Chapter 46. Therapeutic Gynecologic Procedures

The 4 most commonly performed gynecologic procedures in the United States are abdominal and vaginal hysterectomy, tubal sterilization, and dilation and curettage. This chapter will review these procedures, as well as other therapeutic operations. Indications, contraindications, technique, and complications will be discussed for each procedure.

Indications

The procedure of cervical dilation and uterine curettage (D&C) is usually performed for 1 of the following indications: diagnosis and treatment of abnormal uterine bleeding, management of abortion (incomplete, missed, or induced), or diagnosis of cancer of the uterus. The diagnosis of abnormal bleeding is discussed in Chapter 38; D&C as a method of induced abortion is discussed in Chapter 58. This section will discuss the remaining therapeutic uses of D&C.

Technique

Cervical Dilation

Dilation of the cervix may be conducted under paracervical, epidural, spinal, or general anesthesia, depending largely on the indication for the procedure. Perioperative antibiotic prophylaxis is not recommended, but venous thromboembolism prophylaxis should be used in patients 40 years and older or with additional risk factors. Cervical dilation usually precedes uterine curettage but may be performed in a patient with cervical stenosis prior to insertion of an intrauterine contraceptive device (IUD) or radium device for treatment of cancer. Dilation may also precede hysterosalpingogram or hysteroscopy.

The patient is placed in the dorsal lithotomy position, with the back and shoulders supported and the extremities padded. The inner thighs, perineum, and vagina are prepared as for any vaginal operation; the surgeon and assistant should adhere to surgical principles of asepsis. A thorough pelvic examination under anesthesia is mandatory prior to performing cervical dilation, in order to determine the size and position of the cervix, uterus, and adnexa and the presence of any abnormalities. The patient voids normally before the operation if possible; urinary catheterization is used only if significant residual urine is suspected.

A right-angle retractor is placed anteriorly to gently retract the bladder. A weighted speculum is placed posteriorly to reveal the cervix. Under direct vision, the anterior lip of the cervix is grasped with a tenaculum, avoiding the vascular supply at 3 and 9 o'clock. The cervix is grasped firmly but with care taken not to compromise, or especially perforate, the endocervical canal. With gentle traction, the cervix can be brought down toward the introitus. Before proceeding further, a complete visual examination should be made of the cervix and the 4 vaginal fornices, because the latter areas (especially posteriorly) are otherwise difficult to examine. Areas that appear abnormal (even benign inclusion cysts) should be noted and followed as appropriate. Areas that are clearly abnormal should be biopsied. After the cervix and vagina are evaluated, the uterine cavity is examined. A uterine sound is gently inserted into the endocervix and then advanced into the uterine cavity in the plane of least resistance and most compatible with the position of the uterus as revealed by pelvic examination. The depth of the uterine cavity is recorded as well as any abnormalities such as leiomyomas or septa.

Perforation of the uterus during D&C is most likely to occur at the time of uterine sounding or cervical dilation. Recognized uterine perforations during D&C occur at a rate of 0.63–1.0% according to 2 large classical studies. The majority of perforations are thought to be due to misdirected or excessive force. Perforation is more likely to occur if the woman is postmenopausal (1 in 38), has cancer (1 in 48), or is post pregnancy (1 in 122). Other risk factors include having a retroverted or anteverted uterus or having cervical stenosis. Unless there is evidence of hemorrhage, injury to the bowel, or evulsion of the omentum, conservative treatment of uterine perforation is best.

If severe cervical stenosis is suspected from the preoperative office examination, cervical softening agents such as misoprostol or Laminaria tents may be used. Both oral and vaginal misoprostol and Laminaria tents have demonstrated a benefit over placebo in the ease of cervical dilation in pregnant and premenopausal women. In a systematic review of 10 randomized controlled trials involving premenopausal women undergoing hysteroscopy compared preprocedure misoprostol versus placebo to aid in cervical dilation, preprocedure misoprostol resulted in a reduced need for cervical dilation (relative risk [RR], 0.6; 95% confidence interval [CI], 0.5–0.7), a lower rate of cervical laceration (RR, 0.22; 95% CI, 0.1–0.6), and an increase in cervical dilatation (RR, 2.66; 95% CI, 1.7–3.5), but a higher rate of side effects (vaginal bleeding, cramping, and elevated temperature). For every 4 premenopausal women who received misoprostol prior to hysteroscopy, 1 avoided the need for further cervical dilation. For every 12 premenopausal women receiving misoprostol, 1 cervical laceration was avoided. The vaginal route of misoprostol may be more effective than oral misoprostol as shown by 1 study. In postmenopausal women and women who have been pretreated with gonadotropin-releasing hormone, randomized controlled trials have produced inconclusive results.

The most common dilators used are the Hegar, Pratt, and Hank dilators. Hegar dilators are relatively blunt, gently curved, and numbered sequentially according to width (ie, a No. 7 dilator is 7 mm wide). Pratt and Hank dilators differ from Hegar dilators in being more gradually tapered (“sharper”); they may have a solid core (Pratt) or a hollow center (Hank), allowing egress of trapped blood and air. Pratt or Hank dilators are measured in French sizes (a No. 20F Hank dilator is approximately the same diameter as a No. 9 Hegar dilator). The choice of dilator is largely based on surgical training; many prefer not to use the more pointed Hank dilators in a small postmenopausal uterus.

Endocervical Curettage

Fractional curettage should be used for abnormal uterine bleeding or if genital tract neoplasia is suspected. The cervical canal should be curetted prior to dilation of the cervix and curettage of the endometrial cavity, in order to preserve the histologic characteristics of the endocervix and prevent contamination of the endometrial sample with endocervical cells. If cervical conization is planned for diagnosis or treatment of cervical intraepithelial neoplasia, uterine sounding precedes conization, but cervical dilation and fractional curettage follow in order to minimize denuding of the endocervical epithelium. The Gusberg curette is a small, slightly curved instrument particularly well suited for endocervical curettage. The curette is placed in the endocervical canal to the level of the internal os; with a firm touch, each of the 4 walls is curetted with a single stroke, with the specimen delivered onto a coated cellulose sponge with a twirling motion of the curette. (The coated cellulose sponge is preferred over ordinary surgical sponges because tissue is less likely to adhere to it.) The cervix is then dilated as described earlier and curettage of the endometrium performed. The endocervical and endometrial specimens are immersed in fixative in separate containers and submitted to the pathologist.

Complications from endocervical curettage are rare in nongravid patients. Because of obvious risks to the fetus and membranes, endocervical curettage is contraindicated in pregnant women. Healing of the curetted endocervix may take 3 weeks or more; the cervical epithelium commonly takes 2 weeks to heal following a routine Papanicolaou (Pap) smear. Tissue should be allowed to heal before follow-up Pap smears are taken because regenerating cells are often mistaken for dysplastic cells.

Endometrial Polypectomy

The uterine cavity is explored with polyp forceps prior to diagnostic or therapeutic endometrial curettage. It is easier to remove polyps prior to curettage, preserving the histologic integrity necessary to differentiate benign uterine polyps from neoplasia. In a large series advocating routine exploration of the endometrial cavity preceding curettage, 64% of 130 diagnosed endometrial polyps were removed by ureteral stone forceps. Thirty-nine percent of the polyps were removed with exploring forceps after the curettage had been carried out. Pedunculated or submucous leiomyomas, intrauterine and intracervical synechias, and uterine anomalies may be first suspected at passage of the polyp forceps.

The technique of polypectomy includes gentle insertion of the forceps in the plane most compatible with the position of the uterus (as for uterine sounding). The forceps are opened slightly, rotated 90 degrees, and removed. Many clinicians repeat this procedure through 360 degrees, completely exploring the uterine cavity.

Skillful use of hysteroscopy for diagnosis and treatment of synechias, septa, leiomyomas, and polyps is preferred to blind polypectomy and curettage. With the new, narrow hysteroscope, the procedure is easily done as an office procedure similar to colposcopy for biopsy or laser conization.

Endometrial Curettage

Endometrial curettage is often both diagnostic and therapeutic. It is indicated for treatment of complications of pregnancy, including incomplete or missed abortion, postpartum retention of products of conception, and placental polyps. The procedure is also useful in women with menorrhagia who are hypovolemic and refractory to medical management to stop the acute bleeding. D&C should not be used to treat dysfunctional uterine bleeding in women without hypovolemia, because it has no effect on mean blood loss in subsequent periods (with the exception of the first period following the D&C) and is inferior to medical management. D&C is inferior to hysteroscopy in diagnosing and treating abnormal uterine bleeding due to uterine fibroids or endometrial polyps. It is contraindicated in infection, such as acute endometritis, salpingitis, and pyometra. If infected placental tissue must be removed, the D&C should follow a period of parenteral antibiotics. The technique of endometrial curettage is tailored to the individual patient. In determining the hormone responsiveness of the endometrium, a small but representative sample may be obtained from the anterior and posterior walls. When curettage is being performed therapeutically, a systematic, thorough approach is indicated. The largest sharp curette that can comfortably fit through the dilated cervix is chosen. A serrated curette may cause injury to the underlying basalis layer of the endometrium and myometrium. The anterior, lateral, and posterior walls are scraped with firm pressure in a clockwise or counterclockwise fashion from the top of the uterine fundus down to the internal os. The top of the cavity is curetted with a side-to-side motion. The curettings are retrieved onto the waiting gauze and immersed in fixative as soon as possible. If endometrial curettage is being used for diagnosis of infection (eg, tuberculous endometritis), a portion of the curettings should be placed in containers appropriate for culture (without fixative).

A single curettage will not remove the entire endometrium. Thorough curettage by an experienced gynecologist often removes 50–60% of the endometrium, as determined by immediate postcurettage hysterectomy. If risk factors for endometrial cancer are present and clinical suspicion for neoplasia persists despite a histologic diagnosis of benign endometrium, further evaluation with hysteroscopically guided biopsy or hysterectomy is indicated.

