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| '''Anesthetic Management for Open Total Abdominal Hysterectomy'''
| | Click "MGH Article" above to access |
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| (A .pdf version of this article can be found at: https://drive.google.com/file/d/1JA8422EBYvM0zORB-Gt3-L-4qJKTSlUj/view?usp=sharing)
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| '''Indications'''
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| * Large uterine fibroids, gynecological malignancy requiring lymph node dissection and/or high tumor burden, adenomyosis depending on size, endometriosis
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| '''Anatomy'''
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| * The uterus is extremely vascular. The blood supply to the pelvis is largely derived from the internal iliac (hypogastric) artery. This leads into the uterine arteries, superior, middle, and inferior vesical arteries middle and inferior hemorrhoidal arteries, and the vaginal arteries. Pelvic circulation also has robust collaterals. This is important for two reasons: surgical bleeding is possible, and ligation of major arteries (including internal iliac) is a viable option for refractory hemorrhage.
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| * The uterine fundus and cervix are innervated by L1-L4 sympathetics via the hypogastric plexus
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| * Afferent signaling from the pelvic viscera, including the uterus, synapse with the T10-L4 spinal cord segments. By contrast, the cervix is served by nerve fibers from the S2-S4 spinal cord segments.
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| * Lymphatic drainage of the female reproductive organs is via through the pelvic and paraaortic lymph nodes in the retroperitoneum; superficial and deep inguinal lymph nodes may be involved as well.
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| * Anatomic considerations of tumor compression must be considered: aortocaval compression, decreased diaphragmatic excursion from compression, adhesions and scarring, especially in cases of prior surgery.
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| '''Preoperative management'''
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| * Ensure beta-HCG (urine detects >25 mIU/L, serum detects 1-3 mIU/L) is obtained if indicated and clarify any contraceptive use.
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| * Pre-op may call regarding DVT prophylaxis, this should be administered so long as there is no neuraxial anesthesia planned for the case
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| * Obtain comprehensive medical history including hypothyroidism and coagulopathies if f abnormal uterine bleeding is a concern
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| * Anxiety is prevalent in this patient population and may increase anesthetic requirement and pain experience. Additional considerations include patients who have had prior spontaneous/missed/therapeutic abortions or prior complications with fertility and malignancy. Chronic pelvic pain is commonly comorbid with other psychiatric conditions as well. Strongly consider adding PO Lorazepam 0.5-1mg prn to premedication regimen in addition to IV midazolam after IV cannulation.
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| * Patients who present for surgical management of gynecologic malignancies require additional considerations. The tumor mass may create anatomic and physiologic alterations, including aortocaval compression, respiratory compromise, changes in renal or hepatic function, and the potential for adhesions and scarring.
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| ** Prior operations, chemotherapy, or radiation therapy may be associated with difficult access, PONV, myocardial depression, immunocompromise, anemia, and coagulopathy.
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| '''Intraoperative management'''
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| '''Considerations'''
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| * Women generally have a larger volume of distribution of lipophilic drugs (benzodiazepines and opiates) and smaller volume of distribution for hydrophilic drugs (muscle relaxants) than men due to greater ratio of body fat to water distribution.
