Laparotomic Hysterectomy

Laparotomic Hysterectomy (hysterectomy via laparotomy)

Key Points


  • Appropriate when hysterectomy is indicated but the vaginal or laparoscopic approach is not feasible because of some combination of leiomyoma size, number and location or if there is a concern regarding the possibility of coexisting cancer such as leiomyosarcoma.
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  • While the Pfannenstiel incision is preferred, when the uterus is very enlarged, modifications of the transverse incision are often required to obtain adequate exposure (the Cherney or Maylard incisions); rarely is a vertical incision necessary. 
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  • The preoperative use of gonadotropic releasing hormone modulators, in addition to allowing the correction  of existing anemia, may facilitate the procedure by reducing leiomyoma and overall uterine volume.
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  • The surgeon should be prepared for the frequent anatomical distortion created by leiomyomas that can affect the location of blood vessels, course of the ureter, the borders of the urinary bladder and even the anatomy of the sigmoid colon. This may require comfort and competence with working in the pelvic retroperitoneum such as the paravesicle and perirectal spaces.
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  • In some instances, the locations of the ureters, bladder, and rectum may be facilitated by the placement of ureteric stents, instillation of a contrast such as methylene blue in the bladder, or with the use of a rectal obturator.

 

Defining Laparotomic Hysterectomy

Laparotomic (open abdominal) hysterectomy is the surgical removal of the uterus through a laparotomy; an incision into the abdominal cavity. When the entire uterus (corpus plus cervix) is removed, it is termed a total hysterectomy; when the cervix is preserved the procedure is called supracervical or subtotal hysterectomy. Further discussion of supracervical hysterectomy can be found here.  The basic principles of laparotomy are discussed here, while determining the optimal route of hysterectomy -  the vaginal, laparoscopic, or laparotomic approaches - is discussed here. 

Indications

Not all patients with fibroids who are candidates for hysterectomy are good candidates for the vaginal or laparoscopic techniques. The choice of approach often depends on the training and skill of the surgeon and the surgical team; many in the list that follows will preclude vaginal or laparoscopic hysterectomy for some, but not for others. The circumstances when laparotomic hysterectomy for fibroids may be the best approach include:


Large Fibroids

The definition of “large” will vary, especially when location is taken into account. A 8 cm diameter cervical leiomyoma (FIGO Type 8) presents different surgical risks and demands on technique than a similar sized Type 6, or 7 tumor located in the corpus. Those operating on cervical fibroids must be adept at managing the surrounding organs and structures by operating in the retroperitoneal spaces to identify and protect the ureters, bladder, and often the sigmoid colon. Even in well trained hands, cervical tumors may require the laparotomic approach.


Large Uterus

The definition of “large uterus” and how surgeons and surgical teams approach such a challenge will vary as it does with large fibroids. And there is more to how the phenotype affects this decision than simple uterine volume. For example, if the cervix and lower uterine segments are relatively uninvolved with leiomyomas, expert vaginal surgeons may be able to safely remove the uterus without resorting to the laparotomic incision. On the other hand, and as discussed under “large fibroids", cervical and lower segment expansion by leiomyomas may make vaginal and even laparoscopic surgery more difficult, leading to the decision to remove the uterus laparotomically. In other situations, the uterus is so large that laparoscopic access is difficult if not impossible, even after the use of volume reducing pharmacotherapy. In such instances, laparotomy may be the only option.

Preoperative Assessment

Preoperative Management including Patient Optimization

There are several issues that must be addressed before any surgery, and particularly "major" abdominal surgery for women with leiomyomas that include normalization of iron status, uterine volumetric reduction, and optimization of comorbidities that can include diabetes, hypertension, hypothyroidism, obesity, and other medical illnesses. For details regarding patient optimization before hysterectomy, please see preoperative considerations under surgical principles


Operating Room Setup and Equipment

ToolBox

Generic

Scalpel handle

Blade 10”

Retractors

2 Surgical Sponge Clamp

Dressing Forceps 12”

2 Kelly Clamp, Curved Large 10”-12”

2 Mosquito Clamp, Curved 5”2 Kocher Clamp, Straight 6 ¼”

1 Metzenbaum Scissors, Curved 14”

1 Mayo Scissors, Straight 8”

1 Mayo Hegar Needle Drive, straight or curved

1 Vascular Clamp 14”

1 Myoma screw[1] [2] 

RF electrosurgical generator

Electrodes for cutting and/or coagulation 

How does this apply to a laparotomic hysterectomy?



Specific Technique 1

Specific Technique 2

 Specific Technique 3

Tool Box

Selecting the Incision
The type of incision depends on the need for exposure considering the uterine volume, size and numbers of leiomyomas, the probable need for retroperitoneal dissection, the surgeon’s experience, availability of equipment, and patient requests. The types of incision can be found here under the surgical principles.

Performing the Hysterectomy starting with Exposure

Intraoperative Complications

Postoperative Management

References

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