Perforation of the uterus occurred in 0.63% of a large series of D&Cs. Perforation is suspected when the sound or curette meets no resistance at the point expected by uterine size, consistency, and position determined by preoperative bimanual examination. Curettage may be continued if the area of suspected perforation is avoided. Should suction curettage be associated with perforation, laparoscopy must be used to continue the procedure to avoid aspiration of bowel into the uterine cavity. In the case of suspected perforation, the patient should be observed for at least 24 hours in the hospital for possible infection or hemorrhage. In a series of 70 uterine perforations, 55 were treated expectantly, and only 1 patient developed complications (pelvic abscess drained via colpotomy). In 7 patients, hysterectomy was elected but not indicated by operative findings. Today, laparoscopy is the method of choice for evaluating perforations in the hemodynamically stable patient.

Endometrial Biopsy

Outpatient curettage, or endometrial biopsy, should always be a diagnostic and not a therapeutic technique. The many techniques available, all compared to D&C under adequate anesthesia, are discussed in Chapter 35.

This section will discuss the therapeutic uses of hysteroscopy.

Indications & Contraindications

See Table 46–1.

Technique

Hysteroscopes exist as both flexible and rigid models. Operative hysteroscopes are rigid and typically 8–10 mm in external diameter. The outer sleeve encloses a fiberoptic light source, a channel used to introduce a medium to distend the uterus, and a channel through which probes, forceps, and electrocautery or laser instruments may be visually directed in the uterine cavity. Viewing angles vary from 0 to 70 degrees.

The uterine cavity, which is normally collapsed, must be distended by a medium. Carbon dioxide is used in the outpatient setting for diagnostic purposes. Low-viscosity, electrolyte-poor fluids include glycine 1.5%, sorbitol 3%, and mannitol 5%. These fluids can be used with monopolar devices during electrosurgery because they do not conduct electricity. Glycine 1.5% and sorbitol 3% are hypo-osmolar solutions. The use of these fluids can cause hyponatremia and decreased serum osmolality, which can lead to cerebral edema and death. Mannitol 5% is iso-osmolar and acts as its own diuretic. It may cause hyponatremia but not decreased serum osmolality. Low-viscosity electrolyte fluids include normal saline and lactated Ringer's solution. These fluids are isotonic, which decreases the risk of hyponatremia and decreased serum osmolality. Pulmonary edema can still occur, and therefore, careful attention should be paid to the fluid deficit. Two disadvantages to the use of electrolyte solutions are mixing of blood, which limits visualization, and the inability to use monopolar electrosurgery because these solutions are electroconductors. However, it is possible to conduct electrosurgery in electrolyte fluids using bipolar electrosurgical systems.

High-viscosity fluids include dextran-70, which is a colorless, viscous, polysaccharide solution. The advantage of using dextran is that it is immiscible with blood, which allows for clear visualization in the presence of bleeding. The disadvantage is that it is sticky, and when dry, can harden and crystallize into the equipment. Dextran can cause rare but serious complications including anaphylactic reactions, fluid overload, pulmonary edema, and coagulopathy. The manufacturer recommends that patients be followed closely for pulmonary edema in the following situations: the procedure lasts >45 minutes, absorption of more than 250 mL of dextran-70, resection of large areas of endometrium, or administration of intravenous fluids at more than maintenance rate. If pulmonary edema develops, the patient may need plasmapheresis, because dextran-70 contains mainly high-molecular-weight molecules that are excreted slowly or not at all from the kidneys. Beet sugar allergy is an absolute contraindication to using dextran-70. The volume of dextran-70 is usually limited to 300 mL but must not exceed 500 mL.

An abundance of instruments are available for use in hysteroscopic procedures, including blunt probes, microscissors, alligator clamps, rollerball electrode, wire loop for excision and coagulation (resectoscope), and devices for nonresectoscopic system endometrial ablation. Local or general anesthetics are chosen on the basis of expected hysteroscopic findings or procedures, concomitant operations planned, and the desires and cooperation of the patient. Most hysteroscopic examinations and virtually all therapeutic procedures are performed under general anesthesia. Following administration of anesthesia, the urinary bladder is drained, and the anterior lip of the cervix is grasped with a tenaculum. The cervix should then be gradually dilated to the same diameter as the external sleeve of the hysteroscope in order to provide a snug fit. An assistant must be constantly present during hysteroscopy to monitor uterine insufflation so that the pressure never exceeds 100 mm Hg and the flow rate of the distending medium never exceeds 100 mL/min. The chance of fluid overload is markedly increased when the mean infusion pressure exceeds the mean arterial pressure. The lowest infusion pressure needed to obtain good visualization should be used. The assistant and surgeon must monitor the fluid deficit closely to prevent volume overload. The surgeon should be sitting comfortably, with all instruments available to perform the hysteroscopic procedure safely and expeditiously. Following the procedure, intrauterine instruments should be inspected for their integrity. The microscissors in particular are delicate and could break within the uterus. If dextran is used, it must be immediately flushed from the hysteroscope before it is allowed to dry.

Complications

Hysteroscopic surgery is generally safe in experienced hands. The most common complications include cervical laceration (1–11%), hemorrhage (2.4%), and fluid overload (1.5%). Other complications include uterine perforation, visceral injury, carbon dioxide and air embolism, and rarely death. With laparoscopic observation, the serious complication of uterine perforation can almost always be prevented. If overt bleeding occurs during resection of a septum, polyp, or leiomyoma, the laparoscopic probe can be held against the uterine vessels to slow the blood flow. Alternatively, the bleeding area can be electrocoagulated, or a Foley catheter may be inserted into the uterine cavity and inflated to provide a tamponade. Infection is an unusual complication following hysteroscopy, and prophylactic antibiotics are not recommended. Air and carbon dioxide emboli are rare but serious complications that can result in circulatory collapse. Signs and symptoms of embolization include chest pain and dyspnea in the awake patient, sudden hypotension, decrease in oxygenation and/or in end-tidal carbon dioxide, or cardiac dysrhythmias in the anesthetized patient. Other findings include the presence of a “mill wheel” cardiac murmur, hypotension, tachycardia, or bradycardia. If gas embolization occurs, the patient should be placed in the left lateral decubitus position with the head tilted downward 5 degrees. This position favors movement of gas in the right ventricle toward the apex of the right ventricle. The gas may then be aspirated via cardiocentesis or by passing a catheter down the jugular vein into the right ventricle.

Complications of distending media include hyponatremia and pulmonary edema if an excessive amount results in vascular intervasation. The American College of Obstetricians and Gynecologists (ACOG) has adopted the following guidelines for fluid monitoring. (1) Hydration of patients should be monitored closely pre- and postoperatively. (2) If low-viscosity, electrolyte-poor fluids are used, the fluid deficit should be monitored at an extremely close interval when a deficit of 750 mL is reached. The procedure should be terminated in elderly patients, in patients with comorbid conditions, and in patients with cardiovascular compromise. (3) If fluid deficit reaches 1000–1500 mL of a nonelectrolyte solution or 2500 mL of an electrolyte solution, the procedure should be terminated. Electrolytes should be obtained, administration of diuretics should be considered, and further diagnostic and therapeutic interventions should begin as indicated. (4) In an outpatient setting with limited acute care and laboratory services, consideration should be given to terminate the procedure at a lower fluid deficit threshold. (5) An automated fluid monitoring system facilitates early recognition of excessive deficit in real-life totals. (6) In the absence of automated fluid monitoring, an individual should be designated to frequently measure intake and outflow and report the deficit to the operative team. Patients who need treatment for fluid overload from hypotonic agents may require transfer to an acute care facility and consultation. Seizure, permanent brain damage, and death have been reported with serum sodium levels of 112–118 mmol/L. If hyponatremia has existed for <24 hours, rapid correction can be made. However, if hyponatremia has existed for over 48 hours, rapid correction should not be undertaken due to the risk of neurologic compromise, seizures, and death. Consultation is strongly encouraged in these circumstances.

Prognosis

With proper selection of patients, hysteroscopic surgery has high success rates. Small pedunculated leiomyomas and polyps are usually retrieved by an experienced, patient surgeon. Submucous leiomyomas may be destroyed if they are not too vascular. In the treatment of intrauterine adhesions, the chance for success and restoration of a normal endometrial cavity depends on the density and extent of the adhesions and the area of normal endometrium remaining after dissection. Following hysteroscopic surgery for infertility in which the endometrium is denuded, postoperative estrogen therapy is prescribed by many physicians to promote rapid endometrial growth.

Both resectoscopic and nonresectoscopic endometrial ablation techniques exist and appear to be equivalent with respect to successful reduction in menstrual flow and patient satisfaction at 1 year (Table 46–2). Despite the high satisfaction rate, both resectoscopic and nonresectoscopic endometrial ablations are associated with hysterectomy rates of at least 24% within 4 years of the procedure.

Laparoscopy is a transperitoneal endoscopic technique that provides excellent visualization of the pelvic structures and often permits the diagnosis of gynecologic disorders and pelvic surgery without laparotomy.

Laparoscopes range in diameter from 3–12 mm and have lenses with a viewing angle ranging from 0–135 degrees. The instrument has an effective length of over 25 cm and can be used with a fiberoptic light box. To facilitate visualization, carbon dioxide (CO2) must be instilled into the peritoneal cavity to distend the abdominal wall.

Use of a pneumatic insufflator permits continuous monitoring of the rate, pressure, and volume of the gas used for inflation. In addition to the equipment used for observation, a variety of other instruments for resection, biopsy, coagulation, aspiration, and manipulation can be passed through separate ports or inserted through the same port as the laparoscope. Laparoscopic ports range in diameter from 3–20 mm in diameter. A laser (CO2 or Nd:YAG) may be used with the laparoscope.