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| * Faster emergence relative to men is common in propofol anesthetics due to a rapid decline in serum concentrations of Propofol
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| '''IV Access'''
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| * Two IV's, ideally one 18g minimum given risk of bleeding
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| '''Monitoring'''
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| * Standard ASA monitors
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| * Consider processed EEG for propofol infusion
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| * Arterial line rarely indicated. Consider if patient is high risk for rapid cardiopulmonary decompensation (e.g. compromised biventricular function, severe valvular disease, moderate to severe pulmonary hypertension)
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| '''Induction'''
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| * Choice, base on patient considerations
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| * Antibiotics are generally cefazolin and metronidazole, but this can vary depending on procedure and prior ID
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| '''Airway Management'''
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| * Endotracheal intubation is required given length of procedure and positioning
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| * If patient is relatively healthy, ask your attending if you can practice new airway techniques (i.e. Miller blade, video laryngoscopy, asleep fiberoptic intubation, intubating through iLMA)
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| '''Positionin'''g
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| * Supine, arms out, Trendelenburg
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| '''Maintenance of anesthesia'''
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| * Choice, consider TIVA if high risk for PONV
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| '''NMB'''
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| * Required, choice
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| '''Special considerations and critical portions'''
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| * Bladder mobilization is very stimulating and may precipitate vagal response
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| * Dissection around pelvic floor may lead to bleeding
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| * Gastric decompression indicated; if TAH is a part of a more extensive surgery, ask the surgical team if an NGT will be required post-operatively
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| * If there is concern for ureteral injury, cystoscopy may be performed. This involves administration of fluorescein or indocyanine green to facilitate visualization of urine entry into bladder bilaterally. ICG may transiently lower pulse oximetry readings
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| '''PONV'''
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| * Patients are often high risk for PONV. Consider scopolamine patch preoperatively. Consider an antiemetic regimen that includes 2mg midazolam and dexamethasone 0.1mg/kg at beginning of the case and ondansetron 4mg and haloperidol 1mg at the end. Consider TIVA if particularly concerned. Dexmedetomidine infusion has antiemetic properties as well (see analgesia section)
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| '''Analgesia'''
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| * Hormonal decreases, such as those witnessed in menopause, have been associated with increases in pain sensitivity
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| * Tylenol and Celebrex preoperatively; surgical team may prescribe gabapentin
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| * Epidural is rarely employed for these cases, but is occasionally performed as a part of an exploratory laparotomy for malignancy
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| * ERAS protocol recommends hydromorphone as the long-acting opiate of choice and avoidance of morphine
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| * Ketamine in TAH: mechanism of action is NMDA-receptor antagonism. Has not proven to be an efficacious analgesic preop, intraop, and postop in open hysterectomy studies as measured by postoperative opioid consumption and VAS
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| * Lidocaine in TAH: mechanism of action is multifactorial and not well characterized, although thought to be decreased inflammatory response by affecting granulocyte recruitment and transitively cytokine release. Additional mechanisms can include reducing sensitivity of spinal cord neurons via glycine and NMDA modulation. Two trials investigated the use of perioperative lidocaine infusion in patients undergoing total abdominal hysterectomy. There was no difference between lidocaine and placebo in the primary outcomes (length of hospital stay or 6-min walk distance). Secondary outcomes (pain scores, opioid consumption, PONV, recovery, and fatigue scores) for either study also showed no difference. Interestingly, lidocaine has proven to be an effective analgesic in laparoscopic gynecological procedures. General dosing includes a 1mg/kg bolus on induction followed by an infusion of 1.5 mg/kg/h of IBW. If employing lidocaine, calculate total local anesthetic dose if the surgeons are doing a block at the end of the case. Occasionally, if large enough incision, the surgeons may place rectus sheath catheters as well
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| * Dexmedetomidine in TAH: mechanism of action is alpha-2-agonism in the locus coeruleus, and potentially in the substantia gelatinosa, to decrease A-delta and C-fiber transmission and substance P release. Studies demonstrate efficacy in prevention of PONV after open hysterectomies. Analgesia has been seen at intraop doses of 0.05 mcg/kg/h, but with a higher incidence of hypotension requiring vasopressors in PACU
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| * Magnesium in TAH: mechanism of action is NMDA-antagonism. Can be bolus of 30-50mg/kg and/or infusion of 6-20mg/kg/h intraop. Common to administer 2g over 30-60 minutes to prevent hypotension. Literature, however, on its efficacy is controversial, with some studies finding no statistically significant decreased opiate consumption postop and others demonstrating a statistically significant decrease in postop opioid consumption and sleep quality. The theoretical risk of prolonging NMB via recurarization seen in older, less robust studies has proven to be clinically insignificant even at doses of up to 13g intraop
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| '''Complications'''
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| Ureteral damage or transection and hemorrhage are the most common complications seen in these patients
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| '''Dispo'''
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| Often inpatient for 1-2 days
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| '''References'''
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| * Burstal R, Danjoux G, Hayes C, Lantry G. PCA ketamine and morphine after abdominal hysterectomy. Anaesth Intensive Care. 2001 Jun;29(3):246-51. doi: 10.1177/0310057X0102900304. PMID: 11439794.
