysterectomy. (Johnson et al, 2005)

Figure 1. Types of Hysterectomy IV. Approaching the Uterus: Abdominally or Vaginally

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The uterus may be removed abdominally or vaginally or by a combination of the two routes. Abdominal approach may further be categorized as open abdominal or laparoscopic. Although abdominal approach continues to be the most common approach worldwide, uterine access by the vaginal route is associated with fewer complications, a shorter hospital stay, faster recovery and lower costs. Most patients with gynecologic malignancies are operated by open abdominal route, though laparoscopic and robotic surgical techniques are increasingly being used for endometrial and cervical cancer surgery. Significant uterine enlargement and/or fixity, adnexal fixation and obliteration of the Pouch of Douglas are some other factors suggesting preference for abdominal approach. (Duhan, 2012)

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Figure 2. (Kovac. 2004)

V. Techniques A. Total abdominal hysterectomy This is, by far, one of the commonest gynaecological major operations. Abdominal hysterectomies are usually performed for large uterine fibroids, endometriosis and dysfunctional uterine bleeding etc. A further extension to total
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abdominal hysterectomy is the Radical hysterectomy which is reserved for carcinoma of the cervix or uterus. For total abdominal hysterectomy, the patient is placed in dorsal position. Incision to the abdomen is made vertically or transversely according to the indication and size of the uterus. After opening the peritoneal cavity, abdominal sponges are used to pack the bowel and Balfour retractor is applied to have good access of the operating field. Uterus is grasped with medium sized clamps and pulled out of the incision to expose the anterior surface of the uterus. The round ligament on each side is identified and clamped using firm grasping clamps like Kocher or Spencerville. Anterior fold of broad ligament is opened starting from the round ligament. After cutting and ligating the round ligament on each side, a window is created where peritoneum is thin with the index finger to clamp the infundibulo pelvic ligament which is then cut and transfixed. Urinary bladder is pushed down after opening the utero vesical fold completely. It is important to carefully identify the correct plane and reflect the bladder from the centre of the cervix as lateral reflection could lead to inadvertant bleeding. Next step is to clamp the uterine arteries at the level of internal cervical os with heavy clamps like Roberts or Mangots hugging on to the cervix and ligating them carefully. Then the cardinal ligament are clamped, cut and ligated, going medially towards the cervix to avoid injury to the ureters till the vagina is reached. The uterus is removed and the anterior and posterior walls of the cut vagina are grasped by Volsellum forceps. The vagina is closed with either figure of eight sutures or in button hole fashion in which vagina is left open. (Masheer and Najmi, 2012)
B. Supra cervical hysterectomy

One of the commonest indications for performing supra cervical hysterectomy is Endometriosis where there is frozen pelvis and difficulty in accessing the area below the level of uterine arteries. In supra cervical or subtotal hysterectomy, body of the uterus is removed in exactly the same fashion as the total abdominal hysterectomy until the level of ligation of uterine arteries. After this level, the uterine body is cut from the cervix and haemostatic sutures are taken on the cut edge of the left over cervix. Some surgeons also prefer to perform the conization of the endo cervix in order to reduce the chances of cervical cancer. Women undergoing supra cervical hysterectomy are advised to
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follow up with their Pap smear in the similar fashion as before the surgery. (Masheer and Najmi, 2012) C. Radical hysterectomy Patient selection is critical for radical hysterectomy. Young, thin patients with early stage carcinoma of cervix are usually the best candidates. Obesity is at times associated with carcinoma of the endometrium and is a relative contraindication. Preoperative preparation and informed consent are the prerequisite as in any other surgery. Patient is placed in dorsal position. Abdominal incision is midline as it gives excellent access to pelvis and Para aortic lymph nodes are easily approachable when required. After opening the peritoneal cavity, peritoneal cytology is taken. Large sponges are used to pack the bowel and Balfour retractor is applied to have good view of the pelvis. If the patient is obese Book Walter retractor provides excellent access to the pelvis. In radical hysterectomy round ligament is clamped on each side closed to the pelvic side wall and broad ligament is opened superiorly up to the paracolic gutter and the incision is extended inferiorly and medially to open the Utero-vesical fold. Laterally non toothed forceps can be used to freed the peritoneum from the adjacent soft tissue and reaches to the triangle bounded by urinary bladder medially, iliac vessels laterally and the pelvis inferiorly. If the ovaries are to be conserved the index finger is placed on the medial side of the ovary and then pierces the peritoneum through the thinnest part and clamp is applied and infundibulopelvic ligament is then cut. The same steps are repeated on the other side. Uterine artery needs to be skeletonized so that it is completely separated from the ureters and obliterated hypogastric artery should be identified at this point. The uterine vessel should be accurately clamped with Meigs forceps close to its origin at the internal iliac artery. Now make sure that bladder is separated from the cervix. This can be easily done by pushing down the utero vesical fold with swab folded on the index finger. Next important step is the identification and division of the roof of the ureters tunnel. Usually tissue forceps are placed medially to uterine arteries and canal roof is clamped and cut, exposing the ureters and this pedicle is tied. Next step is separation of ureters laterally from the upper vagina, this will expose cardinal ligament. Posteriorly peritoneum is opened just below the cervix, revealing soft tissue between vagina and
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the rectum. It is important to work under direct vision keeping an eye on the ureter. Make sure that uterosacral ligaments are free and away from the ureters and Zippelin forceps are applied and uterosacrals are cut. Another Zippelin clamp is applied on the cardinal ligament, it is cut and ligated and uterus is removed. Vault is closed with running suture or button hole fashion but caution must be applied on reviewing the ureters. Radical hysterectomy is usually accompanied by dissection of pelvic lymph nodes. Some authorities prefer to do it before performing radical hysterectomy and some do it afterwards. (Masheer and Najmi, 2012)
D. Total vaginal hysterectomy