The laparoscope has become an invaluable tool in both diagnostic and operative gynecologic procedures. However, its use requires considerable expertise, and it should always be used by a surgeon familiar with the management of complications. Laparoscopic procedures are major intra-abdominal operations performed through small incisions. This technique is rapidly performed and has a low morbidity rate and a short convalescence period. In many cases, laparoscopy may replace conventional laparotomy for diagnosis and treatment of gynecologic problems. It is a cost-effective outpatient procedure.

Indications

The indications will increase with the clinician's experience and as technical innovations permit even more complicated procedures.

Diagnosis

1. Differentiation between ovarian, tubal, and uterine masses (eg, ectopic pregnancy, ovarian cyst, salpingitis, myomas, endometriosis, and tuberculosis)

2. Pelvic pain (eg, possible adhesions, endometriosis, ectopic pregnancy, ovarian torsion or hemorrhagic ovarian cyst, salpingitis, appendicitis, and nongynecologic pelvic pain)

3. Genital anomalies (eg, ovarian dysgenesis, müllerian anomalies)

4. Ascites (eg, ovarian diseases vs. cirrhosis)

5. Pelvic injuries after penetrating or nonpenetrating abdominal trauma

6. Diagnosis of occult cancer

Evaluation

1. Infertility (eg, tubal patency, ovarian biopsy)

2. “Second look” after tubal surgery or treatment of endometriosis

3. Peritoneal washings for cytology study

4. Peritoneal culture (eg, Actinomyces or tuberculosis)

5. Evaluation of uterine perforation

6. Evaluation of pelvic viscera to determine the feasibility of vaginal hysterectomy

Therapy

1. Tubal sterilization:

   1. Electrical: Unipolar or bipolar technique

   2. Mechanical: Silastic bands or rings, metal clips

2. Lysis of adhesions, with or without laser

3. Fulguration of endometriosis by laser or thermal cautery

4. Removal of extruded IUD

5. Uterosacral ligament division (denervation)

6. Treatment of ectopic pregnancy

7. Myomectomy

8. Salpingostomy for phimotic fimbria

9. Removal of tuboplastic hoods or splints

10. Ova collection for in vitro fertilization

11. GIFT (gamete intrafallopian transfer for fertilization)

12. Mini-wedge resection of ovary

13. Biopsy of tumor, liver, ovary, spleen, omentum, etc

14. Placement of intraperitoneal clips as markers for radiotherapy

15. Oophorectomy

16. Ovarian cystectomy

17. Laparoscopic-assisted vaginal hysterectomy, laparoscopic subtotal hysterectomy, and laparoscopic hysterectomy

18. Reconstructive surgery for pelvic organ prolapse and urinary incontinence

Contraindications

Absolute

Intestinal obstruction, generalized peritonitis, massive hemorrhage.

Relative

Severe cardiac or pulmonary disease, previous periumbilical surgery, shock, cancer involving anterior abdominal wall.

Additional factors weighing against performing laparoscopic surgery include extremes of weight, intrauterine pregnancy after the first or early second trimester, presence of a large mass, inflammatory bowel disease, and known severe intraperitoneal adhesions.

Preparation for Laparoscopy

Careful explanation of the risks and benefits of the planned procedure must be given to each patient prior to surgery. The risk of visceral and vascular injuries and the need to convert to laparotomy should be discussed with all patients. Patients with prior abdominal surgery, prior pelvic inflammation (appendicitis and pelvic inflammatory disease), or radiation therapy should be told that they are at increased risk of visceral or vascular injury or conversion to laparotomy. Preparation includes no solid food for at least 8 hours prior to surgery, no liquids for more than 6 hours preoperatively, a history and physical examination, and routine blood studies. Preoperative bowel cleansing can aid in visualization during surgery by decompressing the small bowel and sigmoid colon. Abdominal or perineal shaving is usually unnecessary, but skin preparation with an antiseptic is routine. Antibiotic prophylaxis is not recommended because the frequency of wound infection is low.

Anesthesia

Local anesthesia, local anesthesia with systemic analgesia, spinal or epidural block techniques, or general anesthesia with or without endotracheal intubation may be used. Special hazards of anesthesia exist (eg, reduced diaphragmatic excursion because of the pneumoperitoneum and because the patient may be operated on in the Trendelenburg position). Because of these factors, most procedures in the United States are performed with the patient under general anesthesia with endotracheal intubation. With adequate understanding of the physiology involved, effective anesthesia and laparoscopy can be accomplished safely.

An alternative to general anesthesia is local anesthesia with intravenous sedation. The patient may experience transient discomfort during manipulation of the uterine tubes, but in selected patients, this discomfort is easily tolerated.

Surgical Technique

The patient should be placed with her arms at her sides in the dorsal lithotomy position and draped after induction of anesthesia and preparation of the abdomen and pelvic area. The video monitor should be placed in a position that allows for easy viewing by the surgeon, usually at the patient's feet or side. The bladder must be emptied by catheterization to decrease the risk of injury during subsequent introduction and use of other instruments. After careful bimanual examination, a tenaculum is attached to the cervix, and a uterine manipulator (Hasson, HUMI, Hulka, etc.) is placed into the cervical canal to elevate the uterus, which places tissue on tension. A 1-cm incision is made within or immediately below the umbilicus. The peritoneal cavity is entered blindly with a veress needle advanced at a 45-degree angle toward the hollow of the sacrum. Alternatively, the pelvis can be entered by using a trocar-cannula system or under direct visualization via a mini-laparotomy called “open laparoscopy.” Direct insertion of a cannula-trocar system can be accomplished safely if there have been no previous peritonitis or abdominopelvic surgeries. Open laparoscopy minimizes the risk of vascular injuries but does not eliminate intestinal injuries. Carbon dioxide should then be introduced and monitored by the pneumatic insufflator. The amount of gas insufflated will vary with the patient's size, the laxity of the abdominal wall, and the planned procedure. In most patients, 2–3 L of gas will be needed to obtain adequate visualization. The maximum insufflation pressure should not exceed 15 mm Hg. If a veress needle is used, it is withdrawn and the laparoscopic trocar and cannula inserted. After proper abdominal entry, the trocar may be withdrawn and replaced with the fiberoptic laparoscope. The examiner manipulates the intrauterine cannula so that the pelvic organs can be observed. To test for tubal patency, methylene blue or indigo carmine solution can be injected through the intrauterine cannula. Direct observation of a lack of dye leakage attests to tubal patency. A second trocar with a cannula may be inserted under direct laparoscopic vision through a 5-mm transverse midline incision at the pubic hairline. Additional punctures are used as necessary for the placement of other instruments. A number of instruments are available including irrigators, the harmonic scalpel, forceps, scissors, staple applicators, and several vessel sealing and transection systems. Surgical knots may be tied and sutures placed using specially made equipment.

The operation is terminated by evacuating the insufflated gas through the cannula, followed by removal of all instruments and closure of the incisions. The skin can be closed with 3-0 subcuticular suture, skin glue, or steri-strips. Incisions >10 mm require fascial closure to avoid incisional hernias. A small dressing is applied to the wound.

Sterilization

Electrical cautery, Silastic rings or bands, and metal spring clips achieve sterilization by occluding the fallopian tubes. The advantages or disadvantages of the different techniques are of less significance than the skill with which a physician can perform any one technique; therefore, choice of method should depend on which technique is most comfortable for the physician. The failure rate of most sterilization methods is greater in women <28 years old.

Cautery

Laparoscopic sterilization with electrical cautery is one of the most common laparoscopic sterilization methods. Unipolar coagulation has a significantly lower pregnancy rate than bipolar coagulation (7.5/1000 vs. 24.8 over 10 years); however, bipolar coagulation is less likely to cause injury to adjacent structures (eg, bowel). At least 3 cm of the isthmic portion of the tube must be completely coagulated by using sufficient energy (25 W) delivered in a cutting waveform when using bipolar coagulation. The use of a current meter more accurately indicates complete coagulation than visual inspection. Generally, the tube is burned at 2 to 3 different locations, and division of the tube by cutting is not necessary.

Silastic Bands

Tubal occlusion with Silastic bands or rings results in a slightly higher pregnancy rate (17.7/1000 over 10 years) but fewer ectopic pregnancies. Mechanical problems in placement of the bands and bleeding from the tubes during the procedure are more common.

Clips

Tubal occlusion with clips (Hulka or Filshie clips) has a wide range of failure. Failure rates are higher for the Hulka clip (36.5/1000 over 10 years) than for the Filshie clip (0–4/1000 over 6–10 years). The advantages of using clips are that only a small portion of the tube is damaged (thus increasing the chance of successful sterilization reversal if the patient has regret) and that inadvertent burn injury to the bowel is avoided.

Interval Partial Salpingectomy

Compared to postpartum tubal ligation, interval partial salpingectomy has a higher failure rate of 20.1/1000 over 10 years.

Infertility

In procedures of sterilization reversal, laparoscopic visualization may be needed prior to reanastomosis, particularly if the ligation procedure involved electrocautery. Peritubal adhesions may be lysed with electric scissors, and salpingostomy may be accomplished. The minimal trauma of these procedures using laparoscopy and the saving of a major operative procedure are obvious benefits. Laparoscopy should be considered for women with complaints of abnormal bleeding and unexplained pelvic pain. More liberal use of the laparoscope has led to the diagnosis of many unsuspected cases of endometriosis.

Electrical fulguration of areas of endometriosis or laser destruction of these diseased areas by laparoscopy is a safe, effective, and rapid treatment. The use of laser obviously allows implants on structures such as bowel, bladder, and the fallopian tubes to be treated with a fairly wide margin of safety. Relief may be immediate and striking, whether the woman has complained of dysmenorrhea, dyspareunia, or generalized pelvic pain.

