Hysterectomy is the most common gynecological surgery performed world-wide Menorrhagia secondary to uterine fibroids and unnatural catamenial hemorrhage are the two most common indicants for hysterectomy. An of import factor impacting on the incidence of complications of hysterectomy, apart from the indicant for surgery, is the surgical attack. Most sawboness perform up to 80 % of processs by the abdominal path. The incidence of LAVH performed for benign lesions has increasingly increased in recent old ages. Methods: Surgical indicants and inside informations, histological findings, and postoperative class were reviewed and analysed for 340 patients who underwent hysterectomy in 2011 and 2012.Results: In our survey, fibroid womb ( 27.9 % ) was the prima indicant for executing hysterectomies followed by a DUB ( 22.9 % ) and uterovaginal prolapsus ( UVP-21.8 % ) . During the survey period ( 2011-2012 ) , most hysterectomies were performed abdominally ( 54.4 % ) . Overall station operative complications including major and minor, are significantly higher in the abdominal surgery group as compared to the vaginal and laparoscopic group ( p value= 0.001 ) . Decision: We need to guarantee that trainees get competence in executing hysterectomies vaginally, which is clearly safer than the abdominal attack.
Keywords: Hysterectomy indicants, LAVH, TAH, Intraoperative, Postoperative complications
Introduction
Hysterectomy is the most common gynecological surgery performed worldwide. After cesarean bringing, hysterectomy is the major surgical process most often performed in women1, 2. With increasing promotion in engineering and acquisition of better accomplishments and see the abdominal path is fast being replaced by vaginal and laparoscopic for bulk of indicants as many of the sawboness now consider that descent of the neck and non the uterine size predicts the success of the vaginal path of hysterectomy.
Over the past 2 old ages assorted hysterectomies were performed in our infirmary through different paths for a assortment of indicants.
More than half of the hysterectomies are carried out due to unnatural uterine hemorrhage, which is associated with a broad scope of diagnosings that include uterine fibroids, adenomyosis, endometriosis and dysfunctional uterine hemorrhage ( DUB ) . Menorrhagia secondary to uterine fibroids and unnatural catamenial hemorrhage are the two most common indicants for hysterectomy.
An of import factor impacting on the incidence of complications of hysterectomy, apart from the indicant for surgery, is the surgical attack.
The type of hysterectomy depends on the upset be treated, the size of the womb, and the accomplishments and penchant of the sawbones. The abdominal attack is indicated in most instances of uterine malignant neoplastic disease, in instances of exigency hysterectomy, and in patients with big fibroids.
Laparoscopic assisted vaginal hysterectomy ( LAVH ) and Vaginal hysterectomy ( VH ) is clinically and economically comparable with Entire abdominal hysterectomy ( TAH ) , with patients ‘ benefits of less estimated blood loss, less analgesia usage, less intra- and postoperative complication rates, less postoperative hurting, rapid patient recovery and shorter infirmary stay3.Studies have reported fewer unspecified infections or feverish episodes in the vaginal group versus the abdominal group4. The figure of doses of injectable anodynes used per patient was significantly more in the TAH group in comparing to LAVH group. Overall complication was 14 % in LAVH and 10 % in TAH though the differences were non significant5.
In LAVH, greater entire uterine weight and morcellation are associated with longer operative times. Blood loss correlatives with uterine weight when vaginal morcellation is besides used. An addition in the operative clip and a higher blood loss can be expected as the uterine weight additions and can be predicted taking morcellation methods into account6.
Measuring surgical attacks harmonizing to the type and badness of complications identifies the hazard factors most strongly associated with each attack. Further, by giving rise to proficient betterment, such appraisal will ensue in safer patient intervention.
MATERIALS AND METHODS
Surgical indicants and inside informations, histological findings, and postoperative class were reviewed and analysed for 340 patients who underwent hysterectomy in 2011 and 2012.
