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This activity describes the current status of abdominal hysterectomy, which represents the most common gynecologic surgical procedure performed in the United States. It will highlight the most common indications, will review surgical steps, and describe the role of the inter[professional team in the evaluation and management of the patient undergoing abdominal hysterectomy. Objectives: Identify the anatomical structures considered landmarks for abdominal hysterectomy. Describe the surgical steps of the abdominal hysterectomy. Identify the most common indications of abdominal hysterectomy. Access free multiple choice questions on this topic.

Abdominal hysterectomy was first performed in 1843. Prior attempts at removal of the uterus date back to ancient times, when vaginal hysterectomy was performed to treat uterine prolapse or inversion. Laparoscopic assistance was used to facilitate minimally invasive hysterectomy in 1989 and further advanced in 2005 with the approval of the robotic-assisted technique. Today, abdominal, vaginal, laparoscopic, robot-assisted, and a combination of vaginal and laparoscopic techniques are utilized for hysterectomy. The surgical approach to hysterectomy depends on the clinical indication, the technical experience of the surgeon, the resources available, the general health condition of the patient, and patient preference. An abdominal hysterectomy involves the removal of the uterus through an incision in the abdominal wall. As minimally invasive techniques have become more available, the rates of abdominal hysterectomy have declined since the less invasive approaches offer benefits such as less post-operative pain, expedited recovery times, and better short-term quality of life after surgery, as well as shorter hospitalization stays and reduced costs. Furthermore, the use of hysterectomy, in general, has decreased as alternatives to hysterectomy continue to gain favor, such as endometrial ablation for symptomatic uterine bleeding and uterine artery embolization for uterine leiomyomas.[1][2][3] Still, hysterectomy remains the most appropriate management option for many patients.[4][5] Large uterine size has been cited as a common reason for choosing the abdominal approach to hysterectomy, as it has been thought that an enlarged uterus may require better visualization and exposure due to higher risks of blood loss, injury to neighboring viscera, and prolonged operating times. However, there are no specific recommendations up to which uterine weight or size should qualify a patient for abdominal hysterectomy, and studies have shown that minimally invasive techniques, such as laparoscopy, can safely remove larger uteri.[6][7] Despite these findings, abdominal hysterectomy remains a common route of surgery being most commonly indicated for uterine fibroids, followed by abnormal uterine bleeding, prolapse, and endometriosis.[8]

We can categorize the most common complications of hysterectomy into infectious causes, venous thromboembolic disease, injury to the genitourinary and gastrointestinal tracts, bleeding, nerve injury, and vaginal cuff dehiscence.[24] Additional potential complications after an abdominal hysterectomy include pelvic organ prolapse, pelvic organ fistula, urinary incontinence, and intestinal ileus. As with any surgery requiring general anesthesia, there is also the risk of adverse reactions to anesthetics. Abdominal hysterectomy has been determined to have higher odds of postoperative complications within 30 days of surgery and an overall higher risk of complications when compared to other minimally invasive techniques of hysterectomy such as laparoscopy.[25] The most common complications of abdominal hysterectomy are described below: Infection The most common infections identified after a hysterectomy include vaginal cuff cellulitis, pelvic abscess or infected hematoma, wound infection, and urinary tract infection. The risk of infection increases with operative times that exceed 3 hours, lack of preoperative antibiotics, and patient factors such as comorbid medical conditions, compromised immune status, obesity, and poor nutrition.[24] Vaginal cuff cellulitis presents late in the hospital course or soon after discharge. Patients can be asymptomatic with spontaneous resolution of the inflammation or can present with fever, purulent vaginal discharge, pelvic pain, and exam findings of tenderness or induration at the vaginal cuff.[26] These findings can be differentiated from those of infected pelvic hematoma or abscess, which tend to present later after discharge from the hospital, with symptoms of pelvic pain, fever, and rectal pressure, and exam findings of a fluctuant, tender mass, or purulent discharge at the vaginal cuff.[24] Venous Thromboembolism (VTE)

