Hysterectomy

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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

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
  • 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

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 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.