HYSTERECTOMY

WHAT IS HYSTERECTOMY?
hmmmmmm
HYSTERECTOMY

• Is a surgery to remove a woman's uterus or womb.

After a hysterectomy, you no longer have menstrual
periods and can't become pregnant. Sometimes the
surgery also removes the ovaries and fallopian
tubes. If you have both ovaries taken out, you will
enter menopause.
SURGICAL PREPARATION
Perioperatively
A. PRE-OPERATIONAL
• The purpose of the preoperative workup is to assist the
gynecologic surgeon in preparing their patient for surgery. In
most cases, this workup includes patient evaluation,
stratification of risk, and risk factor modification. The surgeon
is thus able to reduce delays in the preparation phase, to
enhance patient safety, to recognize and treat complex medical
problems, to reduce evaluation costs, and to minimize case
delays and cancellations.
GOALS OF THE PRE-OPERATIONAL STAGE
• Obtain and review specialty consultations. Assist with
patient evaluation and risk-factor modification.
• Identify significant medical conditions by reviewing the
following:
History and physical examination findings
Hospital and clinic medical records
Appropriate test results
GOALS OF THE PRE-OPERATIONAL STAGE
• Modify significant conditions that are associated with perioperative
complications.
• Educate the patient. Provide information about the anesthetic plan,
including available options and their associated risks.
• Notify the patient about preparation issues, such as nothing-by-mouth (ie,
NPO) requirements and medication instructions.
• Develop an appropriate to the patient, surgeon, primary care physician
(PCP), and anesthesiology team. anesthetic plan.
• Communicate the results of the whole evaluation
PRE-OPERATIVE EVALUATION
• The purpose of the preoperative evaluation is not to provide a general
screening examination. Normal healthy women undergoing minor
procedures may be seen by both the surgeon and the anesthesia
personnel on the day of surgery in the preoperative holding area. These
patients should receive written and oral instructions and be allowed to
ask questions while in the waiting area. However, women with
significant medical conditions should be seen at least 1 week before
surgery to allow time for risk assessment, specialty consultation, and
patient preparation. 
GENERAL MEDICAL HISTORY
• Medications
• Allergies to medications, food, and environmental allergens
• Hospitalizations, including previous surgeries and
anesthetics
• Illnesses
REVIEW OF SYSTEMS
• Cardiovascular disease – Congenital conditions, ischemia, valvular failure,
dysrhythmia, peripheral vascular processes
• Pulmonary conditions – Smoking, 
chronic obstructive pulmonary disease (COPD)
• Endocrine disease
• Gastrointestinal disease
• Neurologic conditions – Cerebrovascular, peripheral, or central neurologic
processes
• Hematologic conditions – Anemic and coagulopathic processes
OBSTETRIC AND GYNECOLOGIC HISTORY
• Menstruation
• Menstrual pattern – Cycle interval, duration, and amount of flow; moliminal
symptoms, dysmenorrhea, intermenstrual bleeding
• Menarche
• Last menstrual period
• If postmenopausal – Age of menopause, recent vaginal bleeding, vasomotor
symptoms, hormone replacement therapy (HRT) history
• Gravidity – Description of each pregnancy
• Birth control – If sexually active, current method, past methods; if sterilized, date and method
• Sexual history – Preference (ie, heterosexual, bisexual, homosexual); orgasmic; if sexually active,
dyspareunia; problems, concerns, questions
• Infertility – Difficulty becoming pregnant, evaluation or treatment for infertility
• Papanicolaou (Pap) smear – Last Pap test, abnormalities
• Infection – Vaginal discharge, previous vaginal infections, sexually transmitted diseases (STDs), 
pelvic inflammatory disease (PID)
• Pelvic relaxation – Prolapse, vaginal splinting to defecate, urinary retention, urinary incontinence
• Breast disease – Masses, discharge, pain, past problems, family history of breast cancer, surgery
FAMILY HISTORY