Patient is placed in dorsal lithotomy position with buttocks at the end of table. Two Jacobss tenacula are used to grasp the anterior and posterior lip of cervix. Simple saline solution or adrenaline with the dilution of 1:100000 is injected into the vaginal mucosa at its junction with the cervix. After injecting the solution the Mucosa is incised with scalpel around the entire cervix. Index finger is used to dissect the bladder up to the peritoneal vesico uterine fold. Alternatively, sharp dissection can also be done for this step. A right angle retractor is placed under the vaginal mucosa and bladder to elevate them and the peritoneal fold is incised with Mayos scissors. Cervix is lifted up with Jacobss tenacula and peritoneum of cul-de-sac is incised. A curved Heaney clamp is placed in posterior cul de sac. The clamp is applied next to cervix and uterosacral ligaments are cut with mayos scissors and ligated. This suture not only ligates the uterosacral ligament but plicates the pedicle to vaginal cuff. The cardinal ligament is clamped adjacent to lower uterine segment and ligated.The uterine arteries are clamped, cut and ligated in the similar fashion close to the junction of lower uterine segment with internal cervical os. Uptil this step ligating and securing the pedicles is relatively easy as they are easily approachable surgically. The next step is clamping and ligating the tubo- ovarian ligaments. This step can be difficult sometimes especially if the uterus is enlarged. In such circumstances, either the fundus of the uterus can be delivered outside or uterus can be bisected longitudinally in the midline and each pedicle can then be secured separately. Heaney clamps are applied to tubo- ovarian round ligament either directly or by following any of the above methods and uterus is then removed through the vagina.
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Re-peritonealization is carried out with purse string sutures starting from anterior peritoneal edge and continued down through the uterosacral cardinal ligament pedicles and the vaginal mucosa. Vaginal cuff is sutured with running locking stitch and is left open. (Masheer and Najmi, 2012)
E. Laparoscopic hysterectomy

Laparoscopic hysterectomies were introduced as a replacement of abdominal hysterectomy with the benefit of avoiding incision of the abdomen. Patient should be placed in dorsal lithotomy position. Uterine manipulator is inserted according to the size of introitus and parity of the patient. Dilatation of cervix is rarely required to place the uterine manipulator. Foley catheter is inserted into the urinary bladder. The best way to minimize laproscopic injuries is to insert primary Trocars with maximum care. Most of the gynecologists prefer closed entry technique in which carbon dioxide is insufflated via Verses needle into the peritoneal cavity. Other method is open technique in which a small incision is made into the rectus sheath and has direct access to peritoneal cavity. The incision for laparoscopy should be vertical from the base of the umbilicus as it is the thinnest part of the abdominal wall. The Verses needle should be sharp and its spring mechanism should be properly working. Lower abdominal wall should be stabilized by grasping and holding it upwards with one hand so that veress is inserted perpendicular to the skin with the other hand. Two audible clicks are usually heard when veress pierces the fascia and the peritoneum respectively. In case of difficult or failed attempts either the open method or the palmers point entry should be approached. For primary trocar insertion intra-abdominal gas pressure should be 20-25 mmHg which is later reduced to 12-15 mmHg for surgery. The infunibulo pelvic ligament is desiccated with bipolar grasper. It is very important to stay close to the ovaries and transect them using Harmonic scalpel. During this step uterine manipulator should be pushed upwards and on opposite side to provide maximum visualization and good working space. After this step, round ligament is transected in order to separate the leaves of broad ligament with Harmonic scalpel. This step differs from abdominal hysterectomy where round ligaments are transected as the first step of surgery. Identification of
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correct plane is vital.i.e.where peritoneum is loose and easily separable, uterovesical fold is opened anteriorly to mobilize the bladder down. It should be carefully done in patients with previous cesarean sections and uterine surgeries. Once the bladder is down, ureters are retracted laterally, so tha uterine arteries can be desiccated with bipolar grasper and transected with harmonic scalpel Two small incisions are made with Harmonic scalpel medial to uterine vessels so as to free the cervix from the transcervical ligaments. Vaginal fornices can be identified by pushing in upward direction with the uterine manipulator and Harmonic scalpel is used to cut the cervix from the vagina. Uterus is then removed and a glove with sponges is placed into the vagina to maintain pneumoperitoneum. Vaginal cuff is closed in a running fashion, with almost one centimeter thickness including vaginal mucosa and pubocervical and rectovaginal fascia. It is recommended to suture the rectus sheath of all non-midline port over 7mm and midline port greater than 10mm to avoid hernia formation (Masheer and Najmi, 2012) VI. Outcome of Hysterectomy TAH Duration of surgery (min) Duration of anaesthesia (min) Stay in hospital (days) Sick leave/recovery (days) Peroperative blood loss (mL) (Ottosen C & Lingman, 2000) 68 110 3.7 28.1 225 VH 81 118 2.8 21.3 287 LaVH 102 146 3.1 19.7 311

