OBSTETRIC HYSTERECTOMY

Dr. Adaiah Soibi-Harry

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 Outline
• Introduction
• Historical Background
• Epidemiology
• Predisposing Factors
• Indications
• Management of Obstetric Heamorrhage
• Pre-operative Planning
• Surgical Challenges
• Surgical Technique
• Complications
• Conclusion
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 Introduction

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 Introduction
• Obstetric or Peripartum hysterectomy
• The removal of the corpus uteri alone or with the cervix at the time of a caesarean section, or shortly
after a vaginal delivery.

• Caesarean hysterectomy
• Is performed immediately after a cesarean delivery for severe hemorrhage .

• Postpartum hysterectomy
• Is performed after a vaginal delivery for delayed hemorrhage or infectious complications.

• Described as one of the riskiest and most dramatic operation in modern obstetrics and thus
associated with significant maternal morbidity and mortality.

• Meets the definition of a maternal near miss.

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 Historical Background
• 1768- Joseph Cavallini first proposed caesarean hysterectomy in animal
experiments.
• 1869- Horatio Storer performed the first documented caesarean hysterectomy
on a patient in the United States. However the patient died 68 hours after
surgery.
• 1876- Eduardo Porro of Milan described the first cesarean hysterectomy in
which both mother and baby survived and the procedure was named Porro’s
technique.
• Modifications of Porro’s technique by Godson in 1884 and Lawsontait in 1890.
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 Epidemiology
• The reported incidence of emergency obstetric hysterectomy varies between 0.2 and
5.4 in 1000 deliveries. In general, the average incidence is put at 1 in 1000
deliveries, with higher incidences reported in developing countries.

• In a study by Olamijulo et al. in 2012: the local incidence in LUTH was 2.56 per

1000 deliveries with case fatality rate of 11.8%.

• It is associated with severe maternal morbidity, where 90% of these women may need

blood transfusion, 40% required ICU care, 24% were re-operated and 10% had

bladder or ureteric injury, maternal death ranged from 0-24%, significant emotional

stress for the patient and potential lawsuits for the doctor.
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 Predisposing factors
• Previous and current caesarean section
• Abnormal placentation (placenta accreta, increta and percreta)
• Multiple pregnancy (has a 2-8 fold increased risk).

• Retained placenta

• Abruptio Placentae

• Thrombocytopenia

• Multiparity

• Unbooked status
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 Indications
• Severe uterine hemorrhage that cannot be controlled by conservative measures
• Uterine atony: (30-50%)
• Abnormal placentation: (30-50%)
• Extensive uterine rupture
• Uterine vessel laceration

• Severe Uterine sepsis

• Chronic recurrent uterine inversion

• Fibroid riddled uterus

• Planned peripartum hysterectomy.

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Management of Obstetric Hemorrhage
• Use an Algorithm

• Uterotonics, uterine tamponade (eg, intrauterine balloon), ligation of

bleeding sites, uterine artery ligation, placement of B-lynch sutures, and
transarterial embolization, if available and when patient status permits
can be used.

• Activated recombinant factor VII also has recently emerged as a

treatment for postpartum hemorrhage
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Algorithm for Management of Obstetric Haemorrhage

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 Pre-op Management
• Call for help

• Resuscitate patient(ABC), administer oxygen, secure IV access with two wide bore cannula, group
and crossmatch blood and administer crystalloids

• Ensure urethral catheter is passed and monitor intake/output

• Counsel patient and relatives and obtain written consent.

• Inform the most experienced obstetrician in obstetric hysterectomy to be present.

• Mobilize anesthetist, theatre and blood bank team.

• Ensure availability of appropriate surgical instruments, technicians and assistants.

• Give prophylactic antibiotics

• Ensure placement of intermittent compression stockings on patient to decrease the risk for deep
venous thrombosis.
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 Surgical Challenges 1
• Difficulty with identification of external os.

• Significantly dilated blood vessels

• Massive hemorrhage may obscure the operative field and can make suturing of
pedicles more difficult.

• Bulky uterus- difficult visualization of traditional surgical landmarks and planes.

• Tissue may be friable.

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 Surgical challenges 2
• Gross distortion of pelvic anatomy

• Placenta percreta may extend into the bladder and other pelvic organs.

• Scarring from previous cesarean

• The ureters may be sectioned, clamped or stitched because often,

heavy bleeding interferes with proper exposure

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 Surgical Technique 1
Supra-cervical Hysterectomy
• With patient in supine position, under general anaesthesia, routine cleaning and draping is
done

• A vertical midline sub-umbilical abdominal incision is made through the skin, subcutaneous
tissue, to the level of the fascia using a scalpel.

• A 2-3cm vertical incision is made on the fascia and extended upwards and downwards using
a scissors. The rectus muscle is separated vertically, using the fingers

• The peritoneum is grasped around the level of the umbilicus with two Kelly's forceps, checked
to ensure no bowel entrapment, cut between the clamps and extended along the incision
carefully, using a scissors.
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 Surgical Technique 2
Supra-cervical Hysterectomy
• A self retaining retractor is placed to retract the abdomen, and a Doyen retractor is placed

over the bladder.

• If there is massive haemorrhage, the assistant should sweep the small bowel mesentery up

towards the liver and compress the aorta.

• The uterus is elevated out through the incision and the bowels packed away with warm

abdominal packs.

