Abdominal Hysterectomy:
Postoperative Care
Erich Franz Solomayer, Julia Caroline Radosa,
Ingolf Juhasz-Böss, and Russalina Mavrova
Postoperative Care
Optimal postoperative care is an important step of surgical
treatment, especially after open surgery as in case of abdomi-
nal hysterectomy, which is associated with various postop-
erative complications; for example more postoperative
infections; a higher rate of incisional hernia, a higher rate of
thromboembolic complications and higher blood loss and a
three times higher morbidity and mortality rate compared to
vaginal or laparoscopic hysterectomy [1, 2].
Routine postoperative care includes monitoring of a
patient’s hemodynamic and fluid status, pain control and
resumption of normal diet and activity. A standardized
management is recommended to minimize postoperative
­ thermia, swelling and pain) are observed, a microbiological
complications and avoid a prolonged hospitalization of the
patient. Table 109.1 show an overview of the postoperative
care recommendations, which are explained in detail below.
Postoperative Monitoring  After general anesthesia a moni-
toring of hemodynamic and fluid status is recommended dur-
ing the first three to four postoperative hours at an intermediate
care station when available.
Blood check and postoperative bleeding  At least one post-
operative hemoglobin check should be performed after
12–24 h depending on the intraoperative blood loss and the
patient’s condition. Detailed laboratory blood tests are
optional and depend on the patient’s symptoms. In case of a
postoperative hemoglobin drop <10 g/dl (normal hemoglo-
bin levels for wome: 12–16 g/dl) and an iron deficiency
E.F. Solomayer, PhD, MD (*)
Department of Gynecology and Obstetrics,
Saarland University Medical Center, Kirrbergerstraße,
66421 Homburg, Saarland, Germany
e-mail: erich.solomayer@uks.eu
J.C. Radosa, MD • I. Juhasz-Böss, MD • R. Mavrova, MD
Gynecology and Obstretrics, Homburg University Hospital,
Kirrbergerstr, Homburg, Saarland 66421, Germany
© Springer International Publishing Switzerland 2018
I. Alkatout, L. Mettler (eds.), Hysterectomy, DOI 10.1007/978-3-319-22497-8_109
109
a­ nemia patients can be treated with iron replacement ­products
orally or intravenously. In case of an excessive blood loss
with hemoglobin <8 g/dl or symptoms of dizziness blood
transfusion should be considered. Furthermore the bleeding
source should be identified by checking the amount and tex-
ture of the fluid in the drainages and using intravaginal and
abdominal ultrasound to exclude an abdominal hematoma. If
there is a reasonable suspicion of a postoperative bleeding
with excessive blood loss a laparoscopy or re-laparotomy
should be also taken into account.
Wound management  Wounds bandages should be renewed
daily and an inspection of the wound should be performed by
the surgeon. If signs of a wound infection (as redness, hyper-
wound swab should be performed. The swab should be taken
from the bottom of the wound or abscess and not s­ uperficially
Table 109.1  Recommendations for postoperative care management
Monitoring of the hemodynamic and fluid status during the first 3 to
4 postoperative hours at an intermediate care station when available
At least one postoperative hemoglobin check after 12–24 h
depending on the intraoperative blood loss
Detailed laboratory blood tests are optional
Inspection of the wounds and wounds bandages should be renewed
daily
A standardized pain control regime helps in the daily routine
Obstipation prophylaxis and antiemetics are optional
Removing of the bladder catheter during the first 24 h
Removing of drainages after 24–48 h depending on the amount of
fluid flowing off
Early feeding and no special diet
Thromboembolic prophylaxis with low-molecular-weight heparin
under frequent control of the thrombocytes
Fast mobilization
Gynecologic examination, transvaginal ultrasound and ultrasound
of the kidneys before discharge
Discharge instructions (avoiding heavy lifting (> 5 kg), exercises
and vaginal intercourse for 6–8 weeks)
