Dr.Tarig Mahmoud Ahmed

MD SUDAN

HAIL UNIVERSITY KSA

Hysterectomy• Ahysterectomy is the removal of the uterus.

• in the UK – 20 per cent of women will have a

hysterectomy by the age of 60.

• It is tow types:

1) Subtotal hysterectomy (STAH) is removal of the

uterus while the cervix remains.

2) total hysterectomy is removal of the uterus

with the cervix .

• With a STAH the patient will still require

cervical smears as per the screening

programme as there will still be a

theoretical risk of cervical cancer.

• A bilateral salpingo-oopherectomy is where

both ovaries and Fallopian tubes are

removed.

• removal of the ovaries will result in an

immediate post-menopausal state & thus

Hormone replacement therapy may need to

be considered.

• Where the ovaries remain in situ, there is

always a risk of ovarian carcinoma.

Pre-procedure counselling• a description of the procedure.

• the removal or retaining of ovaries and cervix .

• risks of the procedure (anaesthetic risk,

haemorrhage, infection, bowel, bladder or ureteric

damage, deep vein thrombosis & pulmonary

embolus).

• recovery time .

• alternative treatment options to hysterectomy.

Procedurehysterectomy may be achieved using three

approaches:

i. Abdominal: This involves an incision which is

transverse or vertical midline .

ii. Vaginal: This involves removal of the uterus and

cervix via the vagina with no abdominal

incisions.

iii. Laparoscopic: This category can be subdivided to

:

(A)Laparoscopy-assisted vaginal hysterectomy

(LAVH) is where part of the hysterectomy is

performed laparoscopically and part vaginally.

(B)Total laparoscopic hysterectomy (TLH) is where

the whole procedure is performed laparoscopically.

Indications for abdominal

hysterectomy

Indications for vaginal

hysterectomy

• Uterine, ovarian, cervical and Fallopian tube carcinoma.

• Pelvic pain from chronic endometriosis or chronic PID where the pelvis is frozen and vaginal hysterectomy is impossible.

• Symptomatic fibroid uterus greater than 12-week size.

• Menstrual disorders with

a uterus less than 12

weeks in size.

• Micro invasive cervical

carcinoma.

• Uterovaginal prolapse.

Complications

Specific complications of hysterectomy

include:

• haemorrhage

• ureteric injury

• bladder and bowel injury.

Post-procedure workup

• Regular observations.

• Regular analgesia.

• A urinary catheter inserted preoperatively

will remain in the bladder for 24 hours.

• The patient will remain in hospital for 3–5

days.

• Wound sutures will be removed 7–10 days

postoperatively.

• Thrombo-embolic prophylaxis.

Myomectomy• Myomectomy is the removal of fibroid.

• It indicate in:

(A) Menorrhagia with a submucous fibroid.

(B) bulky fibroid uterus causes pressure

symptoms

Pre-procedure counselling• a description of the procedure.

• there is a small but significant risk of

uncontrolled life threatening bleeding during

myomectomy, which could lead to

hysterectomy.

• alternative treatment options (UAE).

ProcedureMyomectomy may be achieved using tow approaches:

i. Abdominal: This involves an incision which is

transverse or vertical midline for bulky fibroid

uterus .

ii. hysteroscopic : a techniques for the removal of

submucous fibroids to avoid major surgery.

Post-procedure workup

• Regular observations.

• Regular analgesia.

• Thrombo-embolic prophylaxis.

• if myometrium involved delivery in next pregnancy

by C/S.

Dilatation and evacuationDefine as dilation of the cervix and surgical evacuation

of the contents of the uterus.

Indication of D&E• Diagnose conditions by collecting tissue

samples for biopsy.

• Evacuation of retained products of conception (ERPOC) - removes any leftover tissue after a spontaneous abortion .

• To remove an embedded intrauterine device (IUD) used for contraception.

Pre-procedure counselling• A description of the procedure.

Inform patient about:

• Risk of damage to the cervix.

• Risk of perforation of the uterus .

• Risk of bleeding.

• Risk of Pelvic infection.

• Asherman's syndrome.

Procedure• The contents of the uterus are removed by

suction using a small plastic cannula

inserted through the cervix and attached to

an electrical pump or a manual vacuum

aspiration (MVA) syringe.

• use of surgical instruments (such as ovum

forceps, curette).

manual vacuum aspiration (MVA)

Post-procedure workup

• Antibiotic therapy.

• analgesia

Cervical cerclage• Cervical cerclage is a procedure in which

stitches are used to close the cervix during

pregnancy to help prevent pregnancy loss or

premature birth.

indicationsHistory-indicated cerclage

• spontaneous second-trimester loss

• preterm delivery.

normally inserted electively at 12–14 weeks of gestation

Ultrasound-indicated cerclage

in cases of cervical length shortening seen on transvaginal ultrasound

usually performed between 14 and 24 weeks of gestation

Rescue cerclage

in the case of premature cervical dilatation with exposed fetal membranes in the vagina.

contraindications to cerclage insertion

● active preterm labour

● clinical evidence of chorioamnionitis

● continuing vaginal bleeding

● PPROM

● evidence of fetal compromise

● lethal fetal defect

● fetal death.

types• Transvaginal cerclage (McDonald)

A transvaginal purse-string suture placed at the cervicovaginal junction, without bladder mobilisation.

• High transvaginal cerclage (Shirodkar)

A transvaginal purse-string suture placed following bladder mobilisation, to allow insertion above the level of the cardinal ligaments.

• Transabdominal cerclage

A suture performed via a laparotomy or laparoscopy, placing the suture at the cervicoisthmic junction.

cerclage

Complications

• Infection

• Vaginal bleeding

• A tear in the cervix (cervical laceration)

• Prolapse of the fetal membranes into the

vagina

• risk of intraoperative bladder damage

• Miscarriage

• A transvaginal cervical cerclage should be

removed before labour, usually between 36+1

and 37+0 weeks of gestation, unless delivery

is by elective caesarean section, in which

case suture removal could be delayed until

this time.

Hysteroscopy• Hysteroscopy involves passing a small-

diameter telescope, either flexible or rigid,

through the cervix to directly inspect the

uterine cavity.

• carbon dioxide or fluids are used as a filling

medium.

Hysteroscope

Indications• postmenopausal bleeding,

• irregular menstruation, intermenstrual

bleeding and postcoital bleeding

• persistent menorrhagia

• persistent discharge

• suspected uterine malformations

• suspected Asherman’s syndrome.

Complications

• Perforation of the uterus.

• Cervical damage – if cervical dilatation is

necessary.

• If there is infection present, hysteroscopy

can cause ascent.

laparoscopy• a surgical procedure in which a fibre-optic

instrument is inserted through the abdominal wall to

view the organs in the abdomen .

laparoscopy

Indications

• Suspected ectopic pregnancy.

• Undiagnosed pelvic pain.

• Tubal patency testing.

• Sterilization.

• cystectomy

• oophorectomy

• endometriosis with cautery or laser.

Complications

• damage to any of the intra-abdominal

structures, such as bowel and major blood

vessels.

• The bladder is always emptied prior to the

procedure to avoid bladder injury.

• Incisional hernia has been reported.

Thank you