• Round Ligament Ligation

The round ligaments are identified, double clamped with Kochers’ forceps divided and suture

ligated.
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Round Ligament Ligation
Posteriorly, a window is created in the broad ligament, the loose areolar
tissue is carefully dissected parallel to the course of the ureter. This allows
visualization of the retroperitoneal space and the ureter throughout its
course.

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 Bladder Dissection
The uterovesical fold is sharply dissected and the bladder
reflected from the lower uterine segment.

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 Tubo-ovarian Pedicle Dissection
Place two straight clamps perpendicular to the uterus incorporating the tube, utero-ovarian
ligament and ovarian vessel, divide and suture ligate .

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Uterine Vessel Ligation
Before approaching the uterine arteries, the bladder is dissected free and displaced below the
operative field using sharp dissection. Avoid lateral dissection into the highly vascular bladder pillars.
A curved clamp is placed perpendicular to the uterine vessels at the level of the internal cervical os,
and the same procedure is repeated on the contralateral side, a second clamp is placed medially and
a third one laterally. The vessels are then transected between the first and second clamp and suture
ligated.

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 Uterine Amputation

• The uterus is amputated with a scalpel or diathermy by cutting

superiorly to the ligated uterine arteries while angling the scalpel or
diathermy blade medially and downward.

• The cervical stump is approximated in an anterior-to-posterior fashion

using interrupted figure-of-eight stitches. Special care should be taken
to avoid the bladder.
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 Total Abdominal Hysterectomy
• Examine the cul-de-sac to ensure that the rectum is not adherent to the posterior
aspect of the cervix and ensure that the bladder has been completely dissected away
from the anterior cervix.

• Place the heel of a curved clamp snugly, just lateral to the cervico-uterine edge and
take descending "bites" of tissue of 1.0-1.5 cm in size, divide medially with scissors
or a scalpel, and ligate the pedicle.

• When dissection of the cardinal ligaments has reached the external os, carefully
inspect the field to ensure that the ureter and bladder are outside the dissection
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planes.
Cardinal Ligament Dissection Posterior Dissection

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 Uterosacral Ligament Dissection

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 Amputation of the Uterus

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 General Considerations
• Drains are not generally necessary.

• Pelvic packing can be used to control low-pressure bleeding in the deep pelvis.
Using Kerlix bandages tied together, the pelvis can be filled with dry gauze and a free
end brought through the facial incision. The skin is left open for removal or
reoperation on the next day.

• Local hemostatic agents and anti-fibrinolytics may be used to help control

generalized oozing.

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 Post Operative Care
• Monitor vital signs closely in the immediate post-op period

• Ensure parenteral antibiotics

• Ensure blood transfusion if indicated

• Institute thrombo-prophylaxis once hemostasis is secure

• When patient is stable the sequence of events should be reviewed and

discussed with her by an experienced obstetrician

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 Complications 1
• Hemorrhage

Adnexal pedicles

-Uterine vascular pedicles

-Cardinal ligaments

-Angles of the vagina and Uterosacral ligament

• Urinary tract injury

- Bladder injury- while dissecting the bladder from the lower uterine segment and vaginal cuff clamp
or suture

- Ureteric injury- Infundibulopelvic ligament clamping (if salpingoophorectomy), Uterine artery

clamping (ureter is about 2cm below), Cardinal ligament dissection and Uterosacral ligament.
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 Complications 2
• Fistula Formation

• Blood transfusion

• Coagulopathies

• Infections -Vaginal cuff cellulitis, Abdominal incision wound break down, Urinary tract
infection

• Psychological Problems

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 Conclusion
• Obstetric hysterectomy is often a procedure of last resort to save a mother’s
life.

• It therefore requires an understanding and anticipation of risks factors,

focused and timely decision-making, experienced and confident surgical skill,
a readily available team as well as availability of the right tools to reduce
maternal morbidity, mortality and optimize patient outcome.

• Regular simulation drills will help prepare most obstetricians and obstetric
residents for this life saving procedure.

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 References
1. Park RC, Duff WP: Role of cesarean hysterectomy in modern obstetric practice. Clin Obstet
Gynecol 23:(2):601, 1980
2. Porro E: Dell'amputazionne utero-ovarica come complemento di taglio cesareo. Ann Univers
Med Chir 237:289, 1876
3. Umezurike CC, Feyi-Waboso PA, Adisa CA. Peripartum hysterectomy in Aba, Southeastern
Nigeria. Australian and New Zealand Journal of Obstetrics and Gynaecology 2008; 48:580-
582.
4. Zeteroglu S, Ustun Y, Engin-Ustun Y, Sahin G,Kamaci M. Peripartum hysterectomy in a
teaching hospital in the Eastern region of Turkey. Eur J Obstet Gynecol Reprod Biol 2005;
120; 57-62.
5. Okogbenin, SA., et al. "Obstetric hysterectomy: fifteen years' experience in a Nigerian
tertiary centre." Journal of Obstetrics and Gynaecology 23.4 (2003): 356-359.
6. Olamijulo, JA., et al. "Emergency obstetric hysterectomy in a Nigerian teaching hospital: a
ten-year review." Nigerian quarterly journal of hospital medicine 23.1 (2012): 69-74.
7. Jacobs AJ. Peripartum hysterectomy. UpToDate.www.utdol.com. Accessed April 12, 2010.

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KEEP CALM
AND
SAVE
A MOTHER