In infertility, the laparoscope has been important for ova collection for in vitro fertilization, GIFT, and other procedures. However, it is used less frequently now because most egg retrievals for in vitro fertilization are performed under ultrasound guidance.

Ectopic Pregnancy

In hemodynamically stable patients, laparoscopic linear salpingostomy is the preferred method for conservative management of tubal pregnancies. According to a recent Cochrane Database systematic review, the laparoscopic approach is less successful than the open approach in the elimination of tubal pregnancy due to the higher rate of persistent trophoblast tissue. However, it is feasible in virtually all patients, safe, and less costly compared to the open approach. Long-term follow-up shows a comparable intrauterine pregnancy rate and a lower repeat ectopic pregnancy rate. Persistent trophoblast tissue after laparoscopic salpingostomy can be significantly reduced after a prophylactic single dose of systemic methotrexate. An alternative conservative approach for those who meet the criteria is methotrexate administration.

Laparoscopic Hysterectomy

Laparoscopy can be used for total laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, and laparoscopic subtotal hysterectomy (see section on hysterectomy). Other procedures that can be done via the laparoscope include vault suspension and pelvic reconstruction such as retropubic Burch colposuspension and abdominal sacral colpopexy.

Abdominal & Pelvic Pain

Laparoscopy has proved invaluable in differentiating various causes of acute and chronic pain. The technique may save the patient the necessity of a major exploratory operation. Fluid aspiration and tissue biopsy are possible through laparoscopy. Also, pelvic and intestinal disease can be differentiated. The appendix may be visualized and acute appendicitis may be diagnosed. Numerous cases of pain caused by intra-abdominal adhesions also have been diagnosed by laparoscopy, and relief has been obtained following laparoscopic adhesion resection.

Trauma

In cases of intra-abdominal trauma, laparoscopy can be used to exclude the need for a major abdominal operation.

Miscellaneous

“Missing” IUDs have been removed from the intra-abdominal cavity. Mulligan plastic hoods from tuboplasty procedures, “lost” drains, and other foreign material have been removed from the abdomen by operative laparoscopy.

Postsurgical Care

Patients may be sent home following full recovery from anesthesia, usually in 1–2 hours. Recovery from more extensive procedures such as laparoscopic hysterectomy may require a longer hospital stay of 1–2 days. Postoperative pain is usually minimal, and patients are discharged with a prescription for a simple oral analgesic. The most common complaint is shoulder pain secondary to subdiaphragmatic accumulation of gas. Patients are encouraged to resume full activity, except for sexual relations, the day following surgery. Sexual relations may be resumed several days postoperatively after a simple procedure (eg, tubal ligation). Following extensive operative laparoscopy or other gynecologic procedures, coitus should be delayed for an appropriate interval (ie, until it is unlikely to cause discomfort or damage to the operative site). Patients should routinely be seen in the office 1–2 weeks postoperatively.

Complications

A review of the world experience of laparoscopic gynecologic operations, including 1,549,360 patients, showed an overall complication rate ranging from 0.2–10%. Higher complications rates were noted with prospective studies. The frequency of complications was less for nonoperative or minor procedures (0.06–7.0%) than for major operations (0.6–18%). Complications requiring conversion to laparotomy have been estimated to be 2.1% and are most commonly due to major vascular and intestinal injuries. The readmission rate to the hospital has been quoted to be 0.4–0.5%. The mortality rate for laparoscopy including 1,374,827 patients is 4.4 per 100,000 laparoscopies. The major causes of death are due to intestinal and vascular complications and anesthesia.

Vascular Injuries

Major vascular injuries are infrequent (0.01–0.5%) and are almost 5 times more frequent during blind entry than during the laparoscopic operation itself. Catastrophic bleeding can occur if the aorta; inferior vena cava; or common, internal, or external iliac arteries and veins are injured. The mortality rate due to major vascular injuries is between 9 and 17%, and immediate conversion to laparotomy is almost always needed. Massive bleeding is often concealed in large retroperitoneal hematomas, and often only a small amount of intraperitoneal bleeding is seen. Open laparoscopic technique minimizes the risk of major vascular injury, but aortic injury has been reported in thin patients caused by the scalpel during the skin incision. The incidence of abdominal wall bleeding is 0.5%, and most injuries involve the inferior epigastric vessels (deep and superficial) and muscular vessels. Major bleeding requiring transfusion has been observed. The inferior epigastric vessels run in the lateral umbilical ligaments, and contrary to common belief, the inferior epigastric vessels cannot be seen via transillumination by the laparoscope. These are best avoided by placing the trocars lateral to the insertion of the round ligament into the anterior abdominal wall or 1–2 cm lateral to McBurney's point (one-third the way between the anterior superior iliac spine and the umbilicus).

Intestinal Injury

Bowel injuries are uncommon (0.03–0.5%) but have a mortality rate of 2.5–5%. The colon and small bowel are injured at about the same rate, and they can be injured sharply or via thermal burns. About one-third are related to entry, and the rest are due to operative procedures. Unfortunately, most bowel injuries are not recognized intraoperatively (mean 4.4 postoperative days), likely due to the fact that most patients with laparoscopic intestinal injury do not present with the typical clinical signs of bowel perforation. Most patients present with low-grade fever, leukopenia, or normal leukocyte count. Pain at the trocar site near the injury, abdominal distention, and diarrhea with normal bowel sounds were commonly seen. Peritoneal signs, severe pain, nausea, vomiting, and ileus were uncommon, in a review of 266 cases of intestinal injury. Open laparoscopy has a similar rate of bowel injuries, but they are recognized more commonly intraoperatively.

Urinary Injuries

Urinary injuries during laparoscopy have a similar rate to open procedures (0.02–1.7%). Bladder injuries are more common than ureteral injuries and are recognized more frequently intraoperatively. About two-thirds of urinary injuries occur during laparoscopic-assisted vaginal hysterectomy.

Hernia at Site of Abdominal Wall Trocar

Ventral hernia formation is about 10 times lower with laparoscopy compared with laparotomy (0.06–1% vs. 11–13%). Five-millimeter trocar wounds do not require closure, whereas larger trocar wounds do. Most surgeons close incisions greater than 10 mm, due to the high rate of hernias. Richter's hernias, where only a portion of the intestinal wall is entrapped in a defect of the peritoneum or posterior fascia, can be difficult to diagnose, since an externally visible bulge is often absent. The condition needs a high index of suspicion and can be diagnosed with an ultrasound or computed tomography scan.

Subcutaneous Emphysema & Gas Embolisms

Localized or generalized subcutaneous emphysema occurs in 0.3–2% of cases and generally has no clinical consequences. However, subcutaneous emphysema of the neck, face, and chest may be a manifestation of a pneumothorax or pneumomediastinum.

Postoperative Shoulder Pain

Pain from diaphragmatic irritation can be referred to the shoulder causing discomfort. Irritation of the diaphragm by the formation of carbonic acid (due to use of CO2), stretching of the phrenic nerve by pneumoperitoneum, or pressure from the abdominal organs during Trendelenburg position are possible etiologies. It can be treated with mild analgesics and reassurance.

Sterilization is a permanent method of contraception and is the most commonly used contraceptive method used in the United States. Approximately 700,000 tubal sterilizations and 500,000 vasectomies are performed in the United States annually.

Tubal Sterilization

Thirty-three percent of US women use sterilization as their contraceptive method, and of those, 27% had tubal sterilization and 9% had partners who had a vasectomy. Table 46–3 lists the most common methods of tubal sterilization and their failure rates.

Preoperative Counseling

Clear, comprehensive counseling is essential for women who are considering tubal sterilization. Possible medical and psychological complications must be carefully outlined (see Complications, later); women are more likely to regret having had the operation if they do not know what to expect. The physician should be alert to signs that the patient is undecided about having the operation or is being pressured by her partner or others. Regret or dissatisfaction is more common if the procedure is done postpartum than at another time, and these women are more than twice as likely to feel that preoperative counseling was inadequate. Temporary stress associated with the pregnancy may have influenced a premature decision for sterilization in these women.

Patients should be told that tubal sterilization is usually not reversible. Some methods are sometimes reversible (see Chapter 58). Most studies estimate that about 1–2% of women who undergo tubal sterilization request reversal. The major risk factor for subsequent regret of sterilization is young maternal age (younger than age 30 years) at the time of sterilization. Collaborative Review of Sterilization (CREST) study data showed that women who were younger than 30 years at the time of sterilization were twice as likely to seek information about reversal as women between age 30 and 34. Another major risk factor for regret is marital disharmony at the time of sterilization. In addition, women who have postpartum sterilization are more prone to regret than are women who have interval sterilization. Parity has not been found to be a significant risk factor for regret when controlling for maternal age. Pregnancy rates after tubal ligation reversals range from 55–90% by laparotomy and 31–78% via laparoscopy. Success of tubal ligation reversal depends on the woman's age at the timer of reversal (<35 years old) and length of remaining fallopian tube segment (>4 cm). Some studies have found improved pregnancy results when the initial sterilization procedure was performed using mechanical techniques rather than electrocautery.

Complications

Pain and menstrual disturbances (postbilateral tubal ligation syndrome) have been reported following tubal sterilization. The theory holds that destruction of the mesosalpinx might alter the blood supply and subsequent gonadotropin delivery to the ovary. Ovarian function and hormone production may then be altered. However, prospective controlled studies show that these problems are no more common than in women who have not undergone sterilization. Menstrual changes seem to be related to use of contraceptives—before sterilization. Oral contraceptives are associated with decreased menstrual flow and relief of dysmenorrhea. Once they are discontinued, heavier flow and pain may recur. Complaints of menstrual changes are much less frequent in the second half of the first postoperative year. Patients should be told that pelvic pain or menstrual disturbances may develop after tubal sterilization but are no more common than in other women of similar age and parity.