follow-up visit 2 weeks after surgery
Removing of skin stitches or staples 10–14 days after surgery
1347
1348 E.F. Solomayer et al.

from the surface of the dermis where microbes occupying bowel injury during the surgery. An early feeding (oral intake
the dermis are found physiologically. A calculated antibiotic within 24 h) and fast mobilization stimulate the bowel and
therapy should be started for example with a combination of prevent stasis and postoperative paralytic ileus [3, 4, 5]. Diet
a cephalosporin (e.g. Cefuroxim 3 × 1,5 g i.v.) and metroni- protocols for patients undergoing bowel surgery depend on
dazole (e.g. Clont 2 × 500 mg i.v.). After microbiological the localization and extent of the removed bowel and the rec-
analysis the antibiotic therapy can be adjusted according to ommendation of the surgeon. Usually it is possible to start
the pathogenic agent and its resistances. The therapy should with small amounts of oral intake of fluids within 24 h after
be given for at least 5–7 days. Infections are distinguished in surgery, a soup or yoghurt ca also be chosen. After return of
superficial infections of the dermis and subcutaneous bowel function (e.g. presence of bowel sounds or flatus) oral
abscesses. In case of subcutaneous abscess an incision of the intake of foods can be started with mashed potatoes or white
abscess capsule is necessary. bread and be adapted to normal food depending on patient’s
well-being.
Prevention of postoperative infections  A calculated postop-
erative treatment with antibiotics is not recommended in rou- Intestinal paralysis and postoperative ileus  The intestinal
tine cases. In case of clinical suspicion of a postoperative motility is often reduced after open surgery [6, 7]. This can
infection (fever, shivering) blood samples should be drawn lead to an ileus. Ileus is a blockage of the intestines caused
and inflammatory markers should be assessed. A calculated by a lack of peristaltic (paralytic ileus) or the bowel move-
antibiotic therapy should be started and inflammatory mark- ment is inhibited due to a mechanical blockage (mechanical
ers should be checked regularly. Furthermore an infected ileus). In case of paralytic ileus, muscle or nerve problems
abdominal hematoma should be excluded using intravaginal disrupt the normal coordinated muscle contractions of the
ultrasound. A bowel injury can be excluded by performing a intestines, slowing or stopping the movement of food and
computer tomography with application of oral contrast fluid through the digestive system. A paralytic ileus is often
agent. In case of persistent suspicion of a bowel injury or caused by trauma (e.g. abdominal surgery), lack of activity,
signs of peritonitis a laparoscopy or re-laparotomy should be or as a side effect of certain pain medications, such as mor-
performed. phine. A mechanical ileus is often caused by postoperative
adhesions, inflammation, tumor or volvulus (twisted colon).
Postoperative pain management  Management of postopera- The most common symptoms of ileus are discomfort in the
tive pain decreases suffering and leads to earlier mobiliza- abdomen due to cramping, bloating, diarrhea, or obstipation
tion. This leads to a shorter hospital stay, reduced hospital related symptoms. Nausea and vomiting are also common
costs and increases patients` satisfaction. Pain control symptoms. Ileus is considered a serious medical emergency
regimes can be used standardized. Although it is postulated and should be treated as such. If symptoms appear, further
to tailor the medication to the needs of the individual patient, investigations should be initiated immediately. Medical
a standardized pain control regime helps in the daily routine anamnesis and physical examination are needed to diagnose
and can be easily adapted to the patient’s needs if the stan- an ileus. The presence of bowel sounds should be checked
dardized protocol is not adequate. A multimodal attempt is consecutively via auscultation. Furthermore a X-ray or a
recommended, for example a combination of an opioid based computer tomography using oral contrast agents can be per-
drug (e.g. Oxycodone hydrochloride and Naloxone hydro- formed to exclude a mechanical ileus. Therapeutic treatment
chloride 10/5 mg 2 × 1 p.o. per day), Metamizole (3 × 1 g varies according to these different types of ileus with differ-
p.o. per day) and non-steroidal anti-inflammatory drugs ent patho-mechanisms [8, 9]. In case of paralytic ileus a
(NSAID) (e.g. Ibuprofen 400 mg 3 × 1 p.o. per day) can be nasogastric tube can be placed and the patient should obtain
used. An obstipation prophylaxis is obligatory when opioids drugs stimulating the intestinal motility (e.g. Neostigmine,
are prescribed. Antiemetics can be helpful in cases of Metoclopramide, laxatives and suppositories). In case of
nausea. mechanical ileus surgical removal of the intestinal blockage
should be performed. If left untreated, ileus could lead to
Bladder catheter and drainage management  The bladder death of tissue or cause peritonitis. This infection can be seri-
catheter can be removed during the first 24 h postoperatively ous and potentially life-threatening.
