Total Abdominal Hysterectomy

br removal of the uterus . The first hysterectomy procedure was performed by Charles Clay in November 1843 in Manchester , England . However , the first 2006

There are several types of hysterectomy procedures . These are the abdominal hysterectomy , the vaginal hysterectomy , the HYPERLINK "http /www .gynecare .com /bgdisplay .jhtml ?itemname hysterectomy_types " \l "LAVH " laparoscopically-assisted vaginal hysterectomy (LAVH ) and the HYPERLINK "http /www .gynecare .com /bgdisplay .jhtml ?itemname hysterectomy_types " \l "LSH " laparoscopic supracervical hysterectomy (LSH . The abdominal or open hysterectomy is the traditional type . The most commonly done procedure , it is done through a

large abdominal incision The uterus and the cervix are removed , with or without the removal of the ovaries and the fallopian tubes (Ethicon , 2008 . The next type is the vaginal hysterectomy , wherein instead of an abdominal incision , a vaginal incision is made . This provides for faster healing time and no visible scarring but is not recommended for large fibroids . The third type , the laparoscopically-assisted vaginal hysterectomy , includes the use of a laparoscope which is inserted through a small incision in the navel (Ethicon , 2008 . The last type , the laparoscopic supracervical hysterectomy (LSH , employs the use of a laparoscope and small surgical instruments are inserted through three to four tiny incisions measuring about less than 1 /4 inch each in the navel and abdomen (Ethicon , 2008 In this procedure the cervix is left intact

To further understand this surgical procedure , a thorough understanding of the female reproductive system anatomy is required . The female 's internal reproductive system is composed mainly of the uterus , the vagina and the ovaries . These structures are being supported by the bony pelvis and the ligaments . The bony pelvis is composed of a ring-shaped series of bones these are the innominate bones , the ilium , the ishcium the pubis bones , and the sacrum . There are four types of pelvis , the gynecoid , android , anthropoid , and platypelloid . The gynecoid is the most ideal in giving birth (Bullock , 2000

The ligaments supporting the internal reproductive structures are arranged in a slinglike fashion . The main muscular support for the pelvic organs is the pubovaginalis . It also acts as the actual sphincter surrounding the vagina and the rectum . The major uterine ligaments are the broad and round ligaments . The broad ligaments divide the uterine cavity into anterior and posterior compartments by extending from the lateral margin of the uterus to the pelvic walls . They are two worm-like structures that help maintain the uterus ' mid-position in place (Bullock , 2000

The round ligaments , found just below the fallopian tubes , are fibrous cords that attach to either side of the fundus . Extending through the inguinal canal and terminating in the labia minora 's upper portion these ligaments aid in holding the fundus tilted forward (Bullock 2000

The ovary , which houses the female gametes , is the most important organ in reproduction . The egg cells are vital to the preservation of mankind 's existence - they are needed to produce an embryo , together with the sperm cell , which eventually becomes a human being (Bullock 2000

The uterus is a hollow muscular organ that houses the fetus in its gestation period . Consisting of two sections , the upper portion and the lower portion , it lies anterior to the rectum and posterior to the bladder . The upper portion is the corpus and the lower portion the cervix . The cervix has an external portion , the ectocervix , which is palpable in the upper vagina . It is cobered by squamous epithelium that consists of four layers - the basal , parabasal , intermediate and superficial (Bullock , 2000

The uterine wall is composed of three layers , the endometrium , the myometrium , and the perimetrium . The mucous membrane lining of the uterine cavity is the endometrium . Its function is to provide a suitable location for the implantation of a fertilized ovum and to establish a placenta during gestation . The endometrium is further divided into two layers , the stratum functionalis and the stratum basalis . The stratum functionalis is the superficial layer that is sloughed off with each menstruation and delivery . The deeper layer , the stratum basalis is retained during menses and proliferates to regenerate the stratum functionalis . The middle layer of the uterine wall is the muscular myometrium . Its main function is to contract as an aid in expelling the fetus . The perimetrium covers and protects the outside of the uterus (Bullock , 2000

The uterus is supported by the levator ani muscles and eight ligaments and the blood supply is provided by the uterine artery . Menstruation gestation and parturition are among the functions of the uterus (Bullock , 2000

The fallopian tube , two tunnels that serves as a connection between the uterus and the ovary is about 10 to 12 cm in length . The fallopian tubes have four sections , the interstitial section , the isthmus , the ampulla and the infundibulum . The function of the fallopian tubes is for the transportation of the sperm toward the ovary and also the egg toward the uterus (Bullock , 2000