• Cancer
• Diabetes mellitus
• Osteoporosis
• Cardiovascular disease
• Other familial disorders
HEALTH HABITS
• Tobacco
• Alcohol
• Drugs
• Diet
• Exercise
• Seat-belt use
PHYSICAL EXAMINATION
• Vital signs – Blood pressure, pulse, respiratory rate, body temperature, height, and weight
• General – Body habitus and physical appearance
• Head, ears, eyes, nose, and throat (HEENT) – Abnormalities of the HEENT and airway
• Lungs – Auscultation for equal bilateral breath sounds and presence of rales, rhonchi, and wheezes
• Heart – Auscultation for regularity of rate and rhythm and presence of gallops, rubs, and murmurs;
auscultation for carotid bruits and observation of jugular venous distention, as indicated
• Neurologic – General observation of mental status, cranial nerve function, and sensorimotor ability
INFORMED CONSENT
• A thorough discussion of the proposed procedure and possible complications should occur and be
documented. This ensures that the patient and her family’s expectations for her surgical outcome are
realistic and appropriate.
• In general, the informed consent discussion should include the indications, expected benefits,
alternatives, and the expected course of the problem if the procedure is not performed. The patient
should be informed that complications can occur in any surgical procedure. In addition, one should
explain that treatment of complications or unexpected findings may require consultation with other
surgical specialists.
• Discussing what the surgeon will do to prevent complications, such as use of prophylactic
antibiotics to lower the risk of infection or low molecular weight heparin to prevent pulmonary
embolism, may be helpful.
B. INTRAOPERATIVE
The type of anaesthesia is highly variable between surgical centres
and is in a limited way dictated by type of surgery. General
anaesthesia is the preferred method, with supplemental epidural
analgesia, perineural or infiltrative analgesia when major
postoperative pain is anticipated. Spinal anaesthesia may be an
alternative for abdominal or vaginal hysterectomy allowing for less
postoperative morphine demands, but the use of intrathecal morphine
also includes more postoperative itching
SURGICAL TECHNIQUE
The choice between surgical techniques is often made by the surgeon in
conference with the patient, but the reasons are often unclear. From the view of an
anaesthesiologist, only in the past few years do we have strong scientific support for the
effect of surgical technique on postoperative complaints. It seems evident that a minimally
invasive technique using laparoscopy and/or vaginal approach is superior to laparotomy, in
terms of less postoperative pain, less morphine demand, shorter duration of bladder
catheterisation, better immune function, length of stay in hospital, and measures of
postoperative vitality
POSITIONING
Correct patient positioning is a key component of successful laparoscopic hysterectomy.
Key elements of the proper positioning include:
• Horizontal position of the patient on the table. Trendelenburg position should not be used
prior to the insertion of the primary trocar. Premature induction of the Trendelenburg
position changes the location of the bifurcation of the aorta into its common iliac
branches. In normal circumstances with the patient supine, the bifurcation is at the level
of the upper margin of the umbilicus. With Trendelenburg position, however, this location
shifts caudally in relation to the umbilicus, thereby increasing the risk of aortic injury.
Even a small shift is important because the primary trocar is normally directed at a
45° angle to the horizontal
• Table height should be at or below the waist line of the operating surgeon in order to avoid
muscular fatigue from the non-physiological position of the surgeon’s arms during the procedure.
• The patient’s knees should be widely separated in Allen type stirrups.
• Padded supports should be applied to the foot and posterior calf.
• Deep vein thrombosis (DVT) prophylaxis stockings – above knee type – should be applied before
positioning the legs in stirrups.
• Sequential calf muscle compressors should be in place over DVT stockings.
• Both upper limbs are tucked on the patient’s sides with the IV line in place with extension tubing 
• When available, the body warmer mat should be used to prevent hypothermia and put in
place before placing the patient on the table. Air from a warm blower can be directed onto
the anterior surface of the chest. The patient’s eyes must be taped closed by the
anesthesiologist after instillation of appropriate lubricant.
• The buttocks should be brought near the edge of the lower end of the table in order to
facilitate easy maneuverability of the uterine manipulator
C. POSTOPERATIVE MANAGEMENT
• The care of the gynecologic surgical patient requires an accurate
understanding of the pathophysiologic changes that occur
perioperatively. During this period, the body attempts to
maintain systemic homeostasis despite multiple iatrogenically
induced alterations. Given the proper environment and
appropriate interventions, the body eventually should correct for
these derangements.
SUPPORTIVE POSTOPERATIVE CARE
Check and monitor for:
• Vital Signs
• Postoperative activity
• Fluid and electrolyte balance
• Pain and pain control
• Postoperative fever
FIRST 24-48 HOURS
• Minor: Pyrogens are released from hematogenous seeding of leukocytes or
bacteria (eg, manipulation of a pelvic abscess). Pulmonary atelectasis develops
from hypoventilation secondary to mechanical splinting from incisional pain.
Treatment is symptomatic and consists of antipyretics, an incentive spirometer,
and increased ambulation.
• Major: Necrotizing wound infection is uncommon. Signs may include crepitus,
pain, and edematous discoloration. Treatment consists of aggressive
intraoperative debridement and drainage and broad-spectrum antibiotics.
POST-OP DAYS 2-4

