Hysterectomy

By
Dr/ Hanan morsy

 INTRODUCTION:
- Hysterectomy is a common gynecological operation
worldwide. It is a major surgery, which leads to
significant morbidity and mortality, hence, there must
be a justifiable indication before the procedure is
undertaken. Hysterectomy, a word that originates from
the Greek word hysteros which means uterus, was first
coined in 1889.

 Definition Of Hysterectomy:
- Hysterectomy is the removal of the uterus and, in most
cases, the cervix (neck of the uterus). When ovaries and
tubes are also removed along with the uterus, the
procedure is known as hysterectomy and bilateral
salpingo – oophorectomy.
 Indications:
1- Benign conditions where uterus is primarily involved:
 Dysfunctional uterus bleeding (DUB):
- It is heavy, prolonged or frequent bleeding of uterine
origin in the absence of infections, tumours, pregnancy
or associated medical conditions. (I.e., menorrgagia,
metrorrhagia, or polymenorrhoea).

 Adenomyosis:
- Tissue lining the uterus grows abnormally into the
muscle wall of the uterus. In the case when the uterus is
bulky and presents with menorrhagia and
dysmenorrhea total hysterectomy is done in almost all
the cases.

 Uterine prolapse:
- Symptomatic vaginal relaxation, uterine decencies, and
prolapse are common indications for hysterectomy.

 Uterine leiomyomas:
- Common, non-cancerous growths (tumors) that grow on
or within the uterus. Some may not even be noticed
while others may cause excessive bleeding, pressure on
nearby organs, or grow rapidly. Women with fibroids
usually have more than one. Fibroids can make the
uterus large to the point where an abdominal
hysterectomy would have to be considered. This
accounts for about 30% of hysterectomies.
 Obstetric problems:
- Uncontrolled post partum hemorrhage, uterine rupture,
uterine inversion and interstitial abdominal or cervical
pregnancy may require hysterectomy to prevent death
from hemorrhage

2- Benign conditions:
 Pelvic inflammatory disease (PID):
- In parous women over 35 years of age, total
hysterectomy is preferred if there is fixed retro-
displacement with adnexal masses or if there is
persistent chronic cervitis.
 Pelvic endometriosis:
- Patients with disseminated endometriosis cannot be
treated locally and hysterectomy is required.
 Ectopic pregnancy:
- For cervical, interstitial or abdominal pregnancy,
whenplacenta cannot be removed without removing
uterus.

3- Neoplastic diseases:
 Cervical intraepithelial neoplasia:
- Where family is complete and/or followcheck- up is not
possible hysterectomy is indicated. Vaginal
hysterectomy ispreferred unless contraindicated by
adnexal disease, uterine enlargement, or otherreasons.
  Early invasive cervical carcinoia:
- Once the carcinoma becomes invasive, hysterectomy is
the treatment of choice. Endometrial adenomatous
hyperplasia, adenocarcinoma and sarcoma of uterus
areindications for hysterectomy.

 Ovarian and fallopian tube neoplasms:

- These are rare cases where hysterectomyshould be
preferred.

 Trophoblastic disease:
- In high-risk cases, Abdominal hysterectomy with
bilateralsalpingo- oophorectomy is to be followed
by multi-drug therapy.

 Other causes:
- Malignant disease of other pelvic organs, in
postmenopausalcervical stenosis with recurring
pyometra, recurrent hematometra and possibly
endometriosis. Hysterectomy is also used to be done as
part of surgical sterilization.

 Types Of Hysterectomy:
1- According to approach:
 Abdominal hysterectomy:
- it involves detaching the uterus from the ligaments that
support it and blood vessels that supply it. It is the most
common approach.
  Vaginal hysterectomy:
- the surgeon approaches the uterus through the vagina,
detaches it from its supports and pulls it out. It is done
with women with uterine prolapse.

 Laproscopic hysterectomy:
- the approach can be either abdominal or vaginal
assisted by a laproscope

2- According to organs removed:

 Subtotal hysterectomy (supracervical hysterectomy):
- It is the removal of the uterus only and not the cervix.

 Total abdominal hysterectomy with bilateral

salpingo-oophorectomy (TAHBSO):
- It is the removal of the ovaries and fallopian tubes along
with the uterus and cervix through an incision in the
lower abdomen

 Total abdominal hysterectomy (TAH):

- It is the removal of the uterus and cervix through an
incision in the lower abdomen. The fallopian tubes and
ovaries are not removed.