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| * Dahl V, Ernoe PE, Steen T, Raeder JC, White PF. Does ketamine have preemptive effects in women undergoing abdominal hysterectomy procedures? Anesth Analg. 2000 Jun;90(6):1419-22. doi: 10.1097/00000539-200006000-00031. PMID: 10825333.
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| * Fuchs-Buder T, Tassonyi E. Magnesium sulphate enhances residual neuromuscular block induced by vecuronium. Br J Anaesth. 1996 Apr;76(4):565-6. doi: 10.1093/bja/76.4.565. PMID: 8652332
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| * Grady MV, Mascha E, Sessler DI, Kurz A. The effect of perioperative intravenous lidocaine and ketamine on recovery after abdominal hysterectomy. Anesth Analg. 2012 Nov;115(5):1078-84. doi: 10.1213/ANE.0b013e3182662e01. Epub 2012 Sep 25. PMID: 23011561.
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| * Jarahzadeh MH, Harati ST, Babaeizadeh H, Yasaei E, Bashar FR. The effect of intravenous magnesium sulfate infusion on reduction of pain after abdominal hysterectomy under general anesthesia: a double-blind, randomized clinical trial. Electron Physician. 2016 Jul 25;8(7):2602-6. doi: 10.19082/2602. PMID: 27648185; PMCID: PMC5014497.
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| * Johnson N, Barlow D, Lethaby A, et al. Methods of hysterectomy: systematic review and meta-analysis of randomised controlled trials. ''Br Med J''. 2005;330:1478.
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| * Ko SH, Lim HR, Kim DC, Han YJ, Choe H, Song HS. Magnesium sulfate does not reduce postoperative analgesic requirements. Anesthesiology. 2001 Sep;95(3):640-6. doi: 10.1097/00000542-200109000-00016. PMID: 11575536.
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| * Lauren K. Dunn, Marcel E. Durieux; Perioperative Use of Intravenous Lidocaine. Anesthesiology 2017; 126:729–737 doi: <nowiki>https://doi.org/10.1097/ALN.0000000000001527</nowiki>
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| {| class="wikitable"
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| |Perioperative Use of Intravenous Lidocaine
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| Perioperative lidocaine infusion improves analgesia and recovery after some surgical procedures, possibly through systemic antiinflammatory effects. This commentary provides the clinician with evidence for rational use of perioperative lidocaine infusion in procedures where it is of demonstrated benefit.
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| doi.org
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| |}
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| * Martin R. Tramer, Jurg Schneider, Rene-Andreas Marti, Kaplan Rifat; Role of Magnesium Sulfate in Postoperative Analgesia. Anesthesiology 1996; 84:340–347. doi:
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| * Rekatsina M, Theodosopoulou P, Staikou C. Effects of Intravenous Dexmedetomidine Versus Lidocaine on Postoperative Pain, Analgesic Consumption and Functional Recovery After Abdominal Gynecological Surgery: A Randomized Placebo-controlled Double Blind Study. Pain Physician. 2021 Nov;24(7):E997-E1006. PMID: 34704710
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| * Tsen LC. Anesthesia for Obstetric Care and Gynecologic Surgery. In: Longnecker DE, Mackey SC, Newman MF, Sandberg WS, Zapol WM. eds. ''Anesthesiology, 3e''. McGraw Hill; 2017. Accessed April 15, 2022. <nowiki>https://accessanesthesiology-mhmedical-com.treadwell.idm.oclc.org/content.aspx?bookid=2152§ionid=164237528</nowiki>
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| Alwin Somasundaram and Talia Vogel, 2022
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