The vagina connects the uterus to the outside of the body . Located anterior to the rectum and posterior to the urethra , the vagina has four major functions : for exit flow of menstruation , passageway of fetus during delivery , pathway of sperm as it travels towards the ovum and as a receptacle for the penis during intercourse (Bullock , 2000

These structures , the uterus , the ovaries , the fallopian tubes and the vagina will not be functioning properly without blood supply and neural control . The pelvic structure 's blood supply is mainly derived from the internal iliac artery and its branches . Both sympathetic and parasympathetic nerve supplies are being received by the pelvic structures . Sensory nerves from the uterus travel with the sympathetic nerves to L2 and L4 . The sensory nerves of the cervix travel to S2 , S3 and S4 and transmit through the uterosacral ligaments (Bullock , 2000

Indications for uterine removal are uterine cancer , endometrial cancer cervical cancer , cancer of the ovaries , cancer of the fallopian tubes uterine fibroids , endometriosis , uterine prolapse , and chronic pelvic inflammatory disease (UPMC , 2007 ) Most often than not , the cancerous conditions of the internal female reproductive system are fibroids in nature . Most common is the benign tumors that grow in the muscles of the uterus . Usually , there are no symptoms and there is no need for treatment of these fibroids . But sometimes , fibroids can cause bleeding vaginal discharge , and frequent urination , depending on their location (MedicineNet , 2007

Another indication for Endometriosis , another benign condition that affects the uterus , is most common in thirty year old and forty year old women . It happens when endometrial tissue begins to grow on the outside of the uterus and on nearby organs . Painful menstrual periods , abnormal HYPERLINK "http /www .medicinenet .com /script /main /art .asp ?articlekey 17582 vaginal bleeding , and sometimes loss of fertility , are its symptoms but it does not cause cancer (MedicineNet , 2007

Uterine prolapse is a condition wherein the uterus has dropped from its position within the pelvis into your vagina . The uterus is normally held in place by the muscles and ligaments that make up your pelvic floor Uterine prolapse occurs when pelvic floor muscles and ligaments weaken providing inadequate support for the uterus . The uterus then descends into the vaginal canal . Prolapse can be caused by damage to supportive tissues incurred during pregnancy and childbirth plus the effects of gravity , loss of estrogen and repeated straining over the years can weaken pelvic floor muscles (Mayo Clinic , 2006

Pelvic inflammatory disease is another indication for hysterectomy . It is defined as the infection of the lining of the uterus , the fallopian tubes , or the ovaries (Medline Plus , 2006 ) The most common and known causes of pelvic inflammatory disease cases are caused by the same bacteria that lead to sexually transmitted diseases examples are HYPERLINK "http /www .nlm .nih .gov /medlineplus /ency /article /001345 .htm " chlamydia , HYPERLINK "http /www .nlm .nih .gov /medlineplus /ency /article /007267 .htm " gonorrhea , mycoplasma , etc . Although the cause is most commonly spread through sexual contact , bacteria may also enter the body after gynecological procedures such as the insertion of an HYPERLINK "http /www .nlm .nih .gov /medlineplus /ency /article /002389 .htm intrauterine device , childbirth , HYPERLINK "http /www .nlm .nih .gov /medlineplus /ency /article /001488 .htm miscarriage , therapeutic or HYPERLINK "http /www .nlm .nih .gov /medlineplus /ency /article /001512 .htm " elective abortion , and HYPERLINK "http /www .nlm .nih .gov /medlineplus /ency /article /003917 .htm endometrial biopsy (Medline Plus , 2006

However , there are contraindications to getting this surgical procedure A patient is not considered for this kind of surgery if her uterine size greater than 280 grams , normal weight is around 70 grams , if she had previous multiple abdominal or pelvic surgeries , advanced malignancies in the uterus or ovary (eMedicine , 2006

Before the actual surgery takes place , there is preoperational preparation that the patient will have to undergo . CBC count , PAP smear endometrial sampling , ultrasonography , blood type and cross match , and in some cases , chest radiography , ECG , CAT scan , MRI , cystoscopy , barium enema , IVP , and blood chemistry , are among the diagnostic tests that the patient have to take before the surgery (eMedicine , 2006

In general , a normal CBC would indicate a white blood cell count of 4 ,500 - 11 ,000 cu mm , a red blood cell count of 4 .2 - 5 .4 x 10 /L for females , a hemoglobin of 12-16 gm /dL and a hematocrit percentage of 35 -47 (Smeltzer , 2004 . Abnormal white blood cell count could indicate infection , decreased red blood cell count could indicate bleeding or anemia , while an increase indicates severe diarrhea , dehydration or polycythemia (Smeltzer , 2004

