Introduction
Background
Aim
Overview of hysterectomy
Techniques and indications
Route | Indications | Contraindications |
---|---|---|
Vaginal hysterectomy (VH) | Genital prolapse (50–65% of cases) Hypermenorrhoea/dysfunctional uterine bleeding Symptomatic (bleeding) uterine leiomyomas Microinvasive cervical carcinoma | History of caesarean section (CS) or other pelvic surgery No previous vaginal delivery Large uterus (≥12–14-week gestation size) Coexistent extrauterine pelvic pathology (e.g. adhesions, endometriosis) Need for oophorectomy Invasive tumours |
Laparoscopically assisted VH (LAVH) | Dysfunctional uterine bleeding or symptomatic uterine leiomyomas in patients with contraindicated or difficult VH (e.g. due to previous CS or adhesions) Patients with chronic pelvic inflammatory disease (PID) requiring hysterectomy Patients with endometriosis requiring hysterectomy | Obesity Very large uterus Potentially malignant adnexal mass Risk of laparotomic conversion (e.g. severe post-surgical adhesions, endometriosis requiring bowel resection and/or involving rectovaginal septum) |
Total laparoscopic hysterectomy (TLH) | Same as LAVH + endometrial and cervical tumours | |
Abdominal hysterectomy (AH) | Malignant genital tumours Potentially malignant adnexal mass Uterine leiomyomas not amenable to VH and laparoscopy (e.g. very large uterus, severe adhesions) Endometriosis and PID not amenable to laparoscopy (e.g. due to rectovaginal septum involvement, need for bowel resection) Secondary post-partum haemorrhage (exceptional) | Benign uterine disease (e.g. dysfunctional uterine bleeding or symptomatic uterine leiomyomas) amenable to VH or laparoscopy |
Complications
Route | 30-day major complications (%) | Need for repeated surgery (%) | Mortality (%) |
---|---|---|---|
Radical abdominal hysterectomy (AH) for cancer | 9.8 | 3.0 | 1.1 |
AH for benign conditions | 4.8 | 1.9 | 0.2 |
Vaginal hysterectomy (VH) | 2.4 | 1.0 | 0.03 |
Laparoscopically-assisted VH (LAVH) | 3.4 | 1.5 | 0.1 |
Total laparoscopic hysterectomy (TLH) | 2.6 | 2.0 | – |
Route | All infections | Wound infections | Lymphocele | Vaginal vault haematoma | Bleeding requiring transfusion | Urologic complications (bladder, ureter, fistulas) | Vaginal cuff dehiscence | Gastrointestinal complications |
---|---|---|---|---|---|---|---|---|
Abdominal hysterectomy (AH) (* radical AH for malignancy) | +++ | ++ (* +++) | ++ (* +++) | + | ++ | +/++ (* +++) | + | + |
Vaginal hysterectomy (VH) | +++ | + | +/− | +++ | + | + | +/− | + |
Laparoscopically assisted VH (LAVH) Total laparoscopic hysterectomy (TLH) | ++ | + | + | + | ++ | +++ | ++/+++ | + |
Early post-hysterectomy CT
Indications and techniques
Intraoperative injury (suspected, recognised by surgeon or repaired) to blood vessels, bowel or urinary tract |
Suspected haemorrhage: - dropping haemoglobin - blood from drainage tube - hypotension/shock |
Physical signs of peritonitis |
Persistent or worsening abdominal distension, pelvic or perineal pain |
Suspected infection/sepsis: - fever - increasing leukocyte count and C-reactive protein levels |
Abnormal vaginal examination: - discharge - suspicious physical finding (e.g. swelling, vaginal cuff discontinuity) |
Suspicious, abnormal or extensive transvaginal ultrasound findings (e.g. vaginal vault haematoma or abscess) |
Suspected urologic injury: - hydronephrosis - worsening renal function tests - haematuria, abnormal urinalysis |