The patients were adimitted 2-3 yearss prior to the surgery and a complete work up of the instance is done. Co morbid medical conditions like diabetes, high blood pressure, bosom disease, thyroid disease if any, are looked into and cardiologist or physician ‘s sentiment is sought for the same.
Patients Hb & lt ; 10 gram % are transfused with blood harmonizing to their Hb values. Preoperative fittingness for each patient is obtained from the anesthesiologist prior to posting the instance. Depending on the indicant and path of surgery being performed pre op readying is done. Routinely pre op IV antibiotics like Claforan are given to all patients half an hr before the surgery. 1 unit of blood is reserved for each patient on the twenty-four hours of surgery.
Foley ‘s catherization is done for all the patients undergoing TAH preoperatively and instantly following surgery in instance of LAVH, VH and NDVH. Vaginal battalion ( Roller gauze with betadine ) is routinely kept in all instances of LAVH/VH/NDVH for 24 hour. Romovac drain is considered in those patients in whom intra operative seepage is noticed.
In the postoperative period all patients are kept for observation and monitoring in the surgical ICU. Post operative Hb and PCV is routinely done the undermentioned twenty-four hours forenoon and patients with Hb & lt ; 7 and PCV & lt ; 21 are given a blood transfusion and everyday IV antibiotics ( Cefotaxime and Metronidazole ) are continued for 48 hours followed by unwritten antibiotics for 5 yearss. Metronidazole is discontinued for patients who have nausea & A ; purging as side effects of the drug. Inj.Gentamycin is added in indicated instances of VH with meshplasty, diabetic patients, cardiac or septic instances. Foley ‘s catheter is kept for 24 hours routinely for abdominal hysterectomy and 48hrs for VH/LAVH/NDVH and extended vesica drainage is considered in patients who had required hard vesica dissection during surgery. Romovac drain is removed when the drain end product is & lt ; 25ml.
Patients with abdominal hysterectomy are discharged on the 7th or 8th twenty-four hours after sutura remotion, while NDVH/VH/LAVH patients are discharged on the fourth postoperative twenty-four hours. All patients are advised to reexamine after 6 hebdomads or earlier in the event of any unanticipated complications.
Histopathology studies are routinely reviewed at 6 hebdomads. However, in patients whom malignance is suspected the same is reviewed after 2 hebdomads.
Consequence
Sing the age wise distribution form of patients who underwent hysterectomy the bulk of adult females were in the age group of 40 -49 old ages ( 193 ) . However, the 2nd prima age group was that of immature adult females 30-39 old ages ( 68 ) . The younger adult females hysterectomised were approximately 30 old ages of age, for varied indicants like fibroid womb or endometriosis. The overall average age was 46.9 old ages. Sing the varied pre operative diagnosing for hysterectomy, the highest average age was 57.8 old ages in instances of venereal malignances followed by 55.7 old ages in instances of UVP, whereas the lowest was 40.7 old ages in instances of pre malignant conditions and Adenomyosis.
Preoperative diagnosing showed in Table 1. In our survey, fibroid womb ( 27.9 % ) was the prima indicant for executing hysterectomies followed by a DUB ( 22.9 % ) and uterovaginal prolapsus ( UVP-21.8 % )
Table. 1: Preoperative diagnosing
S.No
Diagnosis
No of patients
Percentage ( % )
1.
Dysfunctional uterine hemorrhage
78
22.9 %
2.
Fibroid womb
95
27.9 %
3.
Endometriosis
33
9.7 %
4.
Utero vaginal prolapsus
74
21.8 %
5.
Adnexal mass
29
8.5 %
6.
Chronic cervicitis
8
2.4 %
7.
Pre malignant conditions
8
2.4 %
8.
Genital malignance
5
1.5 %
9.
Post menopausal hemorrhage
10
2.9 %
Entire
–
340
100 %
The path of hysterectomies were performed showed in the Table 2.
Table. 2: Path of surgery
S.No
Path
No of patients
2011 ( % )
No of patients
2012 ( % )
Entire ( % )
1.
