Perioperative management - Supracervical hysterectomy, bilateral salpingectomy, laparoscopic

A hysterectomy can be performed in different ways:

• Abdominal
• Vaginal
• Laparoscopically-assisted vaginal
• Laparoscopic/robot-assisted

Additionally, a distinction is made between a total hysterectomy with preservation of the cervix and a supracervical hysterectomy.

Uterine fibroids, fibroids are the most common indication for a hysterectomy, approximately 75% of all hysterectomies.

Bleeding disorders

Adenomyosis uteri

Endometriosis

Genital prolapse

Precancerous changes of the endometrium and cervix

Suspicious changes indicating malignancy

The occurrence of an accidental uterine sarcoma during a hysterectomy or myomectomy ranges between 1/205 and 1/7400 (0.49%-0.014%). In a meta-analysis of 10,120 patients, a frequency of 0.29% was found. Due to this risk, electromechanical morcellators were withdrawn, by Ethicon in 2014 and Karl Storz in 2021.

In imaging, there is no reliable preoperative distinction between benign and malignant findings. However, with clinical examinations, "soft markers" in transvaginal ultrasound, possibly MRI, and a thorough medical history, the risk can probably be reduced. Benign uterine fibroids do not contraindicate morcellation. Therefore, it is important to preoperatively inform about the potential dangers of morcellation, alternative approaches and their respective perioperative risks (morbidity and mortality of other surgical techniques), and on the other hand, the low incidence of sarcomas.

The use of retrieval bags also cannot exclude the dissemination of tumor cells. There are different techniques of morcellation:

Manual in bag Morcellation: Insertion of the retrieval bag, luxation of the uterus into it, minilaparotomy, and fragmentation using a scalpel (extra-abdominal).

Contained power Morcellation: Insertion of a retrieval bag, luxation of the uterus into it, electromechanical morcellation within the bag (intra-abdominal).

Morcellation should not be performed in postmenopausal patients with newly developed fibroids or fibroids with a tendency to grow, or newly symptomatic fibroids.

Conducting an adequate medical history and a gynecological examination. The examination is used to identify other pathologies of the uterus or adnexa, in order to possibly avoid a hysterectomy (e.g., submucosal fibroids or pedunculated fibroids, polyp of the corpus uteri). Additionally, determining the actual level of distress and providing information about alternative treatment options.

Laboratory examination (depending on the needs of the clinic)

Further examinations (MRI, CT) are only useful with corresponding indications.

• Wound healing disorder
• Infection, rarely intra-abdominal abscess requiring revision or percutaneous drainage
• Postoperative ileus
• Adhesions
• Vaginal cuff insufficiency
• Injuries to other organs, intestines, bladder, ureters
• Subcutaneous emphysema
• Post-laparoscopic shoulder pain syndrome
• General surgical risks (bleeding, rebleeding, thrombosis, embolism, HIT)
• Possible conversion to open technique in case of complications
• In planned supracervical hysterectomy, information about possible removal of the cervix in case of fibroids in this area or increased bleeding
• Further monthly bleeding possible with a supracervical hysterectomy
• Preventive examinations still necessary, especially with a supracervical hysterectomy
• Urinary retention
• Positioning injuries
• Burns
• Dissemination of benign as well as malignant cells, in rare cases of malignancy, worsening prognosis
• Information about alternative treatment methods

• no preoperative bowel evacuation
• no shaving
• antibiotic prophylaxis during induction of anesthesia (cephalosporins of group 2 and metronidazole)

• Remove catheters, drains, and tampons as early as possible
• Thrombosis prophylaxis for 7 days, adjust if necessary for prolonged immobilization or infection. Extend to 4 weeks for oncological procedures.
• No restriction on food intake

A final examination should be conducted before discharge.

• Physical examination with palpation of the abdomen,
• if necessary, a speculum setting with rectal/vaginal examination should also be performed.
• if applicable, renal ultrasound
• Information on postoperative behavioral measures (resumption of moderate to heavy activities in 3-4 weeks)