VII.

Comparison of Different Approaches to Hysterectomy Vaginal Hysterectomy Compared with Abdominal Hysterectomy
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Shorter duration of hospital stay Faster return to normal activity Fewer febrile episodes or unspecific infections Vaginal Hysterectomy Compared with Laparoscopic Hysterectomy Shorter operating time Laparoscopic Histerectomy Compared with Abdominal Hysterectomy Shorter duration of hospital stay Faster return to normal activity Smaller drop in hemoglobin Lower intraoperative blood loss Fewer wound or abdominal wall infections Longer operating time Higher rate of lower urinary tract (bladder and ureter) injuries (Nieboer et al, 2009) VIII. Complications of Hysterectomy
a) Anaesthetic (cardiorespiratory) and surgical problems like hemorrhage, injuries to

surrounding viscera are avoided by appropriate preoperative evaluation and

b) ensuring senior and multidisciplinary help. c) Rarely, postoperative ileus and destruction. .

d) Urinary tract infection. e) Bleeding per vaginum may occur after a week of surgery due to the vaginal sutures f) falling off or infection. g) Wound infection and inflammation.
h) Venous thromboembolism: Early ambulation, adequate hydration and leg stockings are

some of the non pharmacological measures that help prevent thromboembolism. (Yi et al, 2011)

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REFERENCES

Berek JS, Berek & Novaks Gynecology Fifteenth Edition. 2012 Lippincott Williams & Wilkins Duhan 2012,Techniques of Hysterectomy, in Hysterectomy, eds Al-Hendy A, Sabry M, InTech, Croatia.

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Johnson N, Barlow D, Lethaby A, Tavender E, Curr L, Garry R. Methods of Hysterectomy: Systemic Review and Meta-analysis of Randomised Controlled Trials, BMJ. 2005 June 25; 330(7506): 1478 Kives S, Lefebvre G, Wolfman W, Leyland N, Allaire C, Awadalla A, Best C, Leroux N, Potestio F, Rittenberg D, Soucy R, Singh S. Supracervical hysterectomy. J Obstet Gynaecol Can. 2010 Jan;32(1):62-8. Kovac SR. Clinical opinion: guidelines for hysterectomy. Am J Obstet Gynecol. Aug 2004;191(2):635-40 Lefebvre G, Allaire C, Jeffrey J, Vilos G. SOGC Clinical Guidelines: Hysterectomy, J Obstet Gynaecol Can 2002;24(1):37-48. Masheer S and Najmi N, Peripartum Hysterectomy versus Non Obstetrical Hysterectomy, in Hysterectomy, eds Al-Hendy A, Sabry M, InTech, Croatia. Nieboer TE, Johnson N, Lethaby A, Tavender E, Curr E, Garry R, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. Jul 8 2009;CD003677 Ottosen C, Lingman G. Three Methods for Hysterectomy: a Randomised Prospective Study of Shoirt Term Outcome, Br J Obstet Gynuecol 2000; 107:138-1385 Yi Y, Zhang W, Guo W, Su Y, Laparoscopic-assisted vaginal hysterectomy vs abdominal hysterectomy for benign disease: a meta-analysis of randomized controlled trials, Eur Jour Obs Gyn Repr Bio 159 (2011) 118

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