TAH
142 ( 74.3 % )
35 ( 23.5 % )
177 ( 52.1 % )
2.
VH
38 ( 19.9 % )
38 ( 25.5 % )
76 ( 22.4 % )
3.
NDVH
Nothing
10 ( 6.7 % )
10 ( 2.9 % )
4.
LAVH
8 ( 4.2 % )
61 ( 40.9 % )
69 ( 20.3 % )
5.
Wertheim ‘s
2 ( 1.0 % )
2 ( 1.3 % )
4 ( 1.2 % )
6.
Subtotal
1 ( 0.5 % )
Nothing
1 ( 0.3 % )
7.
Staging laparotomy
Nothing
3 ( 2.0 % )
3 ( 0.9 % )
Entire
191
149
340
Indication
Average age
No pathology
Fibroid tumor
Endometriosis
Benign Ovarian Tumor
Chronic cervicitis / SIL
EH
Ca Ovary
Ca womb
Ca neck
Endometriosis
Entire
DUBiˆ?*
43.8
40
7
15
–
–
14
–
1
–
1
78
Fibroid tumor
41.2
5
75
15
–
–
–
–
–
–
–
95
Endometriosis
40.7
6
5
22
–
–
–
–
–
–
–
33
Prolapse
55.7
70
2
–
1
–
3
–
–
–
–
74
Adnexal mass
47.7
1
–
–
24
–
–
2
–
–
–
29
Chronic cervicitis
45.2
–
–
–
–
8
–
–
–
–
–
8
Premalignant conditions
40.7
–
–
1
–
1
5
1
–
–
–
8
Genital Malignancy
57.8
–
–
–
–
–
–
1
–
4
–
5
PMBaˆ
49.6
3
–
3
–
–
4
–
–
–
–
10
Entire
46.9
125
89
56
25
9
26
4
1
4
1
340
Table.3: Correlation of age, Pre operative & amp ; Histopathological Diagnosis
Abbreviations: iˆ?Dysfunctional uterine hemorrhage, aˆ Post menopausal hemorrhage
An analysis of Histopathological studies, 125 out of 340 adult females ( 36.8 % ) , revealed no important pathology. Out of these adult females, a bulk of the 70 adult females ( 56 % ) underwent hysterectomy for UVP, while in 40 adult females ( 32 % ) ; the indicant for surgery was DUB. In the staying 15 patients, the indicants were fibroid womb, Adenomyosis or postmenopausal hemorrhage ( PMB ) [ Table 3 ]
Out of 78 adult females hysterectomised for DUB, a bulk of the 40 adult females ( 51.3 % ) had no pathology in the womb, while 15 ( 19.2 % ) had Adenomyosis, 14 had endometrial hyperplasia ( EH-17.9 % ) and 7 patients ( 9 % ) were diagnosed with fibroid womb. One patient with a preoperative diagnosing of DUB, aged 52 old ages was diagnosed as holding endometrial malignant neoplastic disease on HPR ( Not diagnosed on Fractional curettement ) . One instance of DUB surprisingly showed HPR of Degenerated merchandises of construct.
95 adult females ( 27.9 % ) in our survey underwent hysterectomy for fibroid womb, out of which a bulk of 75 adult females ( 79 % ) had histopathologically proved fibroids.
In the staying 20 patients, 15 had Adenomyosis, while 5 patients had normal uteri with no unequivocal pathology. 14 other patients with incidental findings of leiomyoma on HPR were operated for varied indicants like DUB, Adenomyosis or prolapsus womb.
In the 74 adult females with UVP, who underwent VH, bulk of 70 adult females had no pathology on HPR. Operated 33 instances with a preoperative diagnosing of Adenomyosis of which merely 22 had proven Adenomyosis on HPR. Entire figure of HPR demoing Adenomyosis was 56 in our survey, out of which, in 34 patients, the preoperative diagnosing was non Adenomyosis. This indicates that the true incidence of Adenomyosis is higher compared to clinical or sonological diagnosing.
