Hysterectomy

Hysterectomy

Anesthesia type	General
Airway	ETT
Lines and access	Peripheral IV
Monitors	Standard 5-lead ECG
Primary anesthetic considerations
Preoperative	Type and cross patients at risk for hemorrhage
Intraoperative
Postoperative	PONV
Article quality
Editor rating	In development
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A hysterectomy is performed for a variety of indications, including uterine cancer, postpartum hemorrhage, fibroids, abnormal uterine bleeding, and endometriosis. It is most commonly performed laparoscopically, and is increasingly an outpatient procedure. It is the second-most common gynecological surgical procedure after Cesarean section in the United States, and it is frequently performed alongside other procedures including bilateral salpingo-oophrectomy and pelvic/paraaortic lymph node dissection.

• Surgical procedure: The selection for surgical approach requires consideration of the patient’s age, medical history, history of prior pelvic surgery, or presence/possibility of adhesions, endometriosis, uterine size and presence of uterine prolapse. The advantage of the laparoscopic approach includes shorter recovery time, quicker return of bowel function, less pain, less bleeding and adhesion formation, as well as lower wound complication rate. THe most common procedure is the laparoscopically assisted vaginal hysterectomy (LAVH) which is begun by laparoscopy with a combination of steps performed vaginally.

Preoperative management

Patient evaluation

System	Considerations
Neurologic
Cardiovascular	patients with advanced cardiac disease may not tolerate physiologic changes from pneumoperitoneum including higher HR, MAP, SVR, PVR and decreased venous return, preload, and CO.
Pulmonary	Many gynecological tumors are associated with cigarette smoking, assess for preexisting lung disease. Assess for respiratory disease, diaphragmatic hernia which increase the risk of respiratory compromise from abdominal insufflation.
Gastrointestinal	High BMI can complicate Trendelenburg positioning through decreasing diaphragmatic excursion when combined with insufflation.
Hematologic	Patients with abnormal uterine bleeding, fibroids frequently have chronic anemia
Renal	Evaluate for volume status as abdominal insufflation decreases preload
Endocrine
Labs	Type and cross all patients CBC in chronic anemia

Patient preparation and premedication

• • The patient should be counseled including limiting NPO duration, alcohol/smoking cessation, review of nutritional status, post pain management options, recovery plan, and possibility of urinary drain post.
    • Multimodal analgesia: Tylenol 650-1000 mg, celecoxib 200-400 mg, gabapentin 300-600 mg for post-op analgesia.
    • Scopolamine patch for PONV prophylaxis in high risk patients
    • IV midazolam for anxiolysis

Regional and neuraxial techniques

• Spinal or epidural can be considered in open approach

Intraoperative management

Monitoring and access

• Standard ASA monitors
• 5-lead EKG
• Urinary catheter
• EEG if utilizing a TIVA
• 1-2 peripheral IVs (16-18 gauge)
• In hemorrhaging patients, consider arterial line and central access

Induction and airway management

• Standard induction
• In unstable patients including hemorrhaging patients, consider etomidate (BP control) and rapid sequence intubation (RSI)
• RSI is usually indicated for patients with an ectopic pregnancy
• OG tube decompression prop to laparoscopic trocar insertion

Positioning

• Dorsal lithotomy position, arms tucked
  • Sciatic and femoral nerve injuries may occur in lithotomy position. Check to minimize hip abduction and external rotation. Carefully pad and secure the knees and heels
  • Watch hands and fingers carefully when arms are tucked at patient’s side.
• Deep Trendelenburg position for laparoscopic approach

Maintenance and surgical considerations

• Intraoperative insufflation may cause:
  • Resp: atelectasis, decrease FRC, increase PIPs, and increase CO2. May also cause endobronchial intubation
  • GI: gastric content regurgitation
  • Cardiac: decreased cardiac output (decreased venous return) and bradycardia from pressure-induced vagal stimulation
  • Hematologic: Blood loss is usually minimal though could be significant during some procedures. Discuss with surgeon ahead of time.
  • Pain: Consider a ketamine infusion for chronic pain patients

Emergence

• PONV prophylaxis, especially in young women at higher risk.
• Post-op pain control plan if surgical approach was converted to laparotomy.

Postoperative management

Disposition

• PACU
• Occasionally, same-day discharge

Pain management

• • Epidural, TAP block/catheters, Rectus sheath block/catheters should be considered if patients surgery was converted to an open approach
  • Consider a PCA if the patient had a larger incision than anticipated
  • Multimodal analgesia as discussed above

Potential complications

• PONV
• Conversion to laparotomy (3.9%)
• Urinary tract injury
• Bowel injury
• Vaginal cuff dehiscence
• Hemorrhage

Procedure variants

	Open	Laparoscopic	Robotic Laparoscopic
Unique considerations
Position		Dorsal lithotomy Steep Trendelenburg	Dorsal lithotomy Steep Trendelenburg
Surgical time
EBL
Postoperative disposition		PACU Poss. same day discharge
Pain management	Regional	Oral narcotics vs. PCA
Potential complications

References

• Nelson G, Altman AD, Nick A, et al: Guidelines for pre- and intra-operative care in gynecologic/ oncology surgery: enhanced recovery after surgery (ERAS) Society recommendations-Part I. Gynecol Oncol 2016; 140(2):313-22.

• Gerges FJ, Kanazi GE, Jabbour-Khoury SI: Anesthesia for laparoscopy: a review. J Clinic Anesth 2006; 18(1): 67-78.