Patients who have undergone tubal sterilization require hysterectomy more frequently than patients who have not undergone this procedure. This is probably because most women who have tubal sterilizations have had children and are therefore more likely to have disorders typically treated with hysterectomy (eg, symptomatic pelvic relaxation, adenomyosis). Patients may have been sterilized secondary to medical reasons and gynecologic disorders that might eventually require further surgery. Some studies suggest that women are more likely to accept a surgical treatment if they have been sterilized.

Failure of sterilization is most often secondary to poor technique, for example, improper application of a clip or ring. Fistula formation may occur. A complication of failure is ectopic pregnancy (7.3 per 1000).

An association between decreased risk of ovarian cancer and tubal sterilization has been shown in several studies.

Technique (See Figs. 46–1 through 46–4).

Postpartum tubal ligation uses a small infraumbilical incision to access the tubes. Mini-laparotomy involves a 2- to 3-cm incision made above the symphysis pubis. The incision is closed in 2 layers.

Hysteroscopic Microinsert Placement

A hysteroscopic tubal sterilization technique (Essure) was approved by the US Food and Drug Administration in 2002 (Fig. 46–5). It consists of a fallopian tube implant and a delivery catheter. The implant is a spring-like device 40 mm in length and 0.8 mm in diameter. It is made of titanium, stainless steel, and nickel that contain Dacron fibers that induce an inflammatory response and final fibrosis of the intramural tubal lumen. The implant is placed into the fallopian tube using a standard hysteroscope (<5 mm) with a 5-French working channel with continuous flow of normal saline. When released, the outer coil expands, which anchors the implant into the fallopian tube. Three to 8 coils should remain in the uterus for optimal placement. The procedure can be performed in the outpatient setting using oral analgesics alone or under local anesthesia with or without intravenous sedation. Hysterosalpingogram should be performed 3 months after the procedure to confirm closure of the fallopian tubes. The patient needs to use an alternative form of contraception until tubal occlusion is documented.

A recent systematic review showed that the bilateral placement success rate was 81–90% with up to 2 attempts. At 3 months postprocedure, 3.5% of patients did not show tubal occlusion, but after 6 months, all women with successful placement showed total occlusion. The Essure system has been shown to be safe, but unintended pregnancies have been reported (64 in 50,000 procedures). The majority of unintended pregnancies occurred in patients with inappropriate follow-up. However, misinterpreted hysterosalpingograms, undetected preprocedure pregnancies, and failure to follow product-labeling guidelines have also led to unintended pregnancies.

Other Methods of Female Sterilization

Because of relatively high morbidity and mortality rates in comparison with tubal occlusion procedures, hysterectomy is justified for sterilization only if there is another unequivocal indication for hysterectomy. Transvaginal tubal ligation via culdotomy or culdoscopy is technically more difficult than transabdominal sterilization and has a higher infection rate. However, there may be less discomfort postoperatively.

Vasectomy

Vasectomy, or vas occlusion, accounts for 9% of sterilizations in the United States. Partial vasectomy is usually done under local anesthesia via a small incision in the upper outer aspect of the scrotum (Fig. 46–6). Sutures or clips are placed tightly around the vas, demarcating a 1- to 1.5-cm segment, which is then excised. The ligated and fulgurated ends are tucked back into the scrotal sac, and the incision is closed. The same procedure is performed on the opposite side. The no-scalpel technique requires no incision because a sharpened dissection forceps is used to pierce the skin and dissect the vas. Microscopic examination confirms excision of vasal tissue.

Vasectomy is as effective as tubal sterilization with a reported failure rate of <1%. Half of the vasectomy failures in the CREST study occurred within 3 months of the procedure. Thus, sterility is assumed only after ejaculates are completely free of sperm after 3 months and after periodic microscopic analysis.

Complications are infrequent, usually involving slight bleeding, hematoma formation, skin infection, and reactions to sutures or local anesthetics.

Hysterectomy is complete surgical removal of the uterus. It is the most common gynecologic surgery and second most common major operation performed in the United States with over 600,000 hysterectomies performed between 2003 and 2004. With advancements in medical and conservative surgical therapy of gynecologic conditions, the need for hysterectomy has declined, with small decreases in rates between 1997 and 2004. More women now wish to avoid major surgery if equally efficacious alternatives exist. Regulatory boards of gynecologists now support the use of hysterectomy as treatment for conditions refractory to more conservative management.

Indications

The indications for hysterectomy can be practically divided into those for the treatment of gynecologic cancer, benign gynecologic conditions, and obstetric complications. Hysterectomy for cancer of the uterus, ovary, and cervix is discussed in Chapters 47–50. Hysterectomy for obstetric complications, including excessive bleeding and molar pregnancy, is becoming less common (see Chapter 21).

The most common benign diseases and disorders (the indication for >90% of surgeries) that warrant hysterectomy are shown in Table 46–4.

Preoperative Evaluation

Diagnostic Tests to Detect Occult Cancer

Prior to hysterectomy, all patients should have a baseline evaluation to detect occult cancer. A Pap smear should be performed within 3 months before operation, and abnormalities should be followed with colposcopic examination with biopsy and endocervical curettage before surgery. Cervical conization is indicated prior to hysterectomy if (1) colposcopy fails to demonstrate the entire squamocolumnar junction, where cervical cancers typically arise; (2) colposcopically guided biopsies reveal cervical intraepithelial neoplasia I or less after a preceding high-grade squamous intraepithelial lesion Pap smear; (3) endocervical curettage demonstrates atypical endocervical cells; and (4) biopsy reveals microinvasive squamous cell carcinoma or squamous adenocarcinoma in situ. Cervical conization for the last scenario is performed to ensure that occult invasive cancer is not present. Frozen-section analysis of cervical conization tissue correlates well enough with “permanent” (hematoxylin and eosin) slide analysis that if intraepithelial neoplasia with clear margins is found, the surgeon may, with reasonable certainty, perform a hysterectomy that will totally include the tumor.

Biopsy for endometrial neoplasia must also be considered in certain clinical scenarios. Generally any woman over age 35 who presents with abnormal uterine bleeding should undergo endometrial evaluation (endometrial biopsy with pipelle, D&C, or hysteroscopy with directed biopsies) before hysterectomy. However, certain clinical situations that produce an unopposed estrogen effect on the endometrium warrant preoperative endometrial evaluation at any age: chronic anovulation and secondary oligomenorrhea, unopposed estrogen therapy for menopause, and known ovarian disorders associated with endometrial neoplasia (eg, polycystic ovarian syndrome, granulosa cell tumors). Unfortunately, frozen-section analysis of endometrial curettings is neither practical nor accurate, so hysterectomy usually must wait for permanent section.

Occult cancer may also be present outside the genital tract. All patients should have their stool checked for occult blood preoperatively. In women 40 years of age or older, mammography is standard.

Preoperative Evaluation of the Pelvis

In the woman with a small, mobile uterus with mobile adnexa, little diagnostic evaluation beyond bimanual examination is indicated. However, pelvic disease may have caused disturbance of normal tissue planes that endanger the urologic and gastrointestinal tracts. The following conditions may indicate the need for more extensive evaluation of the pelvis prior to hysterectomy: (1) pelvic inflammatory disease, especially if repeated, chronic, or associated with a tubo-ovarian complex; (2) endometriosis; (3) pelvic adhesions due to other causes of pelvic inflammation (eg, appendicitis, cholecystitis, previous pelvic surgery); (4) chronic pelvic pain; (5) questionable origin of a palpable pelvic mass; and (6) clinical suspicion of cancer (eg, palpable adnexa in a postmenopausal woman).

The most commonly used preoperative adjunctive diagnostic evaluation is pelvic ultrasound, which has advantages over computed tomography (CT) scan. Ultrasound is helpful in detecting masses in the difficult-to-examine patient (eg, obese) and in confirming a pelvic mass detected on bimanual examination.

Intravenous pyelography (IVP) or CT urogram is helpful in delineating the course of the ureters through the pelvis especially in the setting of inflammatory conditions that could distort or obstruct the ureters. Also, patients with known genital developmental anomalies should have preoperative imaging to look for concomitant urologic anomalies.

Prehysterectomy evaluation of the colon (beyond screening for occult blood in the stool) is indicated in any patient with symptoms for rectal disease. In most cases, proctoscopy or flexible proctosigmoidoscopy is sufficient. In cases of severe pelvic inflammation, chronic pelvic pain, or suspected cancer, complete colonoscopy or barium enema is indicated. Preoperative diagnosis of bowel disease will aid in the selection of the incision. If necessary, a consultant gastrointestinal surgeon can be present during the operation.

Preoperative Bowel Preparation

Preoperative bowel preparation is not required prior to hysterectomy. It has been a common practice in the past to use a mechanical bowel preparation prior to hysterectomy in patients where the likelihood of bowel injury is high. However, recent data in the colorectal literature have refuted these practices. Preoperative mechanical bowel preparation is associated with increased spillage of bowel contents during elective colon resection and leads to a higher rate of anastomotic leaks and wound infections compared to no mechanical bowel preparation.

Prophylactic Antibiotics

The incidence of febrile morbidity is approximately 14% in patients undergoing hysterectomy. Certain risk factors are associated with a higher likelihood of operative site infection. These factors include an abdominal surgical approach, blood loss greater than 750 mL, and no preoperative antibiotics. ACOG also recommends giving additional doses of intraoperative antibiotics during lengthy operations, given at intervals of 1 or 2 half-lives of the drug. A second dose of the prophylactic antibiotic may also be given in surgical cases with a blood loss >1500 mL. Patients diagnosed with a vaginal infection during preoperative evaluation should be treated prior to surgery.

