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

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Editor rating
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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.[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]

  • 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

  1. 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)
  2. "Plotting the downward trend in traditional hysterectomy". ihpi.umich.edu. Retrieved 2021-03-30.
  3. Jaffe, Richard A; Schmiesing, Clifford A; Golianu, Brenda (2014). Anesthesiologist's manual of surgical procedures. ISBN 978-1-4963-0594-7. OCLC 888551588.
  • 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.