We operated 29 instances of adnexal multitudes, out of which 24 were benign tumors, while 2 were malignant.
In our survey, 5 vesica hurts ( 1.4 % ) were noted over a period of 2 old ages, out of which 2 were in TAH ( 1.1 % ) & A ; VH ( 2.6 % ) each and 1 was seen in LAVH ( 1.4 % ) . All were identified on the tabular array and vesica fix was done. In add-on 3 ureteric hurts were noted, all in the abdominal hysterectomy group for big annexal mass, carcinoma neck and carcinoma ovary severally. These hurts were identified station operatively. The difference was nevertheless non important statistically ( p value= 0.84 ) [ Table 4 ]
Table.4: Intraoperative complications:
Hysterectomy
Diagnosis
Bleeding with transfusion
Bladder
Injury
Intestine
Injury
Ureteric
Injury
Entire
TAH/Subtotal
4 / 178
1.
Dub
–
Yes
–
–
2.
Chr cervicitis
–
Yes
–
–
3.
Endometriosis
Yes
–
–
–
4.
Adnexal mass
–
–
–
Yes
LAVH
2/69
1.
Endometriosis
–
Yes
–
–
2.
Fibroid womb
Yes
–
–
–
VH/NDVH
2/86
1.
UVP
–
Yes
–
–
2.
UVP
–
Yes
–
–
Wertheim ‘s
1/4
1.
Ca Cervix
Yes
–
–
Yes
Staging Lap
2/3
1.
Ca Ovary
Yes
2.
Ca Ovary
Yes
Entire No. of complications
4
5
Nothing
3
11/340 ( 3.2 % )
Sing the immediate postoperative complications, fever was noticed in 14.1 % of patients with TAH. On the contrary, 3.2 % of
patients in the vaginal group ( LAVH, NDVH, and VH ) had important station operative febrility [ Table 5 ] .
Table 5: Immediate postoperative complications
Complication
Approach to hysterectomy
No complications
TAH
LAVH
VH/NDVH
Wertheim ‘s
Staging laparotomy
Fever
25
3
2
Nothing
Nothing
30
Bleeding
3
Nothing
4
Nothing
1
8
Wound sepsis
9
Nothing
Nothing
1
1
11
Pain
12
1
Nothing
1
Nothing
14
Urinary ailments
8
Nothing
3
1
Nothing
12
Second laparotomy
2
Nothing
Nothing
Nothing
Nothing
2
Pneumonic Embolism
Nothing
Nothing
Nothing
Nothing
Nothing
0
Death
Nothing
Nothing
Nothing
Nothing
Nothing
0
Resuturing
5
Nothing
Nothing
Nothing
Nothing
5
Vault geographic expedition
3
Nothing
1
Nothing
Nothing
4
Entire no of platinums. With complication
67
( 37.8 % )
4
( 5.8 % )
10
( 11.6 % )
3
( 75 % )
2
( 66.6 % )
86/340
( 25.3 % )
Immediate postoperative complications like bleeding, wound sepsis, hurting, urinary ailments were noticed in 20.1 % of patients with abdominal surgery as compared to 5.2 % of patients in the laparoscopic and vaginal group.
Relaparotomy was done in 2 instances of abdominal hysterectomy and 5 instances were taken for lesion resuturing. No such complications were noticed in the vaginal group.
Vault geographic expedition had to be done for 4 patients out of which 3 were following abdominal hysterectomies.