A broad-spectrum antibiotic should be chosen that is effective against common (but not necessarily all) pathogens causing pelvic infection. The agent should have a low incidence of toxicity and side effects and should be easily administered and cost-effective. The proper dosage should be administered 30 minutes prior to incision to achieve therapeutic levels in tissue at the surgical site. It should not be an antibiotic reserved for serious infection. ACOG recommends intravenous (IV) cefazolin (1–2 g IV), clindamycin (600 mg IV), plus either gentamicin 1.5 mg/kg IV) or quinolone (400 mg IV) or aztreonam (1 g IV), or metronidazole (500 mg IV) plus gentamicin (1.5 mg/kg IV) or quinolone (400 mg IV) prior to vaginal or abdominal hysterectomy.

Thromboembolism Prophylaxis

Hysterectomy is a major surgical procedure, carrying at least a moderate risk of thromboembolism. The risk of calf vein thrombosis, proximal vein thrombosis, and pulmonary embolism can be minimized with the use of graduated compression stockings perioperatively and early ambulation postoperatively. Sequential compression devices will help prevent stasis as well. Compression stockings and devices should be in use prior to administration of anesthesia for optimal effect. For patients at high risk for thromboembolic disease, a dose of 5000 U subcutaneous heparin is given preoperatively and then every 8–12 hours postoperatively while in the hospital. Risk factors include malignancy, obesity, previous radiation therapy, immobilization, estrogen use, prolonged anesthesia, radical surgery, history of thromboembolism, nephrotic syndrome, HIV, and personal or family history of hypercoagulability (inherited thrombophilia). Low-molecular-weight heparin may also be used postoperatively.

Blood Products

It is not necessary to preoperatively cross-match all patients undergoing hysterectomy. Women who are not at particular risk of needing a transfusion during hysterectomy should at least have blood typing and antibody screening prior to surgery. Patients undergoing peripartum hysterectomy or hysterectomy for gynecologic cancer are more likely to need blood transfusion. Patients undergoing elective hysterectomy are more likely to need a transfusion if the starting hematocrit is low (30%), if they have pelvic inflammatory disease or pelvic abscess or adhesions, or if colporrhaphy is performed at the time of vaginal hysterectomy.

Informed Consent

Many women desire, and most insurance companies require, a second opinion prior to scheduling an elective hysterectomy. The patient must understand the diagnosis and be aware of alternative therapies (medical or conservative surgical options) and the risks and benefits of the operation. Common risks of surgery such as wound infection, cuff cellulitis, and blood loss are usually explained during preoperative counseling. The current medicolegal climate mandates the discussion of unusual complications, including the possibility of completing a vaginal or laparoscopic operation via an abdominal route and the risks of viral illness following transfusion, severe postoperative infection (including adnexal abscess), and vaginal vault prolapse.

Technique

Vaginal versus Abdominal Hysterectomy

The route of hysterectomy is chosen according to the following guidelines.

Pelvic Anatomy

The ideal candidate for vaginal hysterectomy has a gynecoid pelvis with a wide pubic arch and a vaginal apex >2 fingerbreadths at the apex. Some descent of the uterus is helpful but not mandatory; procidentia makes for a more complicated vaginal hysterectomy because of the greater vulnerability of the prolapsed ureters.

Uterine Size

Most gynecologists will perform vaginal hysterectomy on a uterus equivalent in size to a uterus at 12 weeks' gestation or smaller or a uterine weight of <280 g. More experienced surgeons have successfully removed uteri of up to 1200 g vaginally using bivalve and morcellation techniques.

Adnexa

In patients with symptoms or pelvic findings suggesting adnexal disease that may indicate adnexectomy, the abdominal route for hysterectomy is preferred. In addition, most surgeons offer patients the option of prophylactic removal of the ovaries after age 45 years old to decrease the risk of ovarian cancer, in spite of the lack of supporting evidence. Such patients may still undergo vaginal removal or laparoscopic-assisted vaginal hysterectomy if otherwise a good candidate for these routes.

Gastrointestinal Tract

Especially in older patients or those with significant history of gastrointestinal complaints, the abdominal approach offers an opportunity for complete examination of the bowel.

Urologic Disorders

Symptomatic or potential stress urinary incontinence can be treated vaginally (suburethral sling) or abdominally (retropubic urethropexy; see Chapter 42). The route of the hysterectomy should depend on the size of the uterus and not on the planned surgical procedure for the incontinence.

Pelvic Organ Prolapse

Pelvic organ prolapse can be treated via a vaginal, laparoscopic, robotic, or abdominal approach, and the choice of route is often surgeon dependent (see Chapter 42)

Medical Disorders

In patients with significant heart or lung disease, the vaginal or laparoscopic approach is preferable when possible because of a lower incidence of postoperative pulmonary complications and earlier ambulation.

Previous Surgery

Most surgeons are willing to perform a vaginal hysterectomy in patients with previous tubal ligation or caesarean section. The surgery would be more problematic in patients with a history of multiple caesarean births or complications (eg, postpartum endomyometritis) or with probable abdominal adhesions from previous laparotomy. Laparoscopic-assisted vaginal hysterectomy may be used in these situations.

The preceding guidelines may certainly be adjusted to the individual patient based on the surgeon's experience and abilities. An examination performed under anesthesia when the physician first sees the patient may help to decide on the approach. Uterine size can be assessed with transvaginal ultrasound. Laparoscopic evaluation of the adnexa will further aid in the decision. All patients anticipating vaginal hysterectomy, laparoscopic hysterectomy, or laparoscopic-assisted vaginal hysterectomy should be told that the operation may have to be completed abdominally if difficulties arise.

Abdominal Hysterectomy

The technique of abdominal hysterectomy varies according to the indication for the operation, the size and placement of vital structures including the ureters (which may be distorted), and the pelvic anatomy. A standard, well-organized approach to abdominal hysterectomy is essential to avoid incidental injury. Modifications are made as necessary, always within an organized plan of operation.

The anesthetic of choice typically includes general endotracheal intubation, an inhalation agent, and an analgesic. Hysterectomies are of such duration and risk that using a mask alone is unwise. In patients with pulmonary compromise, spinal or epidural anesthesia may be used.

A sterile scrub of the abdomen and vagina is done, and a urinary catheter is placed so that the anesthesiologist can monitor urine output intraoperatively. The choice of incision is based on the suspected disease, prior surgeries/incisions, patient preference, and uterine size; in general, a midline incision extending from 2 fingerbreadths above the pubic symphysis to the umbilicus offers the greatest exposure. One modification of the low transverse incision to improve exposure is the Maylard muscle-splitting procedure or the Cherney detachment of the rectus muscles from their insertion on the pubic symphysis. For an uncomplicated hysterectomy with a small uterus, a Pfannenstiel incision is usually sufficient.

The surgeon and assistants should rinse excessive talcum powder from their gloves before making the incision to prevent granulomatous tissue reaction in the wound. Once the incision is complete, peritoneal fluid may be aspirated if the possibility of gynecologic cancer exists. The pelvic organs are then inspected and the upper abdomen palpated in a systematic fashion: right gutter, right hemidiaphragm, liver, gallbladder, pancreas, stomach (assessing the position of the indwelling gastric decompression tube if present), and spleen and right hemidiaphragm (gently, because of the risk of trauma to the spleen), left gutter, para-aortic lymph nodes, and omentum. Excessive bowel manipulation should be avoided to decrease the severity of postoperative adynamic ileus; at the least, the appendix and cecum should be inspected as well as the terminal meter of ileum. Older patients and those with gastrointestinal complaints would benefit from careful palpation and inspection of the bowel from rectum to ligament of Treitz. If desired, the wound may be protected with moist towels, a self-retaining retractor placed, and the bowel packed into the upper abdomen.

The classic extrafascial hysterectomy performed by Richardson remains the mainstay of surgical technique in abdominal hysterectomy. Choice of suture and needle is made according to surgeon experience and preference; 2-0, 0, or 1 absorbable sutures on half-curved taper needles are standard choices. The uterus is grasped either by the fundus with a Massachusetts double-toothed clamp or at the cornua with Ochsner or Kocher clamps. The round ligament is grasped proximal to the uterus; at its midportion, it is ligated by suture, and the suture is tagged with a small hemostat. The round ligament is divided about 0.5 cm proximal to the suture, thus opening the broad ligament at its apex. The anterior uterine peritoneum may be incised at the vesicouterine junction in preparation for advancement of the bladder. The peritoneum only should be incised; the potentially vascular areolar tissue should be avoided. When this procedure is repeated on the contralateral side, the anterior leaves of the broad ligament are opened; the uterine vessels first become apparent. Attention is then directed to the posterior leaf of the broad ligament.

The posterior leaf of the broad ligament is incised beginning at the ligated round ligament. The extent of the incision is determined by the decision to preserve or remove the adnexa. If the adnexa are to be removed, the peritoneum is incised parallel to the infundibulopelvic ligament to the pelvic sidewall; the loose areolar tissue is dissected medial to the internal iliac (hypogastric) artery, which is typically 0.5 cm thick with a visually appreciable (and certainly palpable) pulse. The dissection will reveal a clear area of peritoneum under the infundibulopelvic ligament; below this area at a variable distance lays the ureter on this medial leaf of peritoneum.