 Radical hysterectomy:
- It is the removal of the fallopian tubes, uterus, cervix,
ovaries, nearby lymph nodes and upper portion of the
vagina. This type of hysterectomy is used in the
treatment of some gynecological cancer cases
Technique Advantages Disadvantages

No limitation by the Longest duration of

size of the uterus hospital treatment
Abdominal Combination with ,Highest rate of
reduction and complications
incontinence ,Longest recovery
surgery period
Shortest operation *Limitation by the
time Short size of the uterus
recovery period andprevious surgery
Vaginal ,Combination with *Highest blood
reduction loss.
operations are
possible
Possible even with Long operation time
larger uterus and High instrumental
after previous costs by changing
Laparoscopi- surgery the access path
assisted vaginal ,Combination with
reduction
operations are
possible
 Complications Of Hysterectomy:
 Nausea and vomiting
 Infection
 Internal hemorrhage
 Hematoma
 Internal scar tissue
 Allergic reaction to the anaesthetic
 Blood clots
 Difficulties with urination
 Decreased sexual desire
 Constant pelvic pain
 Feelings of grief and loss
 Injury to the bowel, bladder or ureters
 Fistula
 Vaginal vault prolapsed

 Physical Impact Of Hysterectomy:-

 Skin:
- Features noted as a result of oestrogen deficiency
following menopause may include dryness, loss of
elasticity and vascularity, thinning of the skin. These
changes result in poor wound healing, hair loss and
pigmentary changes
 Vulva and vagina:
- The genital tract is highly estrogen-dependent and body
changes during the menopausal transition and post-
menopause may include vaginal and vulval dryness,
dyspareunia, post- coital bleeding or spotting and
thinning of the labia. Vulvae dryness may worsen
causing itch and irritation.

 Bladder
- Urinary frequency, cystitis and incontinence are more
common around the time of [Link]
oestrogen pessaries or creams may improve
incontinence in the short term.
- Other management options for incontinence include
other medications, physiotherapy and if necessary,
surgery.

 Alternatives for hysterectomy:

Depending on the indication there are alternatives to
hysterectomy:
1- Heavy bleeding
- Levonorgestrel intrauterine devices are highly effective
at controlling dysfunctional uterine bleeding (DUB) or
menorrhagia and should be considered before any
surgery. Menorrhagia (heavy or abnormal menstrual
bleeding) may also be treated with the less invasive
endometrial ablation which is an outpatient procedure
in which the lining of the uterus is destroyed with heat,
mechanically or by radio frequency ablation.
 2- Prolapse
- Prolapse may also be corrected surgically without
removal of the uterus. A vaginal pessary (an object
inserted into the vagina to hold the uterus in place) can
be used as a temporary or permanent form of
treatment for a prolapsed uterus (Medline Plus).
- Vaginal pessaries are available in many shapes and sizes
and must be individually fitted. A surgical procedure

CONDITION ALTERNATIVES TO
HYSTERECTOMY
Uterine fibroids (leiomyomas) 1. Gonadotrophin-releasing
hormone (GnRH) medication
,2. Uterine artery embolization
3. Surgical removal
(myomectomy) [Link]
treatment of pain or bleeding

Endometriosis 1. Oral contraceptives

[Link] Medications
3. GnRH medication
[Link] surgery 5.
Laparotomy without
hysterectomy
Abnormal vaginal bleeding 1. (D&C). Progestins
(hormones) 5. Hysteroscopy
with polypectomy,
myomectomy, or ablation .
 Investigation:-

 Diagnostic Studies:
 Pelvic examination
 Pap smear
 Ultrasound or computed tomography (CT) scan
 Laparoscopy
 Dilation and curettage (D&C) with biopsy
 Complete blood count (CBC)
 Sexually transmitted disease (STD) screen

 Nursing Role:-

 The role of the nurse:

 Preoperative Patient Education
- Preoperative Physical &Psychological preparation
- Mental Status Examination
- Instructions related to the day of the operation.
 Postoperative –Instructions & Intervention
- Exercises
- Walking
- Pelvic Floor Muscles Exercises
- Breathing Exercises
- Diet
- Hygiene
 Instructions On Discharge:
 Activity
 Medication
 Clothing
 Wound Care
 Postoperative Danger Signs:
- Pain that is not relieved by medication
- Fever more than 100 degrees Fahrenheit or chills
- Excessive bleeding, such as a bloody dressing
- Excessive swelling
- Redness outside the dressing
- Discharge or bad odor from the wound
- Allergic or other reactions to medication(s)
- Constipation

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