An analysis of major complications in hysterectomised patients from the clip of discharge up to 6 hebdomads station op, 1 patient with abdominal surgery had Deep vena thrombosis, 4 patients had vesico vaginal fistulous withers ( 2 % ) and 1 patient had uretero vaginal fistulous withers ( 0.5 % ) . On the reverse, merely 1 patient of vaginal hysterectomy had a vault granuloma on 6 hebdomads follow up. No patients in the LAVH or NDVH group had any of the above complications on follow up. However the difference in the rates of fistula formation in abdominal vs. vaginal path is non statistically important ( p value =0. 12 ) [ Table 6 ]
Table.6: Complications from discharge upto 6 hebdomads station surgery
Complication
No. of happenings
Pain
15 ( TAH ) + 2 ( LAVH )
Poor wound mending
5 ( TAH )
Vault prolapsus
1 ( TAH )
Intestine ailments
Nothing
Deep vena thrombosis
1 ( TAH )
Femoral nervus hurt
Nothing
Vesico vaginal fistulous withers
4 ( TAH )
Uretero vaginal fistulous withers
1 ( TAH )
Vault granuloma
1 ( VH )
Entire no of patients
30/340 ( 8.8 % )
Overall station operative complications including major and minor, are significantly higher in the abdominal surgery group as compared to the vaginal and laparoscopic group ( p value= 0.001 )
In our series, the incidence of carcinoma ovary and carcinoma neck was 1.17 % each whereas carcinoma endometrium and adenomyosis were least i.e. 0.29 % each.
In pre malignant conditions, one instance was cervical dysplasia, 26 were endometrial hyperplasia, out of which two showed hyperplasia with atypia.
Discussion
Hysterectomy is the major surgical process most often performed in adult females, after cesarean delivery.1, 2 In our series, 20 % of hysterectomies were done in the age group of 30-39 old ages. An Indian survey in 2010 showed that 33 % of hysterectomies were performed in adult females less than 35 old ages of age7. These Numberss could hold been farther reduced by utilizing alternate curative options like levonorgestrel-releasing intrauterine system, endometrial extirpation or fibroid embolisation. Kripalani et Al found that Ormeloxifene was an effectual and a safe curative option for the medical direction of menorrhagia8. This would farther diminish the figure of hysterectomies for DUB. These figures stress upon the demand for promoting the intervention of benign conditions cautiously and offering hysterectomies more frequently to adult females with defined pathologies in the perimenopausal or menopausal age group.
Fibroid womb ( 27.9 % ) was the most common indicant for hysterectomy, followed by DUB and UVP. A Nigerian third infirmary retrospective survey showed that uterine fibroid was the taking indicant in 38.7 % of patients9. We do non hold the informations to analyse the per centum of adult females with fibroids who were diagnostic to warrant hysterectomy as the lone intervention mode in our survey group. Few hysterectomies were performed for venereal malignances at our Centre over the survey period of two years.This is due to the non handiness of the onco-surgeons. We deny hysterectomy for chronic cervicitis, therefore the incidence is low at 2.4 % .
Most sawboness perform up to 80 % of processs by the abdominal path 10. The incidence of LAVH performed for benign lesions has increasingly increased in recent years11. During our survey period, 54.4 % of surgeries were performed abdominally. However, in the ulterior portion of the survey, this was reduced to 26.8 % , in favor of 73.2 % of hysterectomies that were performed vaginally. This is explained by deficiency of laparoscopy expertness at our Centre during the early portion of our survey period.This besides indicates a favorable tendency towards following a vaginal attack for hysterectomy in contrast to abdominal attack at our institute.
The high incidence of abdominal hysterectomies can in portion be explained by personal penchant, but is chiefly due to miss of preparation and experience taking to reluctance to execute VH in nulliparous adult females in the presence of uterine expansion or in adult females with old pelvic surgery or old cesarean subdivision. The above factors should non be considered contraindications to VH, and there are publications that support this position 12, 13. The principle for LH is to change over an abdominal hysterectomy ( AH ) into a laparoscopic/vaginal process and thereby cut down injury and morbidity10.
Urinary piece of land hurts are reported in about 1 per centum of adult females who undergo pelvic surgery14. Surveies have reported that the rate of hurts varies by indicant and process, being highest following extremist hysterectomy for cervical malignant neoplastic disease ( 1 in 87 ; 95 % CI 61-128 ) and lowest following vaginal hysterectomy for prolapsus ( 1 in 3861 ; 95 % CI 2550-6161 ) .