A Pap smear or Papanicolaou smear indicates a no pathologic change for normal findings (Braun , 2007 . Endometrial HYPERLINK "http /www .nlm .nih .gov /medlineplus /ency /article /003416 .htm " biopsy is a procedure in which a tissue sample is obtained from the endometrium The tissue is thoroughly examined for any cell abnormalities or signs of HYPERLINK "http /www .nlm .nih .gov /medlineplus /ency /article /001289 .htm cancer ( Medline Plus , 2006

Ultrasonography will enable the physicians to view the uterus and its proximal parts in a 2D view . Transabdominal imaging uses a low frequency and is performed to view large fibroids and ovaries that are high in the pelvis and to determine the shape and size of the bladder , uterus vagina , and cervix (eMedicine , 2006

Blood typing and cross matching is necessary in case there is a situation wherein there is an excessive blood loss during the surgery There should be blood bags readily available in case this happens

Before the surgery , the patient will be given enemas and the night before the patient will be asked to eat a light meal for dinner and not to eat past midnight . Antibiotics will be given to prevent onset of infection and the abdominal and or pelvic area will be shaved (UPMC 2007

Once inside the operating room , the patient is placed in lithotomy position . The left arm is tucked the right arm is positioned on an arm board with an IV line and other attachments . A metal bridge crosses the patient 's chest for the surgeon and the assistant to lean on . The surgeon stands to the left of the patient with the apparatus cart on the side . The assistant surgeon stands opposite , cephalad to the arm board The scrub nurse stands next to the assistant surgeon with a small instrument table in front and the ancillary equipment beside him or her (Vietz , 1997 ) This will be just a general set-up , not all hospitals are following this

The surgery will be started by the surgeon by choosing between the vertical incision running from the navel to the pubic bone or the horizontal cut along the top of the pubic hairline , on the abdomen (eMedicine , 2006 . The subcutaneous tissue will be exposed and surgeons will cut it using a Bovie cautery (Inside Surgery , 2007 . The midline fascia will now be dissected , exposing the peritoneum which is grasped with forceps on either side of the midline . The uterus is grasped and pulled out of the incision and superiorly toward the umbilicus to expose the anterior uterine surface . An Ochsner clamp is placed on each side of the round ligament and dividing it after a mattress 0 absorbable suture has been placed on the right and left round ligaments to ligate the ovarian vessels . When the vaginal wall can be compressed between the gynecologist 's fingers , the dissection is stopped . The uterus is the pulled forward and the posterior surface is visualized to insure that it is not adherent to the rectum . The uterus is grasped with a tenaculum and rotated slightly to one side to expose the uterine vessels . Two Ochsner clamps are then placed at 45 degrees to the uterus and slid down onto the uterine vessels . The uterine vessels are incised with a Metzenbaum scissors and the vascular pedicle doubly ligated with silk suture . The similar procedure to ligate the urterine vessels is performed on the opposite side . Teale forceps are applied to the cervical tissue at the level of the vagina . The posterior cervical peritoneum is incised and gently bluntly downward . The incision is carried cirumferentially around the cervix . The uterus is held forward the posterior vaginal wall is incised using curved scissors . The anterior and posterior walls of the cut vagina are grasped by Teale forceps . The lateral edges of the cut vagina are sutured together with figure of eight absorbable 0 sutures . The rest of the vaginal opening is then closed with additional figure of eight absorbably 0 sutures . The reapproximated vagina is the released from the Teale forceps to visualize any bleeding points . The peritoneum is then closed with a running absorbable suture . Fascia is reapproximated using either a running or interrupted large suture . Subcutaneous tissue may be closed using absorbably 2-0 or 3-0 suture . The skin is closed using staples or sutures (Inside Surgery , 2007 ) The procedure will take around 1 to 3 hours

Postoperative complications include surgical wound infection excessive bleeding injury to the bowel , bladder , ureter , or major blood vessel urinary tract infection , postoperative thromboembolism , atelectasis early onset of menopause , and loss of ovarian function (eMedicine 2006 . Symptoms of infection would be fever and foul smelling drainage coming from the wound dressing , if blood studies are conducted , the white blood cell count could be elevated . Excessive bleeding would be indicated by a frequent dressing change and hematology studies should be ed . Thromboembolism is formation in a blood vessel of a clot (thrombus ) that breaks loose and is carried by the blood stream to plug another vessel . The clot may plug a vessel in the lungs , brain gastrointestinal tract , kidneys , or leg as defined in the website medicinenet . Atelectasis is the collapse of the lung or a part of it , as defined in the website medline plus