UTI, an infected intravenous line, or pneumonia may be

present. The workup should include a thorough physical
examination, including intravenous sites, urinalysis,
chest radiography, and sputum culture. Treatment for
UTI or pneumonia consists of appropriate broad-
spectrum antibiotics. For infected intravenous lines,
remove the line, apply local heat, and elevate.
FIFTH POSTOPERATIVE DAY AND BEYOND
The differential diagnosis expands to wound infections, for which the
skin must be opened and drained. Broad-spectrum antibiotics are
administered and adjusted when culture results are available. Local
wound care with adequate drainage is necessary. If no evidence of a
wound infection is present, a computed tomography (CT) scan is
obtained to examine for intra-abdominal or intrapelvic abscess.
Abdominal abscess requires surgical or percutaneous drainage.
Intravenous antibiotics may also be required.
MANAGEMENT OF POSTOPERATIVE PAIN
WHAT TO EXPECT AFTER SURGERY
• Most women go home 2-3 days after this surgery, but complete
recovery takes from six to eight weeks. During this time, you
need to rest at home. You should not be doing housework until
you talk with your doctor about restrictions. There should be no
lifting for the first two weeks. Walking is encouraged, but not
heavy lifting. After 6 weeks, you can get back to your regular
activities, including having sex.
LABORATORY TESTS
That are performed before the surgery begins
• CBC count-This test checks for a low number of red blood cells (anemia) and infection.
• Papanicolaou test-Detects the presence of abnormal cervical cells or cervical cancer.
• Endometrial sampling-Detects abnormal cells in the uterine lining or endometrial cancer.
• Ultrasonography-Uses high-frequency sound (ultrasound) waves to produce images of
internal organs and other tissues. 
• Blood type and cross match-Is performed prior to administration of blood or blood
products (e.g. packed red blood cells). The purpose of the crossmatch is to detect the
presence of antibodies in the recipient against the red blood cells of the donor. blood
transfusion rate is an important consideration when discussing methods of hysterectomy
• Chest radiography-Chest x-ray (CXR) is commonly utilized in preoperative work up for benign hysterectomy.
• CT scan- Uses computers and rotating X-ray machines to create cross-sectional images of the body. These images
provide more detailed information than normal X-ray images. They can show the soft tissues, blood vessels, and
bones in various parts of the body. 
• MRI - MRI of the pelvis can give the doctor information about a woman's uterus, ovaries, and fallopian tubes.
The scan is sometimes used to check a man's prostate and seminal vesicles. It also can check the rectum and anal
area.
• Cystoscopy- Should be performed routinely after any gynecologic procedure associated with a high risk of injury,
such as difficult bladder or ureteral dissection. Findings that justify cystoscopy include de novo hematuria and air
in the Foley bag during laparoscopy.
• Barium enema- A barium enema is an X-ray exam that can detect changes or abnormalities in the large intestine
(colon). The procedure is also called a colon X-ray.
• IVP- Intravenous pyelogram (IVP) is an x-ray exam that uses an injection of contrast material to evaluate your kidneys,
ureters and bladder and help diagnose blood in the urine or pain in your side or lower back. An IVP may provide enough
information to allow your doctor to treat you with medication and avoid surgery.
• Blood chemistry-This test measures the amount of potassium, sodium, and other electrolytes in your blood. These
chemicals help regulate heart rhythms and other body functions. Complete blood count (CBC). This test checks for a
low number of red blood cells (anemia) and infection.
• Tumor markers-A tumor marker is a biomarker found in blood, urine, or body tissues that can be elevated by the
presence of one or more types of cancer. There are many different tumor markers, each indicative of a particular disease
process, and they are used in oncology to help detect the presence of cancer.
• Urinalysis, Electrocardiogram (EKG)- to make sure there are no undiagnosed medical problems that could complicate
your surgery.
• Pelvic ultrasound- may be done to evaluate the uterus and ovaries, depending on the medical history and physical
exam. It detects abnormal cells in the uterine lining or endometrial cancer
SURGICAL INSTRUMENTS
• Abdominal retractor tray (Richardsons, Deavers, malleables,
Balfour w/ bladder blade)
• O’Sullivan-O’Connor abdominal retractor
• Franz abdominal retractor
• Heaney Hysterectomy forceps
• Heaney-Ballentine Hysterectomy Forceps
• Heaney Needleholder
• Jorgenson Curved Scissors
• Lister bandage scissors
• Pennington Forceps
• Russian tissue forceps 8”
• Thumb forceps 5.5”. Serrated