After entire abdominal hysterectomy, hazard was lower after hysterectomy for benign conditions15. In our series, 2.4 % of adult females had urinary piece of land hurts ( 5 vesica hurts, 3 ureteric hurts ) . On analysis of these, we noted that amongst the vesica hurts, 2 were in TAH ( 1.1 % ) , 2 in VH ( 2.6 % ) and 1 in LAVH ( 1.4 % ) .In a survey by Babak Vakili et Al, there were 8 instances of ureteral hurt ( 1.7 % ) and 17cases of vesica hurt ( 3.6 % ) There was no dii¬ˆerence in the rate of bladder hurt among TAH, TVH, and LH ( 2.5 % vs. 6.3 % vs. 2.0 % , severally ; P = .123 ) , although there was a tendency toward a higher incidence of vesica hurt with vaginal hysterectomy16.A similar tendency was observed in our survey.
Amongst the 3 ureteric hurts in our series, all were noted in TAH done for annexal mass or venereal malignances. Vakili et Als have besides reported, that abdominal hysterectomy was associated with a higher incidence of ureteral hurt as compared to VH or LH ( 2.2 % vs. 1.2 % vs. 0 % ) but this was non significant.Vakili et Als have concluded that surgery for prolapsus or incontinency increases the hazard of urinary piece of land hurts. Therefore everyday usage of cystoscopy during hysterectomy should be considered16.However, this is hard to accept in everyday gynecology pattern.
On analysis of surgical fistulous witherss, 4 patients had VVF ( 2 % ) and 1 patient had uretero vaginal fistulous withers ( 0.5 % ) .All fistulous witherss were noted in abdominal surgeries and all patients presented with urinary leak 10-14 yearss station surgery. Surprisingly, all of them were seen in surgeries performed in a peculiar unit. The part of surgical fistulous witherss to the entire fistulous withers prevalence in developing states is little, nevertheless it is frequently supposed that this complication consequences from direct hurt to the lower urinary piece of land at the clip of operation but this is surely non ever the consequence of careless, hurried, or unsmooth surgical technique. In a survey on Vesico-vaginal fistulous witherss in developing states, of the 165 urogenital fistulous withers over the last 12 old ages, 117 were associated with pelvic surgery, and 91 followed hysterectomies ; of these lone 4 % presented with escape of piss on the first twenty-four hours station operatively. In the other instances it was presumed that tissue devascularization during dissection, accidental sutura arrangement, or pelvic haematoma formation or infection developing postoperatively resulted in tissue mortification with escape normally developing 5-14 yearss subsequently. Over distention of the vesica postoperatively may be an extra factor in many of these latter instances.It is likely that patients with a wont of infrequent elimination, or those with inefficient detrusor contractility, may be at increased hazard of postoperative urinary keeping ; if this is non recognized early and managed suitably, the hazard of fistula formation may be increased. The usage of contraceptive catheterisation in the first 24-48 H might be expected to cut down the hazard of post-operative fistulous withers formation, but this has ne’er been proven17.
Decision
Hysterectomy is a major gynecologic operation and more instances of hysterectomy should be performed vaginally, sing the legion benefits it has over the abdominal path. We need to guarantee that trainees get competence in executing hysterectomies vaginally, which is clearly safer than the abdominal attack.
The contraceptive usage of antibiotics to cut down infection and febrility, the adequateness of analgetic regimens, and the right dose of contraceptive Lipo-Hepin intervention are some of the other issues that should be audited to cut down station operative complications. Ideally, we should be able to supply more medical options, such as the levonorgestrel intrauterine system, whenever appropriate, and to hold available the equipment and collective accomplishment necessary to supply any patient with the most appropriate surgical intervention.
Because, few surveies have late been conducted sing the indicants for and complications of elected hysterectomies, the present survey may supply a footing for a future audit of our gynecological pattern and for the comparing of our pattern with others.