The intimate proximity of the ureters to the uterus makes ureteral identification important. Whereas the ureter is usually 4–6 cm deep to the infundibulopelvic ligament at the lateral margin of the uterus, it is only 0.5–2 cm below this vascular bundle at the level of the pelvic brim. Observing the ureter through the peritoneum or palpating the characteristic “snap” of the ureter should serve only to guide dissection and should not be a substitute for identification of the entire ureter through its pelvic course. The ureter tolerates careful dissection well as long as its blood-carrying adventitia is not stripped away. The ureter can always be found and dissection begun at the pelvic brim, where the ureter passes over the bifurcation of the iliac artery. The most serious ureteral injury is the unrecognized insult. The most common ureteral injuries during hysterectomy occur during ligation of the infundibulopelvic ligament, clamping and suture ligation of the uterosacral–cardinal ligament complex, placement of vaginal angle sutures, ligation of the vesicouterine ligament, ligation of the hypogastric artery as an adjunctive measure to lessen operative blood loss, and reperitonealization of the pelvic floor.

Once the course of the ureters is well established, the adnexal component of the operation is completed. If the adnexa are to be removed, the infundibulopelvic ligament is clamped, divided, and double ligated. The ligament may then be ligated again adjacent to the uterus to avoid back bleeding; the infundibulopelvic ligament is divided and the peritoneum incised to the back of the uterine fundus, always cognizant of the proximity of the ureter. If the adnexa are to be preserved, a hole is made in the avascular portion of the posterior leaf of the broad ligament superior to the ureter. The utero-ovarian ligament and fallopian tube are doubly clamped, divided, and ligated, with care taken to avoid incorporation of ovarian tissue into the ligature.

The peritoneal incision can be extended posteriorly around the uterus between the medial portions of the uterosacral ligaments. If the incision of the posterior leaf of the broad ligament is extended over the uterosacral ligaments, there is typically significant bleeding just lateral to the insertion of the ligament at the uterus. The advantages of making an incision between the uterosacral ligaments include clear identification of the rectum and its separation from the uterus, ease of suturing the vaginal cuff, and improved mobility of the peritoneum to allow reperitonealization under less tension.

The bladder is advanced down off of the lower uterine segment prior to clamping the uterine vessels. Surgeons-in-training have more difficulty with advancement of the bladder than with other aspects of abdominal hysterectomy. The principal difficulty in mobilization of the bladder is failure to identify the proper cleavage plane between the bladder and the uterus. At the attachment of the bladder to the lower uterine segment, a median raphe is variably present; it is typically a 1-cm long longitudinal band of thick connective tissue. The raphe is attenuated in pregnant or postmenopausal patients. The raphe is divided at midportion, and loose avascular fibroareolar tissue is seen immediately between the cervix and bladder. The uterus is retracted posteriorly and superiorly, roughly at an angle of 30 degrees to the long axis of the vagina. The midpoint of the peritoneal incision of the bladder flap is gently lifted with forceps; the avascular plane of the vesicovaginal and vesicocervical areolar spaces is continuous once the median raphe is divided. Metzenbaum scissors are pointed to the uterus, and sharp dissection reveals the shiny white pubocervical fascia overlying the cervix. Properly done, the dissection is bloodless, and the plane is recognized by the ease with which the bladder falls away from the cervix. The vesicouterine space is developed 2 cm beyond the anterior vaginal fornix. Care must be exercised in any dissection laterally, because the vesicouterine ligaments (“bladder pillars”) may bleed because of the paracervical and paravaginal veins present laterally.

The uterine vessels may be skeletonized by separating the loose avascular areolar connective tissue from the vessels. The intraligamentous course of the ureter is again checked; it is typically 2–3 cm inferolateral to the insertion of the uterine vessels into the uterus. The uterine vessels are clamped with a curved crushing clamp (eg, Heaney, Zeppelin, or curved Ballantine clamp). Double clamping may be used for larger vessels. It is not necessary to place another clamp on the uterine side of the pedicle to prevent back bleeding if the uterine arteries on both sides of the uterus are clamped before either pedicle is incised. The clamp is applied at the level of the internal os, with the tip of the clamp at a right angle to the long axis of the cervix; the temptation to clamp the entire cervix and “slide off” dragging paracervical tissue into the pedicle should be avoided in order to minimize the risk of the pedicle slipping out of the clamp. The uterine vessels are then ligated by suture at the tip of the clamp. Occasionally, a second application of the curved clamp is necessary to complete ligation of the uterine vessels.

Next, the cardinal ligament is assessed. On occasion, a single application of a straight clamp (Ochsner, Kocher, or Ballantine clamp) will include the cardinal ligament to the level of its attachment at the lateral edge of the cervix and upper vagina. However, with an elongated cervix, multiple pedicles need to be taken before the upper vagina is encountered. A deep knife is often useful in dividing the cardinal ligament adjacent to the uterus, leaving a larger pedicle, which is less likely to slip out of the suture than one remaining after cutting with scissors flush to the clamp. The uterosacral ligaments are clamped at their insertion into the lower cervix, divided at their insertion, and ligated. Alternatively, they may be transected with large Mayo scissors while the vagina is entered posterolaterally. If division and suture ligation of either pedicle of the cardinal–uterosacral ligament complex fails to enter the vagina, the safest approach is to enter the vagina with the knife in the midline, either anteriorly or posteriorly, at the confluence of the vagina with cervix. Once entered, the cervix is circumferentially incised, with long Ochsner clamps used to control point bleeders and elevate the vaginal cuff. The vaginal cuff can also be cross-clamped with a curved clamp (Heaney or Zeppelins) from either side just below the cervix and amputated with Jorgenson's scissors. The cervix is inspected to ensure complete excision. If the cervix is amputated without cross-clamping the vagina, sutures are placed at each lateral vaginal angle to ligate small paravaginal vessels coursing upward through the paravaginal tissues and to provide vaginal vault support. The suture is begun inside the vagina 1 cm from the upper border, then incorporates the cardinal and uterosacral ligaments, and finally transverses the vagina again to end up within the vagina. This suture is tagged, and the procedure is repeated on the contralateral side.

Surgical management of the cuff is individualized. In the case of marked pelvic inflammation and persistent oozing, the cuff may be left open to afford retroperitoneal drainage or allow egress of a closed drain system. In most cases, closing the cuff may reduce granulation tissue and possibly minimize ascension of bacteria from the vagina. The cuff may be closed with either interrupted figure-of-eight sutures or a double running suture; the key points with either closure are inversion of the cut edges into the vagina and hemostasis. If the vagina apex is cross-clamped prior to amputating the cervix, the cuff is closed with either a Heaney suture placed at the tip of each clamp, or with a running suture over each clamp. If a defect remains at the middle of the cuff, this can be closed with interrupted or figure-of-eight sutures.

The pelvis is irrigated and hemostasis checked in a systematic fashion from one lateral pedicle to the ipsilateral round ligament pedicle to the cuff and on to the other side. Small bleeding vessels must be ligated to minimize the risk of retroperitoneal hematoma formation, which may expand or become infected. For diffuse oozing, hemostatic agents such as thrombin powder or thrombostatic absorbable sponges may be useful. There is no advantage to closing the parietal peritoneum. Retained ovaries may be suspended to minimize the risk of torsion and adherence to the vaginal cuff. The utero-ovarian ligament can be conveniently attached to the round ligament stump to suspend the ovaries above the pelvis without placing the infundibulopelvic ligament under tension.

The abnormal appendix should be removed. In cases of hysterectomy for endometriosis, appendectomy will reveal microscopic endometriotic foci in some 3% of cases.

Supracervical Hysterectomy

Supracervical/subtotal hysterectomy, or removal of the uterine corpus without the cervix, made up 95% of hysterectomies prior to the 1940s. Despite Papanicolaou's introduction of his cervical smear, concern over neoplastic changes occurring in the retained cervix made total abdominal hysterectomy (TAH) the leading approach to surgery from the 1950s and on. Several studies have addressed the debate about which approach leads to decreased morbidity. Proponents of supracervical hysterectomy believe that there is less damage to sympathetic and parasympathetic innervation that might occur with paracervical dissection. Thus, bladder function and orgasm are less likely to be affected with supracervical hysterectomy. However, 2 randomized controlled trials assessing psychosocial outcome and resultant sexual function found no difference between the 2 groups. A meta-analysis failed to detect a significant difference in stress or urge incontinence after supracervical versus total hysterectomy. Another randomized, double-blind, controlled trial showed no statistically significant difference in bladder, bowel, and sexual function between women who had undergone total versus supracervical hysterectomy. It has also been proposed that by leaving the cervix, vault prolapse and vaginal shortening might be avoided. Yet, a recent study performed on cadavers found equal resistance to forces applied to the vaginal apex after supracervical and total hysterectomy.

Those in favor of TAH suggest that it decreases the risk of cervical cancer, especially in women who might not follow up for routine Pap smears. In fact, a malignant or premalignant condition of the cervix or uterine corpus is an absolute contraindication to a supracervical hysterectomy. It also eliminates the small risk of cyclical bleeding (6.8%) that can occur after supracervical hysterectomy if residual endometrium is left behind.

Supracervical hysterectomy does decrease length of surgery, blood loss, and febrile morbidity. Current indications for supracervical hysterectomy include difficulty dissecting the cervix, distorted anatomy secondary to pelvic inflammatory disease or endometriosis, and compromised medical condition.

Following ligation of the uterine vessels, the uterine fundus may be amputated from the cervix; the level of amputation should be below the internal cervical os to avoid postoperative uterine bleeding from endometrial remnants. The endocervical canal can be resected or ablated to further avoid cyclical bleeding. The cervical stump is closed with figure-of-eight sutures.

Vaginal Hysterectomy

Vaginal hysterectomies are performed under general or regional anesthesia. Following administration of the anesthetic, a bimanual examination is mandatory before beginning surgery. The perineum is shaved or trimmed as necessary and a sterile wash performed. The patient is placed in a low lithotomy position and draped; the surgeon should participate in proper positioning of the patient, because excessive flexion of the hips can stretch the sciatic nerve and compress the femoral nerve and excessive extension of the knee can jeopardize the peroneal nerves. All bony prominences and soft tissues in contact with the leg stirrups should be carefully padded.

