Difference between revisions of "Hysterectomy"
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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.<ref>{{Cite journal|last=Morgan|first=Daniel M.|last2=Kamdar|first2=Neil S.|last3=Swenson|first3=Carolyn W.|last4=Kobernik|first4=Emily K.|last5=Sammarco|first5=Anne G.|last6=Nallamothu|first6=Brahmajee|date=2018-04|title=Nationwide trends in the utilization of and payments for hysterectomy in the United States among commercially insured women|url=http://dx.doi.org/10.1016/j.ajog.2017.12.218|journal=American Journal of Obstetrics and Gynecology|volume=218|issue=4|pages=425.e1–425.e18|doi=10.1016/j.ajog.2017.12.218|issn=0002-9378}}</ref> It is the second-most common gynecological surgical procedure after | 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.<ref>{{Cite journal|last=Morgan|first=Daniel M.|last2=Kamdar|first2=Neil S.|last3=Swenson|first3=Carolyn W.|last4=Kobernik|first4=Emily K.|last5=Sammarco|first5=Anne G.|last6=Nallamothu|first6=Brahmajee|date=2018-04|title=Nationwide trends in the utilization of and payments for hysterectomy in the United States among commercially insured women|url=http://dx.doi.org/10.1016/j.ajog.2017.12.218|journal=American Journal of Obstetrics and Gynecology|volume=218|issue=4|pages=425.e1–425.e18|doi=10.1016/j.ajog.2017.12.218|issn=0002-9378}}</ref> It is the second-most common gynecological surgical procedure after Cesarean section in the United States<ref>{{Cite web|title=Plotting the downward trend in traditional hysterectomy|url=https://ihpi.umich.edu/news/plotting-downward-trend-traditional-hysterectomy|access-date=2021-03-30|website=ihpi.umich.edu|language=en}}</ref>, and it is frequently performed alongside other procedures including bilateral salpingo-oophrectomy and pelvic/paraaortic lymph node dissection.<ref>{{Cite book|last=Jaffe|first=Richard A|url=http://public.ebookcentral.proquest.com/choice/publicfullrecord.aspx?p=3418805|title=Anesthesiologist's manual of surgical procedures|last2=Schmiesing|first2=Clifford A|last3=Golianu|first3=Brenda|date=2014|isbn=978-1-4963-0594-7|language=English|oclc=888551588}}</ref> | ||
== Preoperative management == | == Preoperative management == | ||
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* Dorsal lithotomy position, arms tucked | * Dorsal lithotomy position, arms tucked | ||
* Often Trendelenburg position for laparoscopic approach | |||
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | === Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | ||
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** Resp: atelectasis, decrease FRC, increase PIPs, and increase CO2. May also cause endobronchial intubation | ** Resp: atelectasis, decrease FRC, increase PIPs, and increase CO2. May also cause endobronchial intubation | ||
** GI: gastric content regurgitation | ** GI: gastric content regurgitation | ||
** Cardiac: decreased cardiac output | ** Cardiac: decreased cardiac output (decreased venous return) and bradycardia from pressure-induced vagal stimulation | ||
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | === Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | ||
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* PACU | * PACU | ||
* Occasionally, same-day discharge | |||
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | === Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | ||
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|+ | |+ | ||
! | ! | ||
! | !Open | ||
! | !Laparoscopic | ||
|- | |- | ||
|Unique considerations | |Unique considerations | ||
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|Position | |Position | ||
| | | | ||
| | |Dorsal lithotomy | ||
Steep Trendelenburg | |||
|- | |- | ||
|Surgical time | |Surgical time | ||
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|Postoperative disposition | |Postoperative disposition | ||
| | | | ||
| | |PACU | ||
Poss. same day discharge | |||
|- | |- | ||
|Pain management | |Pain management | ||
| | |Regional | ||
| | |Oral narcotics vs. PCA | ||
|- | |- | ||
|Potential complications | |Potential complications | ||
Revision as of 11:48, 10 July 2021
Hysterectomy
| Anesthesia type |
General |
|---|---|
| Airway |
Endotracheal tube |
| Lines and access |
Peripheral IV |
| Monitors |
Standard ASA 5-lead EKG |
| Primary anesthetic considerations | |
| Preoperative |
Type and cross patients at risk for hemorrhage |
| Intraoperative | |
| Postoperative |
PONV |
| Article quality | |
| Editor rating | |
| User likes | 0 |
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.[1] It is the second-most common gynecological surgical procedure after Cesarean section in the United States[2], and it is frequently performed alongside other procedures including bilateral salpingo-oophrectomy and pelvic/paraaortic lymph node dissection.[3]
Preoperative management
Patient evaluation
| System | Considerations |
|---|---|
| Neurologic | |
| Cardiovascular | |
| Respiratory | Many gynecological tumors are associated with cigarette smoking, assess for preexisting lung disease |
| Gastrointestinal | |
| Hematologic | Patients with abnormal uterine bleeding, fibroids frequently have chronic anemia |
| Renal | |
| Endocrine | |
| Labs | Type and cross all patients
CBC in chronic anemia |
Patient preparation and premedication
- Midazolam
- Consider scopolamine patch in young women at high risk for PONV
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
- 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)
Positioning
- Dorsal lithotomy position, arms tucked
- Often 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
Emergence
- PONV prophylaxis, especially in young women at higher risk
Postoperative management
Disposition
- PACU
- Occasionally, same-day discharge
Pain management
- NSAIDs, acetaminophen for mild pain
- Opioids for breakthrough pain. Consider PCA for open cases
Potential complications
- PONV
- Conversion to laparotomy (3.9%)
- Urinary tract injury
- Bowel injury
- Vaginal cuff dehiscence
- Hemorrhage
Procedure variants
| Open | Laparoscopic | |
|---|---|---|
| Unique considerations | ||
| Position | Dorsal lithotomy
Steep Trendelenburg | |
| Surgical time | ||
| EBL | ||
| Postoperative disposition | PACU
Poss. same day discharge | |
| Pain management | Regional | Oral narcotics vs. PCA |
| Potential complications |
References
- ↑ Morgan, Daniel M.; Kamdar, Neil S.; Swenson, Carolyn W.; Kobernik, Emily K.; Sammarco, Anne G.; Nallamothu, Brahmajee (2018-04). "Nationwide trends in the utilization of and payments for hysterectomy in the United States among commercially insured women". American Journal of Obstetrics and Gynecology. 218 (4): 425.e1–425.e18. doi:10.1016/j.ajog.2017.12.218. ISSN 0002-9378. Check date values in:
|date=(help) - ↑ "Plotting the downward trend in traditional hysterectomy". ihpi.umich.edu. Retrieved 2021-03-30.
- ↑ Jaffe, Richard A; Schmiesing, Clifford A; Golianu, Brenda (2014). Anesthesiologist's manual of surgical procedures. ISBN 978-1-4963-0594-7. OCLC 888551588.