The most common infections identified after a hysterectomy include vaginal cuff cellulitis, pelvic abscess or infected hematoma, wound infection, and urinary tract infection. The risk of infection increases with operative times that exceed 3 hours, lack of preoperative antibiotics, and patient factors such as comorbid medical conditions, compromised immune status, obesity, and poor nutrition.[24] Vaginal cuff cellulitis presents late in the hospital course or soon after discharge. Patients can be asymptomatic with spontaneous resolution of the inflammation or can present with fever, purulent vaginal discharge, pelvic pain, and exam findings of tenderness or induration at the vaginal cuff.[26] These findings can be differentiated from those of infected pelvic hematoma or abscess, which tend to present later after discharge from the hospital, with symptoms of pelvic pain, fever, and rectal pressure, and exam findings of a fluctuant, tender mass, or purulent discharge at the vaginal cuff.[24] Venous Thromboembolism (VTE) Patients undergoing major gynecological surgery have a significant risk of developing deep venous thrombosis (DVT) and pulmonary embolism (PE) when no thromboprophylaxis is given. The incidence of DVT after gynecologic surgery has been found in some studies to be higher in open procedures and in patients with malignant conditions.[27] The exact incidence of VTE after hysterectomy is difficult to approximate, as many cases go unrecognized. The risks of thromboembolic events must be balanced against the potential risk of major perioperative bleeding. Thromboprophylaxis is only recommended for patients undergoing gynecological surgery who are considered to be at increased risk of VTE.[28] Genitourinary and Gastrointestinal Tract Injuries

Patients undergoing major gynecological surgery have a significant risk of developing deep venous thrombosis (DVT) and pulmonary embolism (PE) when no thromboprophylaxis is given. The incidence of DVT after gynecologic surgery has been found in some studies to be higher in open procedures and in patients with malignant conditions.[27] The exact incidence of VTE after hysterectomy is difficult to approximate, as many cases go unrecognized. The risks of thromboembolic events must be balanced against the potential risk of major perioperative bleeding. Thromboprophylaxis is only recommended for patients undergoing gynecological surgery who are considered to be at increased risk of VTE.[28] Genitourinary and Gastrointestinal Tract Injuries Injury to the genitourinary tract during pelvic surgery, while rare, can lead to a high risk of patient morbidity. Studies have indicated radical hysterectomy as the most common type of pelvic surgery associated with urologic complications.[29] The bladder is injured more frequently than the ureters. A review of urinary tract injuries during benign gynecologic surgery found lower rates of bladder injury after abdominal hysterectomy than after laparoscopic and vaginal approaches, consistent with other studies within the literature.[30] Injury to the bladder occurs most commonly during dissection within the vesicovaginal plane, whereas injury to the ureter is most common to occur during dissection along the pelvic sidewall, particularly when encountering the infundibulopelvic ligaments where the ovarian vessels are ligated, but also during ligation of the uterine vessels and at the bladder base.[24] While injuries to the bladder and ureter may be noted during surgery, injury to the serosal layer of the bladder may go unnoticed during surgery if the defect in the bladder wall is not full-thickness, and delayed presentation of vesicovaginal fistula can occur.[31] GI tract injuries during an abdominal hysterectomy can occur via thermal injury, direct mechanical damage, and indirectly through interruption of vascular supply. Bleeding Abdominal hysterectomy is associated with more bleeding than the other routes of hysterectomy, with an average blood loss of 400mL. Studies have shown that estimated blood loss above this caliber is associated with increased risks of major postoperative complications and increased hospital stay.[32] Nerve Injury

Bleeding Abdominal hysterectomy is associated with more bleeding than the other routes of hysterectomy, with an average blood loss of 400mL. Studies have shown that estimated blood loss above this caliber is associated with increased risks of major postoperative complications and increased hospital stay.[32] Nerve Injury Damage of the femoral nerve is the most common cause of neuropathy described after pelvic surgery, and the most common site of injury is at the anterior surface of the psoas muscle from direct compression by a self-retained retractor and at the inguinal canal from indirect stretch injury while the patient is in the prolonged dorsal lithotomy position.[33] Other nerve injuries include the iliohypogastric and ilioinguinal nerves at the level of the anterior abdominal wall during laparotomy or excessive stretching of the fascia, the obturator nerve from an inadvertent crush injury by clamps or excessive stretching, and rarely, the peroneal nerve due to positioning of the legs in the stirrups. Vaginal Cuff Dehiscence Cuff separation can occur within days of surgery or years later. The separation may be along the entire length or localized to a portion of the vaginal incision and can be of partial- or full-thickness. The most feared complication associated with vaginal cuff dehiscence is the evisceration of intraperitoneal contents through tissue separation. Total abdominal hysterectomy has been associated with a lower risk of vaginal cuff dehiscence compared to laparoscopic procedures.[34]