Post operational recovery would include that the patient stays in the recovery room for around 3 hours until stable and will be transferred to a private room afterwards . An indwelling catheter is left in the bladder for 12-24 hours and 2-3 L IV fluids are infused for another 24 hours Diet is restricted to "full liquids " and is increased to "regular diet as tolerated " by the next day . Analgesics maybe supplemented by IV narcotics for the first postoperative night (Vietz , 1997 ) It takes 4-6 weeks to recover after the surgery . Lifting anything heavy for 6 weeks after the surgery is prohibited and return to normal sexual activities is expected after also after 6 weeks (eMedicine , 2006

Even though hysterectomy is the treatment for these types of female internal structure diseases , there are still nonsurgical alternatives that should always be considered first . Hormonal therapy gonadotropin-releasing hormone antagonists , progesterone-containing intrauterine device , endometrial ablation , cryotherapy , and uterine artery embolization have been used with success (eMedicine , 2006 ) Also if it is benign , there may have treatment options besides hysterectomy First is drug therapy . There are medications that may help relieve heavy or irregular uterine bleeding . Many times women have hysterectomies because of bleeding related to hormonal imbalances - the uterus itself might be perfectly healthy . Correcting hormonal imbalances may be a better alternative than surgery (Mayo Clinic 2006 ) There is also what is called an Endometrial ablation . If there is heavy or irregular uterine bleeding , this minimally-invasive procedure might relieve the symptoms . With a special device , a surgeon uses electricity , heat or cold to destroy the lining of the uterus and stop uterine bleeding (Mayo Clinic , 2006 ) Uterine artery embolization is also an option , a procedure that involves blocking the blood supply to the tumor . Without blood , the fibroids shrink over time , which can reduce painful and uncomfortable symptoms , such as heavy bleeding or an enlarged abdomen (Mayo Clinic , 2006 ) If there are fibroid tumors , a myomectomy can surgically remove the tumors while leaving your uterus intact . Getting rid of the tumors relieves abnormal bleeding and painful symptoms (Mayo Clinic , 2006 ) And finally , focused ultrasound surgery . An adapted version of a magnetic resonance imaging machine allows a doctor to visualize your anatomy , then locate and destroy (ablate ) fibroid tumors inside your uterus without making an incision (Mayo Clinic 2006

Bibliography

Braun , D (2007 ) What a normal pap smear means [Internet] , Obgyn .net Available from [Accessed 14 January 2008]

Bullock , Barbara L Reet L . Henze (2000 ) Focus on Pathophysiology Philadelphia : Lippincott Williams and Wilkins

ETHICON Women 's health Urology (2008 ) Hysterectomy [Internet] . United States . Available from : [Accessed 14 January 2008]

Gor , H (2006 ) Hysterectomy [Internet] , eMedicine . Available from : [Accessed 14 January 2008]

Inside Surgery (2007 [Internet] . United States . Available from : [Accessed 14 January 2008]

Mayo Clinic (2006 ) Hysterectomy : Surgery to remove your uterus

[Internet] . United States . Available from : [Accessed 14 January 2008]

Medline Plus HYPERLINK "http /www .nlm .nih .gov " \t "TheNewWin " U .S National Library of Medicine (2006 ) Pelvic Inflammatory Disease [Internet] . United States . Available from [Accessed 14 January 2008]

Smeltzer , S . C Brenda G . Bare (2004 ) Medical-Surgical Nursing . 10th ed . Philadelphia , Lippincott Williams and Wilkins

Trupin , S (2007 ) Hysterectomy [Internet] ,MedicineNet . Available from : [Accessed 14 January 2008]

University of Pittsburgh Medical Center (2007 ) Hysterectomy [Internet] United States . Available from : [Accessed 14 January 2008]

Vietz ,

(1997 ) Pelviscopic Intrafascial Hysterectomy

[Internet] Available from [Accessed 14 January 2008]

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Figure SEQ Figure \ ARABIC 1 Figure 2 : Vaginal Hysterectomy

Figure 3 : Laparoscopic assisted Hysterectomy

Figure 4 : Laparoscopic supracervical Hysterectomy

Figure 5 : internal female reproductive system

Figure 6 : The uterine walls

Figure7 : Ovaries ...