Hysterectomy - Laparoscopic Vaginal

The most commonly performed operation in the US (650.000/yr) after C-section.  Age range 30-80 years. Stress incontinence and obesity are associated conditions. Preop diagnoses are usually uterine myoma, pelvic relaxation syndrome, pelvic pain 2 to endometriosis or adhesions, uncontrolled uterine bleeding/dysmenorrhea, endometrial hyperplasia, and gynecological cancers.

Two possible approaches with several variations/combinations - vaginal or abdominal, both receive pre-op antibiotics (cefoxitin or cefotetan and clindamycin)

Vaginal

• Patients in the dorsal lithotomy position are preferred as it offers significantly less morbidity and mortality. Limited use when pelvic bony architecture, uterine size, pelvic adhesions, or the presence of gynecological cancers require an abdominal approach
• To prevent peroneal nerve injury, the area of the leg leaning against the stirrup should be well-cushioned
• EBL 100-200 mL
• Pelvic relaxation syndrome is the most frequent preop diagnosis for vaginal hysterectomy
  • Prolapse of the uterus
  • Intestines in the pouch of Douglas (enterocele = vaginal hernia)
  • Bladder into the anterior vaginal wall (cystocele)
  • Urethra into the anterior vaginal wall (urethrocele)
  • Rectum into the posterior vaginal wall (rectocele)
• In the above cases, the hysterectomy is often accompanied by an anterior/posterior colporrhaphy (surgical intervention for both cystocele and rectocele), bladder neck suspension, and perineoplasty (tightening of the vagina)

Abdominal

• Patient supine
• EBL 200-300 mL

Morbidity

Infection, femoral nerve injury with Lithotomy position, hemorrhage, injury (bladder, bowel, ureter, vesicovaginal fistula, thromboembolic events)

Laparoscopic Vaginal Hysterectomy (LVH)

Advantages

Shorter recovery time, rapid return of bowel function, less pain, and a lower complication rate

Disadvantages

Higher cost requires an increased level of surgical expertise

Procedure

An LVH begins with laparoscopy and ends with four or more steps vaginally. Laparoscopic access to the abdomen via a Veress Needle or direct-trocar insertion, followed by CO₂ insufflation and insertion of accessory trocars. CO₂ insufflation is usually 15 mmHg (pneumoperitoneum) for a better view. The course of ureters is noted, and then dissection of surrounding tissues to the free uterus can be done. The bladder also freed—possible use of 5 mL indigo carmine IV to verify intactness of bladder (can cause increased BP). The procedure ends with vaginal removal of the uterus if not removed by morcellation (segmental removal). The abdominal cavity is reevaluated, irrigated, and cleared for blood and debris. Incisions closed. The pneumoperitoneum will be lost during this procedure, and it's essential to keep instruments free of bowels or other abdominal structures as this occurs.

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

Anesthesia

GA due to pneumoperitoneum, possible need for muscle relaxant, 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

ETT

Maintenance

Isoflurane

Vecuronium or atracrium

Fentanyl

Emergence

Zofran IV, avoid coughing on extubation, use lidocaine IV and via ETT. Consider deep extubation (spontaneous ventilation, suctioned, emerge on a mask)

Pneumoperitoneum       

• Provides a view of the surgical area, room for instruments to move
• There is a 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
• Risk of pneumothorax due to barotrauma (increased PIP due to decreased pulmonary compliance)
• Left shoulder pain (CO₂) - diaphragmatic irritation - alleviate with three big breaths after CO₂ is released before closure of the abdominal wall
• Increased intraabdominal pressure predisposes to passive gastric regurgitation, possible OGT 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, smaller incision

Complications

Brady dysrhythmias - see under cardiac

Bleeding - vascular puncture rare

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, increased PIP
• 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 breathing work.

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 CN IX 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 - premedicate with ZRA and treat with Zofran and Decadron intraop

Labs

• Low H&H if persistent bleeding, so check H&H preop and T&C if indicated.
• F/C 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 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