The urinary bladder may be drained by catheter, but this step is optional. The cervix is grasped with a tenaculum. As the surgeon exerts gentle traction downward on the cervix, 2 assistants maintain exposure with lateral vaginal retractors and protect the bladder with an anterior Heaney retractor. If desired, the junction of the vagina and cervix can be injected with a 1% 1:1000 epinephrine solution to minimize blood loss during incision of the cervix. Beginning posteriorly to minimize obscuring the field with blood, the surgeon circumferentially incises the cervix down to the level of the pubovesicocervical fascia. Gentle traction with the bladder retractor and downward traction of the cervix will allow exposure of the fibers of fascia between bladder and cervix, which are incised. When the bladder has been advanced up off of the cervix, attention is given to the posterior attachment of the cervix. While the assistant pulls the uterus upward, the posterior vaginal mucosa is tented away from the cervix. With the patient in the Trendelenburg position to allow as much emptying of the posterior cul-de-sac as possible, the posterior cul-de-sac is incised with a single stroke of the scissors. A retractor is placed within the opening, exposing the uterosacral ligaments. The uterosacral ligaments are grasped with Heaney clamps, making certain that the peritoneum posterior to the ligament is within the clamp. The ligament is cut and ligated with 2-0 or 0 absorbable suture and tagged with a hemostat for later manipulation of the cuff.

The cardinal ligament may next be clamped if the bladder is safely advanced; likewise, the uterine vessels are included in the next application of the Heaney clamps. The anterior cul-de-sac is entered by blunt and sharp dissection to the anterior vesicouterine fold of peritoneum. The anterior retractor is placed within this opening, and the bladder is gently lifted upward. The surgeon now clamps, incises, and ligates in pedicles the remaining portions of the broad ligaments bilaterally, incorporating the tissue between the anterior and posterior leaves of the broad ligament. The round ligament, utero-ovarian ligament, and fallopian tube are excised from the uterus and incorporated into these pedicles, and the uterus is removed from the field. A larger uterus may require special manipulation for delivery through the vaginal introitus (eg, bivalving the uterus in the midline, morcellation of the uterus into multiple extractable segments, or myomectomy). Rarely, in the event of a narrow introitus, an episiotomy may be performed to facilitate in the delivery of the uterus. The final suture on the utero-ovarian ligament is tagged to allow careful inspection of the tubes and ovaries. If ovarian disease is suspected or if prophylactic oophorectomy is planned, a clamp is placed above the ovary and uterine tube on the infundibulopelvic ligament for suture ligature, while traction is placed on the last stay suture. The entire ovary must be removed, because an ovarian remnant may become cystic and produce pain many years after the hysterectomy.

Once all pedicles are inspected and found to be hemostatic, some surgeons advocate closing the peritoneum with a running 2-0 absorbable suture, incorporating the cardinal and uterosacral ligament pedicles for support of the vaginal vault. Lateral vaginal angle sutures are placed from the vaginal mucosa at 2 o'clock, inside the cuff and including the uterosacral pedicle, then out through the cuff to the 4 o'clock position. If anterior or posterior colporrhaphy is planned, that operation is completed prior to complete closure of the cuff. The cuff may be closed in either a horizontal or vertical manner, grasping full vaginal thickness, by an interrupted absorbable 0 suture or a running simple suture. One small randomized controlled trial showed improved preservation of vaginal length with vertical closure. The goals of closure are obliteration of the cuff's dead space back to the peritoneum and approximation of the cut edges of the vagina to afford healing and minimize postoperative granulation tissue. Modifications of the just-described technique are made by virtually every gynecologic surgeon based on operative findings and experience. Some surgeons will close the posterior cul-de-sac to prevent development of an enterocele or will shorten the uterosacral ligaments to suspend the vaginal vault. As in abdominal hysterectomy, the cuff can be left open to promote drainage with a running locked absorbable 0 suture. Another technique to drain the closure is insertion of a T-tube above the cuff, which is associated with a demonstrable reduction in postoperative febrile morbidity.

After the operation is completed, the vagina and perineum are gently cleansed. An indwelling bladder catheter is inserted and a vaginal pack may be placed. The patient is returned slowly to the dorsal supine position.

Laparoscopic Hysterectomy

The laparoscope can be used to aid vaginal hysterectomy by freeing abdominal adhesions (laparoscopic-assisted vaginal hysterectomy; LAVH) or to free the uterus in its entirety with removal via the vagina with the assistance of uterine manipulators (ie, V-care). Supracervical hysterectomy can also be done laparoscopically with morcellation and removal by culdotomy or through extended trocar sites. Advantages to laparoscopic hysterectomy (LH) include decreased length of hospital stay, decreased postoperative analgesia, and decreased convalescence period. There may be a lower complication rate compared to TAH, but there is no difference versus vaginal hysterectomy. Advantages of LH include the ability to inspect the peritoneal cavity and ovaries. Studies present conflicting data on whether there is a benefit of LH compared to vaginal hysterectomy in respect to hospital stay and blood loss. However, the laparoscopic approach requires significantly more operating time and a well-trained, experienced surgeon. Because of the costs for the endoscopic equipment, LH has been found to be more expensive despite the shorter hospital stay.

Complications with LH include hemorrhage and bowel or urinary tract damage. Conversion to abdominal hysterectomy may occur, especially in cases with large leiomyomas obstructing access to upper pedicles.

Postoperative Care of the Hysterectomy Patient

The details of postoperative care are dictated by the indications for surgery and the individual patient's overall medical condition. General guidelines include the following:

1. A Foley catheter is left indwelling for 24 hours, but ideally not longer to decrease the risk of urinary tract infections.

2. Prophylactic postoperative antibiotics are not necessary unless there is concern for an underlying infection diagnosed at time of surgery.

3. Hydration, 2–3 L/d of balanced electrolyte solution, is given intravenously, depending on blood loss and intraoperative replacement.

4. Sips of water may be given the first night, followed by clear liquids or regular diet on the next postoperative day depending on the patient's appetite. The absence of bowel sounds and flatus should not delay the advancement of diet.

5. Prophylactic heparin therapy, sequential compression device, or antiembolic stockings are used in patients according to risk for thromboembolic complications.

6. Ambulation is begun on the first postoperative day.

7. Adequate analgesia is given parenterally. Once the patient can tolerate a regular diet, she can be switched to oral analgesics.

Complications

Perioperative deaths may be due to cardiac arrest, coronary occlusion, or respiratory paralysis. Postoperative deaths are usually the result of hemorrhage, infection, pulmonary embolus, or intercurrent disease. A recent study of the morbidity of more than 10,000 hysterectomies found the mortality rate to be <0.1% with equal rates in the abdominal, laparoscopic, and vaginal groups. Mortality rates increase with age and medical complications for both vaginal and abdominal hysterectomies.

The bladder may be injured in 1–2% of all hysterectomies. Consequences are slight if the injury is to the dome of the bladder—which is usually the case away from the trigone. Ureteral injury occurs in 0.7–1.7% of abdominal hysterectomies and 0–0.1% of vaginal hysterectomies. The essential point is to recognize urologic injuries and correct them intraoperatively, avoiding the serious postoperative complications that occur from urinary extravasation.

Damage to the bowel occurs in 0.2–0.5% of all hysterectomies. A preoperative mechanical bowel preparation has not been shown to decreased morbidity after bowel resections; however, bowel preparation is preferred for laparoscopic hysterectomy to assist with bowel decompression. Small bowel injuries, assuming no obstruction, can be closed in a single layer or multiple layers depending on surgeon preference. The injury should be closed perpendicular to the long axis of the bowel. If multiple-layer closure is used, an interrupted or running layer of 3-0 silk or absorbable sutures is used to reapproximate the mucosa followed by interrupted 2-0 absorbable or silk sutures in the serosa. Bowel resection and anastomosis may be required for larger injuries. Large bowel injuries are repaired in the same fashion as small bowel injuries. Lack of a mechanical bowel preparation is not an indication for a colostomy. Large injuries may require bowel resection and reanastomosis. After the repair, the pelvis is copiously irrigated and a drain is used by some surgeons.

The most serious postoperative complication is hemorrhage (0.2–2% of patients). Bleeding usually originates at the lateral vaginal angles and is amenable to vaginal resuturing in most cases. Blood products are replaced as needed.

Infection remains the most common complication following hysterectomy. Even with immaculate technique and careful patient selection, the gynecologic surgeon can still expect a 10% rate of postoperative febrile morbidity. A postoperative temperature of 38°C (100.4°F) or higher on 2 consecutive determinations 6 hours apart must be investigated by (1) careful interview of the patient for localizing symptoms (eg, productive cough, intravenous line pain), (2) thorough physical examination (including pelvic examination for inspection and palpation of the cuff), and (3) appropriate laboratory studies (eg, urinalysis, chest x-ray, gram-stained smear of sputum, or complete blood count). Antibiotics are begun only if a focus of infection is identified or highly suspected. Broad-spectrum antibiotics covering anticipated pathogens are prescribed; single-agent semisynthetic penicillins (eg, piperacillin) and cephalosporins (eg, cefoxitin) offer sufficient coverage. In the presence of sepsis, multiagent comprehensive coverage (eg, penicillin, an aminoglycoside, and an anaerobic agent such as clindamycin or metronidazole) must be prescribed.

Granulation of the vaginal vault is part of the normal healing process and is evident on speculum examination in over half of cases. The granulation is rarely troublesome; light cauterization with silver nitrate sticks or electrocautery eliminates the granulation tissue promptly in most cases. Many suggestions have been made on ways to minimize granulation, including management of the cuff (open vs. closed), choice of suture (plain gut vs. chromic vs. newer synthetics), and drainage techniques. The most important common denominator is close apposition of the cut vaginal edges, which can be accomplished with any of the techniques.