to reduce the risk of an urinary tract infection. An intra-­
operatively placed drainage (e.g. Robinson or Penrose drain- Thromboembolic prophylaxis  Thromboembolic prophy-
age) can be removed after 24–48 h depending on the amount laxis with low-molecular-weight heparin (e.g. Enoxaparine
of fluid measured and the fluid’s texture. 40 mg, s.c. once a day) under frequent control of the throm-
bocytes is fundamental. In case of a benign uterine pathology
Postoperative diet  A special postoperative diet is not neces- it should be continued for 5–7 days, in case of malignancy
sary after an abdominal hysterectomy, except in cases of for 4–5 weeks [10]. Without thromboembolic prophylaxis
109  Abdominal Hysterectomy: Postoperative Care
a b
Fig. 109.1 (a) Ultrasound of a normal kidney, (b) Ultrasound of a kidney with grade III renal calyx reflux
the risk of deep vein thrombosis in patients after major
­general or gynecologic surgery is 15–30 %; the risk of lethal
pulmonary embolism is 0.2–0.9 % [11].
Mobilization  A fast mobilization is important for the post-
operative outcome, a physiotherapist can be involved and
help the patient with mobilization instructions.
Postoperative adhesions  Postoperative adhesions have
important consequences for patients, surgeons and the health
system. Abdominal hysterectomy is a surgical procedure
with a high risk of adhesion-related complications.
Postoperative adhesions have been observed in up to 94 % of
patients after laparotomy [12]. Ellis et al. reported of 34.6 %
patients who underwent open abdominal or pelvic surgery
were readmitted a median 2.1 times over 10 years for a dis-
order directly or possibly related to adhesions [13]. Pelvic
adhesions can be the result of inflammation or surgical
trauma. Several measures to prevent adhesion, for example
placing of barrier agents between the pelvic structures [14,
15], have been proposed, but up to now none has been suc-
cessful enough to find widespread acceptance. Laparoscopic
lysis of adhesions is proposed for patients who have failed
conservative measures [16].
Hospital stay  The length of hospital stay after abdominal
hysterectomy depends on the patient’s mobility and is in
average 3–5 days.
Examinations  All patients should undergo gynecologic
examination, transvaginal ultrasound and ultrasound of the
kidneys before being discharged to exclude a vaginal cuff
dehiscence, a renal calyx reflux and a postoperative abdomi-
nal hematoma. Figure 109.1a shows an example of a normal
kidney, and Fig. 109.1b shows an example of a grade III
1349
renal calyx reflux which is pathologic. A vaginal cuff
dehiscence is a rare complication of total hysterectomy
­
(0.24–0.31 %) [17, 18]. Possible sites of origin can be poor
wound healing, excessive intra-abdominal pressure at the
vaginal incision site or pelvic floor defects. Prompt surgical
and medical intervention is required to avoid bowel eviscera-
tion and sequelae including peritonitis, bowel injury, necro-
sis and sepsis. It is important to know that this is a
complication which occurs mostly few weeks after surgery.
Patients should be advised to avoid vaginal intercourse for
6–8 weeks. An iatrogenic ureter injury is generally asymp-
tomatic and can lead to a renal calyx reflux after weeks,
which is associated with consistent pain. An ultrasound of
the kidney or an urography may help to identify this compli-
cation, prevent renal damage and is also important forensi-
cally. A postoperative abdominal hematoma or pelvic fluid
accumulation can also occur as postoperative complications.
A small hematoma or a small amount of pelvic fluid accumu-
lation do not need further surgical intervention, but should be
observed via sonography. In case of distinct hematoma a
laparoscopy or re-laparotomy should be considered.