• Tissue forceps
• Adson tissue forceps 5”. Serrated
• Backhaus towel clamp
• Foerster thumb forceps
• Allis forceps
• Ochsner Forceps
• Mayo pean forceps
• Lahey forceps
• Crile forceps
• Operating scissors
• Mayo scissors
• Metzenbaum scissors
• Mayo Hegar needle holder
• Heaney needle holder
• Crile wood needle holder
• Mayo heggar needle holder
• Yankauer suction tube
• Auvard speculum
• Army navy retractor
• Braun tenaculum
• Heaney Simon Vaginal retractor
• Jackson retractor
VIDEO CLIP
VIDEO LINKS
• https://youtu.be/xZN4HJ7rtq4
• https://youtu.be/JVTs7qb2J3E
• https://youtu.be/e3xPBIOqkv4
POSSIBLE COMPLICATIONS
l Damage to the bladder and or ureter.
l Damage to the bowel.
l Hemorrhage requiring blood transfusion(common).
l Return to theater because of bleeding/wound dehiscence.
l Pelvic abscess/infection.
l Venous thrombosis/pulmonary embolism
• Electrolyte and acid-base abnormalities
• Hyponatremia
DISCHARGE PLANNING
FOCUS
ABDOMINAL PAIN
DATA
• The client complains of moderate abdominal pain, 24 hours after surgery. Pain scale of
6/10. client also complains of discomfort and altered ability to perform ADLs due to pain
ACTION
•  DO NOT drive yourself home. You should be able to do most of your regular activities in 6 to 8
weeks. 
• DO NOT lift anything heavier than a gallon (4 liters) of milk. If you have children, DO NOT lift
them.
• Short walks are ok. Light housework is ok. Slowly increase how much you do.
• Ask your provider when you can go up and down stairs. It will depend on the type of incision
you had.
• Avoid all heavy activity until you have checked with your provider. This includes strenuous
household chores, jogging, weightlifting, other exercise and activities that make you breathe
hard or strain. DO NOT do sit-ups.
• DO NOT drive a car for 2 to 3 weeks, especially if you are taking narcotic pain
medicine. It is OK to ride in a car. Although long trips in cars, trains or airplanes
are not recommended during the first month after your surgery.
• DO NOT have sexual intercourse until you have had a checkup after surgery.
• Ask when you will be healed enough to resume normal sexual activity. This takes
at least 6 to 12 weeks for most people.
• DO NOT put anything into your vagina for 6 weeks after your surgery. This
includes douching and tampons. DO NOT take a bath or swim. Showering is OK.
To manage pain:
• You will get a prescription for pain medicines to use at home.
• If you are taking pain pills 3 or 4 times a day, try taking them at the same times each day
for 3 to 4 days. They may work better this way.
• Try getting up and moving around if you are having some pain in your belly.
• Press a pillow over your incision when you cough or sneeze to ease discomfort and
protect your incision.
• In the first couple of days, an ice pack may help relieve some of your pain at the site of
surgery.
Diet at home:
• Try eating smaller meals than normal and have healthy snacks in
between. Eat plenty of fruits and vegetables and drink 8 cups (2 liters)
of water a day to keep from getting constipated. Try to make sure and
get a daily source of protein to help with healing and energy levels.
• If your ovaries were removed, talk with your provider about treatment
for hot flashes and other menopause symptoms.
Wound care at home:
• Change the dressing over your incision once a day, or sooner if it gets dirty or
wet.
• Your provider will tell you when you do not need to keep your wound
covered. Typically, dressings should be removed daily. Most surgeons will
want you to leave the wound open to air most of the time after you are
discharged from the hospital.
• Keep the wound area clean by washing it with mild soap and water. DO NOT
take a bath or submerge the wound under water
• You may remove your wound dressings (bandages) and take
showers if sutures (stitches), staples, or glue were used to close
your skin. DO NOT go swimming or soak in a bathtub or hot tub
until your provider tells you it is OK.
• Steristrips are often left on incision sites by your surgeon. They
should fall off in about a week. If they are still there after 10 days,
you can remove them, unless your provider tells you not to.
Further instructions:
• Contact your primary healthcare provider or gynecologist if:
• You have heavy vaginal bleeding that fills 1 or more sanitary pads in 1 hour.Your wound
opens.
• You have a fever, and your wound is red and swollen.
• You have yellow, green, or bad-smelling discharge coming from your vagina.
• You feel new pain or fullness in your vagina.
• You have questions or concerns about your surgery, medicine, or care.
RESPONSE

• Client reported pain relief timely.

• Client was able to understand, cooperate and apply the
interventions pertaining to homecare.
• Client was able to perform self care reliance from time
to time.
• Client was able to perform proper wound care.
THANK YOU