Hysterectomy - Laparoscopic Supra Cervical

It is the most commonly performed operation in the US (650.000/yr) after C-section.  Age range 30-70 years. Stress urinary incontinence and obesity are associated conditions

Preoperative Diagnosis

• Uterine myoma (38% - can cause bleeding and infertility)
• Malignancy (15%)
• Pelvic pain 2 to endometriosis or adhesions (5%)
• Ovarian tumors (10%)
• Uncontrolled uterine bleeding/dysmenorrhea (13%)
• Adenomyosis (9% - ectopic glandular tissue in muscle)
• Endometrial hyperplasia (3%)
• Uterine prolapse (1%)
• Less common are pelvic infections, complications from pregnancy, and delivery

Two possible approaches with several variations/combinations - Vaginal or abdominal, both receive pre-op antibiotics (Cefoxitin or Cefotan and Clindamycin)

Total Laparoscopic Hysterectomy (TLH)

Advantages

Excellent visibility and exposure. Shorter recovery time, rapid return of bowel function, less pain, and a lower wound complication rate.

Disadvantages

Higher cost requires an increased level of surgical expertise

Procedure

Laparoscopic access to the abdomen via a Veress Needle or direct-trocar insertion, followed by CO₂ insufflation and insertion of accessory trocars. CO₂ insufflation usually comes to 15 mmHg (pneumoperitoneum) for a better view. Diagnostic laparoscopy is performed. The course of ureters and the dissection of surrounding tissues to the free uterus are noted. The bladder is also freed—possible use of 5ml indigo carmine IV to verify intactness of bladder (can cause increased BP). The course of the ureters is noted through the peritoneum until they are no longer visible at the level of the cardinal ligaments (contains uterine artery and vein). The peritoneum is opened above or below the ureter, and hydro dissection (using an injection of water) is performed to lift the peritoneum off the ureter without damaging it. Hydrodissection can help identify tissue planes and limit blood loss (bleeding caught early).

If the uterus was removed via the vagina, the pneumoperitoneum would be lost. Still, since the procedure is done laparoscopically, the pneumoperitoneum can be maintained by placing a glove with 2 4x4s in the vagina, whereafter the vaginal wall is cut circumferentially. The uterus pulled to mid-vagina, thus maintaining the pneumoperitoneum. The vaginal cuff is closed transversely using laparoscopic sutures; any coexisting cystocele or enterocele is repaired.

Another option is morcellation of the uterus and removal via a 10 mm suprapubic port or placement in a specimen bag, which is removed via a small suprapubic incision.

The abdominal cavity is reevaluated, irrigated, and cleared for blood and debris. Incisions closed.

Preoperative Considerations

Antibiotics per surgeon

Possible cefazolin

Incision

Laparoscopically with insertion of abdominal trocars

Surgical Time

2-6 hrs. depending on possible adhesions or endometriosis issues

Preop area

Verify NPO, consent signed, questions answered, then Versed 2 mg and/or Robinul 0.2 mg IV

EBL

100-800 mL depending on anatomy and dissection

Mortality

0.08-0.2/1,000

Morbidity 

2.5% - overall complication rate

4.2/1,000 - conversion to laparotomy

Rare - air embolism, peroneal nerve damage from lithotomy, puncture of a major vessel or viscous, insufflation of incorrect site

1.6% - urinary and ureteral trauma, including fistula

Pain Score

6-9

Positioning

Lithotomy

• High risk of neurological and vascular complications
• Both legs should be simultaneously elevated and flexed at the hip to prevent hip dislocation or postoperative back and hip pain. Allen universal stirrups are used
• Common Peroneal nerve injury - most common nerve injury with lithotomy position (foot drop, lower-extremity paresthesia)
• Femoral nerve or lumbosacral plexus stretch injuries are caused by acute abduction and external rotation of the hips
• Arterial or venous occlusion and nerve injury from flexion of hips >90 degrees can cause kinking or compression of femoral neurovascular structures
• Obstruction of the popliteal vein impedes venous outflow due to extreme flexion of the knee
• Compromise of the vascular structures in the popliteal space from leg holders supporting the leg under the knee
• Prevention of Peroneal nerve damage- pad area of the leg leaning against stirrups (or pad the stirrup), prevent hyperflexion of the hip, which can cause femoral and lateral femoral cutaneous nerve palsy, obturator and saphenous nerve injury may occur
• Check and pad pressure points, check eyes, brachial plexus injury if supination of hand with arm >90 degree
• Possible finger injury when hands tucked with manipulation of the foot of the bed. Consider arms to side with padding if possible or wrap hands
• Ulnar nerve injury - prevent with hands supinated, <90degrees. Symptoms include numbness/tingling in the 4th and 5th finger and, in severe cases, a "claw-like" deformity.  Ulnar neuropathy is more frequently associated with preexisting asymptomatic neuropathy, prolonged hospital stays, and extremes of body habitus

Steep Trendelenburg to help with surgical visualization

• Normotensive pt compensates for increased CVP and PAP with vasodilation and decreased HR due to stimulation of baroreceptor reflex
  • Hypotensive pt may not be able to respond in the same manner
• Hypovolemia can be unrecognized in lithotomy, and Trendelenburg's position as MAP can appear normal
• Cardiac patients
  • Trendelenburg may increase myocardial work due to increased CVP, SV, and CO - pt may not be able to tolerate - may decrease CO
• If PVD
  • Increased risk of ischemia
• POVL (post-operative vision loss) due to increased ocular venous pressure and a simultaneous decrease in perfusion pressure.