Discharge instructions  Patients should avoid heavy lifting
(> 5 kg) and exercises for 6–8 weeks to minimize traction on
the fascia and prevent an abdominal hernia. Vaginal inter-
course should be avoided for 6–8 weeks to prevent vaginal
cuff infections and allow the vaginal cuff to heal
completely.
In 2011, a panel of 12 experts used the modified Delphi
method and literature review to develop multidisciplinary rec-
ommendations for graded resumption of activity after laparo-
scopic, vaginal and abdominal hysterectomies and adnexal
surgery (Vonk Noordegraaf et al. [19]). The panel considered
65 activities and judged 38 to be relevant for ­convalescence
1350
recommendations. The recommendations were then judged as
feasible by 63 physicians. Examples of recommendations
after vaginal hysterectomy include avoiding lifting or carrying
over 10 kg, bicycle riding and vacuum cleaning for 3 weeks,
and avoiding lifting or carrying over 15 kg and “standing and
walking during the entire working day” for 4 weeks.
Restrictions for the same sets of activities were changed
to 3–4 weeks and 6 weeks, respectively, after abdominal hys-
terectomy, and to 2–3 weeks, respectively, after laparoscopic
supracervical hysterectomy. The Dutch authors point out that
the optimum lengths of inability to work after laparoscopic,
vaginal and abdominal hysterectomy are 4, 4 and 6 weeks,
respectively for sedentary work and 10, 10 and 12 weeks,
respectively, for physically demanding jobs.
Follow-up  An ambulant follow-up visit is recommended
2 weeks after surgery in gynecologic out-patient practice.
The follow-up visit should include an evaluation for poten-
tial complications (e.g. wound healing problems, postopera-
tive abdominal hematoma, vaginal cuff dehiscence or a
renal calyx reflux) and an examination of the abdomen,
wound and vaginal cuff in case of a total hysterectomy. Skin
stitches or staples should be removed 10–14 days after sur-
gery. As the patients are often discharged before the arrival
of histopathological results, the gynecologist should give
the patient a review of the histo-pathologic results. In case
of a malignant pathology further treatment should be
initiated.
Long-term outcome  Hysterectomy can be associated with
an earlier onset of menopause [20, 21, 22]. Patients should
be informed about the risk of osteoporosis and the options of
prevention such as vitamin D and calcium substitution.
On the other hand, there are reports of improved overall
sexual functioning after hysterectomy [23, 24]. These effects
can be explained by postoperative symptom relief.
Several studies report an association of urinary incontinence
following hysterectomy irrespective of the surgical technique.
Due to this fact the risk for subsequent uro-­gynecological sur-
gery is increased, a fact which should be mentioned in the pre-
operative counselling of the patients [25, 26].
Conflict of Interest Statement  The authors organize lapa-
roscopic training workshops and take part in presentations
supported by Storz, Erbe, Johnson & Johnson and Takeda
(category A).
References
1. Clarke-Pearson DL, Geller EJ. Complications of Hysterectomy.
Obstet Gynecol [Internet]. 2013;121:654–73. Available from:
http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landi
ngpage&an=00006250-201303000-00023
E.F. Solomayer et al.
2. Wiser A, Holcroft CA, Tulandi T, Abenhaim HA. Abdominal ver-
sus laparoscopic hysterectomies for benign diseases: evaluation of
morbidity and mortality among 465,798 cases. Gynecol Surg.
2013;10:117–22.
3. Andersen HK, Lewis SJ, Thomas S. Early enteral nutrition within
24 h of colorectal surgery versus later commencement of feeding
for postoperative complications. Cochrane Database Syst Rev.
2006;(4):CD004080.
4. Zhao YQ, Tong WH, Wang Q. Fast-track colorectal surgery. World
Chinese J Dig. 2011;19:2048–52.
5. Lewis SJ, Egger M, Sylvester PA, Thomas S. Early enteral feeding
versus “nil by mouth” after gastrointestinal surgery: systematic
review and meta-analysis of controlled trials. BMJ. 2001;323:
773–6.
6. Livingston EH, Passaro EP. Postoperative ileus. Dig Dis Sci.
1990;35:121–32.
7. Baig MK, Wexner SD. Postoperative ileus: a review. Dis Colon
Rectum. 2004;47:516–26.