Abdominal hysterectomy remains a common surgical route for hysterectomy for benign disease for a wide range of clinical indications. Optimal healthcare outcomes are achieved when there is a collaboration among the healthcare team involved in the care of the patient, from the time the patient checks into the facility at pre-op until the patient is discharged from the hospital, whether from the post-op recovery unit or after an inpatient stay. An interprofessional team may be made up of nurses, technicians, physicians, surgical assistants, residents, medical students, among other personnel. The initial care begins prior to the day of operation at the office visit, where it is the responsibility of the physician to discuss the procedure at length, including an assessment of risks vs. benefits and alternative options, while addressing any concerns, expectations, and questions that the patient may have. On the day of the operation, nurses have an important role in assessing the patient’s vital signs and clinical conditions to ensure clinical stability. Physicians obtain all necessary informed consent for the procedure. Prior to obtaining consent, the physician should ensure that the patient is fully informed, understands the nature of the disease for which the procedure is being proposed, the anticipated results and prognosis, risks of not receiving treatment, and recognized possible alternative forms of treatment. All possible complications should be discussed as well as that additional treatment for complications may be required. It is important that the patient is assessed by both the surgeons and anesthesiologists prior to the operation. Calm reassurance and the professional nature of the entire operative team is helpful to the patient and their loved ones prior to surgery.

The initial care begins prior to the day of operation at the office visit, where it is the responsibility of the physician to discuss the procedure at length, including an assessment of risks vs. benefits and alternative options, while addressing any concerns, expectations, and questions that the patient may have. On the day of the operation, nurses have an important role in assessing the patient’s vital signs and clinical conditions to ensure clinical stability. Physicians obtain all necessary informed consent for the procedure. Prior to obtaining consent, the physician should ensure that the patient is fully informed, understands the nature of the disease for which the procedure is being proposed, the anticipated results and prognosis, risks of not receiving treatment, and recognized possible alternative forms of treatment. All possible complications should be discussed as well as that additional treatment for complications may be required. It is important that the patient is assessed by both the surgeons and anesthesiologists prior to the operation. Calm reassurance and the professional nature of the entire operative team is helpful to the patient and their loved ones prior to surgery. Once in the operating room, scrub technicians and nurses prepare and confirm the proper functioning of all necessary instruments and equipment. Nurses should assist the physician with all preoperative procedures. The surgeon performs a final assessment of the anatomy prior to surgery with a pelvic examination. During the surgery, the surgical assistants and scrub technician should assist the surgeon in handling the instruments and ensuring proper lighting for maximum visualization of the surgical field. The nurse remains alert to any needs of the surgical team, such as equipment adjustments, patient positioning, or communications with outside personnel. At the conclusion of the procedure, the nurse documents the intraoperative blood loss and urine output. The anesthesiologist should continue to monitor vitals and hemodynamic stability, while all members of the team are responsible for ensuring the general status and comfort of the patient.

Once in the operating room, scrub technicians and nurses prepare and confirm the proper functioning of all necessary instruments and equipment. Nurses should assist the physician with all preoperative procedures. The surgeon performs a final assessment of the anatomy prior to surgery with a pelvic examination. During the surgery, the surgical assistants and scrub technician should assist the surgeon in handling the instruments and ensuring proper lighting for maximum visualization of the surgical field. The nurse remains alert to any needs of the surgical team, such as equipment adjustments, patient positioning, or communications with outside personnel. At the conclusion of the procedure, the nurse documents the intraoperative blood loss and urine output. The anesthesiologist should continue to monitor vitals and hemodynamic stability, while all members of the team are responsible for ensuring the general status and comfort of the patient. The best surgical outcomes for abdominal hysterectomy occur when the interprofessional team taking care of the patient is coordinated and agreeable in their efforts. Effective communication and cooperation among nurses, physicians, technicians, and learners are key.