Anesthesia

GA due to pneumoperitoneum, need for muscle relaxation, and management of patient discomfort - often shoulder and chest discomfort with pneumoperitoneum

ETT to prevent any aspiration and possible OGT

Monitors

Pulse ox, ECG, NIBP, Temp, Bair hugger. PNS if using muscle relaxants

Induction

Preoxygenation

Lidocaine 1 mg/kg/IV

Propofol 1-2 mg/kg/IV

Fentanyl 1-3 mcg/kg/IV

Succinylcholine 0.5-1.5 mg/kg/IV

LTA with ETT

Maintenance

Isoflurane

Vecuronium or atracurium

Fentanyl

Emergence

Zofran IV, avoid coughing on extubation, use lidocaine IV and via ETT. Consider deep extubation (spontaneous ventilation, suctioning, emerging on the mask)

Pneumoperitoneum       

• Provides a view of the surgical area, room for instruments to move
• High risk for complications as the inferior vena cava, aorta, iliac arteries, and veins, as well as bladder, bowel, and uterus, are close to the infraumbilical site.
• Gas embolism symptoms: hypotension, dysrhythmias, cyanosis, pulmonary edema, Millwheel murmur
  • Release Pneumoperitoneum, place on the left side, aspirate air if possible via CVP line
• Risk of pneumothorax due to barotrauma (increased PIP due to decreased pulmonary compliance)
• Left shoulder pain (CO₂), caused by diaphragmatic irritation, is alleviated with three big breaths after the CO₂ is released before the abdominal wall closes.
• Increased intraabdominal pressure, which predisposes to passive gastric regurgitation, possible OG to decompress and minimize the risk of aspiration
• Increased intraabdominal pressure also appears to decrease splanchnic perfusion and hepatic blood flow significantly
• Try to keep intra-abdominal pressure <15 mmHg

Advantages

Decreased post-op pain, less post-op pulmonary impairment, reduction in post-op ileus, shorter hospital stay, earlier ambulation, and smaller incision.

Complications

Brady dysrhythmias - see under cardiac

Bleeding - vascular puncture rare

Hypothermia - secondary to large fluid volumes. Use a fluid warmer and Bair hugger

Extra-abdominal insufflation - possible VAE or subcutaneous air, which can compromise the airway in some cases

Neuropathies from Lithotomy position

Fluid overload - risk of CHF, edema

Anesthetic considerations

Respiratory

• Increased risk of atelectasis, decreased FRC, VC, and compliance
• Increased Peak airway pressure and ventilation-perfusion mismatch (shunt with under ventilation compared to perfusion)
• Pulmonary congestion and edema
• Risk of hypercarbia from absorbed CO₂, monitor ETCO₂ and decreased PaO₂
• Avoid Nitrous oxide as it can diffuse into CO₂-containing intraabdominal space and increase distention.
• Trendelenburg with increased risk of R main stem intubation
• Reverse Trendelenburg with increased FRC and decreased work of breathing

Cardiac

• May have ascites and pleural fluid present if cancer is involved. Evaluate the patient for SOB and any underlying respiratory diseases
• Evaluate exercise tolerance/cardiac status
• Decreased venous return, decreased CO, and increased SVR
• Increased MAP, increased HR (baroreceptor response)
• Bradycardia due to peritoneal or fallopian-tube stimulation - stop the surgery, deflate pneumoperitoneum, administer atropine 0.5 mg/IV or glycopyrrolate 0.4-0.6 mg/IV
• Trendelenburg position increases intrathoracic pressures (cephalad displacement of abdominal contents), which activates baroreceptor reflex through CNIX in the carotid and CN X in the aortic arch, leading to increased PNS, and decreased SNS activity
• Celiac reflex can be initiated indirectly as a result of pneumoperitoneum; the symptoms are bradycardia, apnea, and hypotension

GI

• Dehydration and electrolyte abnormalities due to bowel prep/poor appetite
• Higher risk for N/V - pre-medicate with ZRA and treat with Zofran and Decadron intraop

Labs

• Low H&H if persistent bleeding, so check H&H preop, T&C if indicated
• Foley Cath to monitor output/bleeding

Other

• Muscle relaxant if laparoscopic procedure - reversal with neostigmine and Glycopyrrolate
• Neuromuscular blockade: Lower insufflation pressures, better visualization, prevent movement
• Warm fluids, heat, and humidified gases

Pain

• Consider IM/IV morphine for pain management post-op
• Possible Toradol, if OK with the surgeon

Additional things to consider if using a spinal

• GETA vs. spinal anesthesia - if spinal = increased need of fluid due to vasodilation, T4-T6 level
• Can use bupivacaine 0.75% (2 mL), possibly with Astramorph for spinal (preservative free 0.5-1 mg/mL). Use a small dose of Astramorph
• Note increased risk of post-dural puncture headache in younger females and history of motion sickness

Postoperative complications

PONV

VTE

Hypothermia