8. Mattei P, Rombeau JL. Review of the pathophysiology and man-
agement of postoperative ileus. World J Surg. 2006;30:
1382–91.
9. Luckey A, Livingston E, Taché Y. Mechanisms and treatment of
postoperative ileus. Arch Surg. 2003;138:206–14.
10. AWMF. Prophylaxe der venösen Thromboembolie. Eur J Vasc
Med. 2009; AWMF 003/0(38):76.
11. Greer IA. Epidemiology, risk factors and prophylaxis of venous
thrombo-embolism in obstetrics and gynaecology. Baillieres Clin
Obstet Gynaecol. 1997;11:403–30.
12. Bolnick A, Bolnick J, Diamond MP. Postoperative adhesions as a
consequence of pelvic surgery. J Minim Invasive Gynecol [Internet].
2014. Available from: ­http://linkinghub.elsevier.com/retrieve/pii/
S155346501401601X.
13. Ellis H, Moran BJ, Thompson JN, Parker MC, Wilson MS, Menzies
D, et al. Adhesion-related hospital readmissions after abdominal
and pelvic surgery: a retrospective cohort study. Lancet. 1999;353:
1476–80.
14. Farquhar C, Vandekerckhove P, Watson A, Vail A, Wiseman D.
Barrier agents for preventing adhesions after surgery for subfertil-
ity. Cochrane Database Syst Rev 2000;(2):CD000475.
15. Watson A, Vandekerckhove P, Lilford R. Liquid and fluid agents for
preventing adhesions after surgery for subfertility. Cochrane
Database Syst Rev. 2000;(3):CD001298.
16. Szomstein S, Lo Menzo E, Simpfendorfer C, Zundel N, Rosenthal
RJ. Laparoscopic lysis of adhesions. World J Surg. 2006;30:
535–40.
17. Hur HC, Guido RS, Mansuria SM, Hacker MR, Sanfilippo JS,
Lee TT. Incidence and patient characteristics of vaginal cuff dehis-
cence after different modes of hysterectomies. J Minim Invasive
Gynecol. 2007;14:311–7.
18. Hur H-C, Donnellan N, Mansuria S, Guido R, Lee T. Vaginal cuff
dehiscence after different modes of hysterectomy. Obstet Gynecol.
2012;119:382–3.
19. Vonk Noordegraaf A, Huirne JAF, Brölmann HAM, Van
Mechelen W, Anema JR. Multidisciplinary convalescence rec-
ommendations after gynaecological surgery: a modified Delphi
method among experts. BJOG Int J Obstet Gynaecol. 2011;118:
1557–67.
20. Farquhar CM, Sadler L, Harvey SA, Stewart AW. The association
of hysterectomy and menopause: A prospective cohort study. BJOG
Int J Obstet Gynaecol. 2005;112:956–62.
21. Riedel HH, Lehmann-Willenbrock E, Semm K. Ovarian failure
phenomena after hysterectomy. J Reprod Med. 1986;31:
597–600.
22.
Oldenhave A, Jaszmann LJ, Everaerd WT, Haspels AA.
Hysterectomized women with ovarian conservation report more
severe climacteric complaints than do normal climacteric women of
similar age. Am J Obstet Gynecol. 1993;168:765–71.
109  Abdominal Hysterectomy: Postoperative Care 1351

23. Rhodes JC, Kjerulff KH, Langenberg PW, Guzinski GM.

25. Brown JS, Sawaya G, Thom DH, Grady D. Hysterectomy and
Hysterectomy and sexual functioning. JAMA. 1999;282: urinary incontinence: a systematic review. Lancet. 2000;356:
1934–41. 535–9.
24. Radosa JC, Meyberg-Solomayer G, Kastl C, Radosa CG,
26. Altman D, Granath F, Cnattingius S, Falconer C. Hysterectomy and
Mavrova R, Gräber S, Baum SRM. Influences of different hysterec- risk of stress-urinary-incontinence surgery: nationwide cohort
tomy techniques on patients’ postoperative sexual function and study. Lancet. 2007;370:1494–9.
quality of life. J Sex Med. 2014;11:2342–50.