Abdominal hysterectomy

A 57-year-old woman is scheduled for an abdominal hysterectomy due to uterine fibroids. She is very anxious about her surgery. 

S/P total abdominal hysterectomy and bilateral salpin-goophorectomy at age 20... 

FIGURE 91-1. Diagram of female reproductive tract (uterus, fallopian tubes, ovaries, vagina). Dashed-line box outlines what is removed during the total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH-BSO). 

Abdominal hysterectomy SSI rates are correspondingly lower than vaginal hysterectomy rates. However, prophylactic antibiotics are still recommended regardless of underlying risk factors. 

Both cefazolin and antianaerobic cephalosporins (e.g., cefoxitin, cefote-tan) have been studied extensively for abdominal hysterectomy. Singledose cefotetan is superior to single-dose cefazolin. The antibiotic course should not exceed 24 hours in duration. 

Abdominal hysterectomy 1 g doses 30 to 90 min before surgery and repeated 8 and 16 h later. 

There is also a single study looking at the addition of paclitaxel to adjuvant radiation for patients with high-risk early stage carcinoma of the endometrium (107). Essentially they have shown that post total abdominal hysterectomy, bilateral salingo-oopherectomy,... 

Gesztesi, Z., Scuderi, P. E., White, P. F., Wright, W., Wender, R. H., D Angelo, R., Black, L. S., Dalby, P. L., MacLean, D. Substance P (neurokinin-1) antagonist prevents postoperative vomiting after abdominal hysterectomy procedures, Anesthesiology 2000, 93, 931-937. 

Debus G, Schuhmacher I. Endometrial adenocarcinoma arising during estrogenic treatment 17 years after total abdominal hysterectomy and bilateral salpingo-... 

In a 50-year-old woman with uremia the platelet count fell from 149 x 109/1 to 45 x 109/1 after an abdominal hysterectomy with prophylactic desmopressin, and she developed a fatal subdural hemorrhage (65). 

Chia YY, Lo Y, Liu K, et al. The effect of promethazine on postoperative pain a comparison of preoperative, postoperative, and placebo administration in patients following total abdominal hysterectomy. Acta Anaesthesiol Stand. 2004 48 625-630. 

A laparoscopy is performed and the cysts drained. The patient is prescribed GnRh analogue plus add-back therapy. Two months later she is readmitted with left loin pain, hot, cold and dizzy symptoms. The impression is a flare-up of the endometriosis. The pain team prescribed morphine 2 hourly. Patient had radical operation subtotal abdominal hysterectomy and bilateral salpingo-oophorectomy. 

Options are medical hormonal treatments and/or surgery. Surgical treatment by laparoscopic ablation of endometriotic lesions plus adhesiolysis may improve fertility. Hormonal treatments should not be used for endometriosis in women with fertility problems as they tend to lead to ovarian suppression. Laparoscopic ablation of endometrial deposits may relieve pain in some women. Radical surgery (e.g. total abdominal hysterectomy, salpingo-oophorectomy or both) is reserved for women who have completed their family and in whom other treatments have failed. It is usually curative although... 

Postoperative nausea and vomiting (PONV) is common after laparotomy and major gynaecological surgery, e.g., abdominal hysterectomy The use of propofol, particularly when given to maintain anaesthesia, has dramatically reduced the incidence of PONV. Antiemetics, such as cyclizine, metoclo-pramide, and ondansetron, may be helpful. 

Snijdelaar DG, Katz J, Clairoux M, Sandler AN. Respiratory effects of intraoperative alfentanil infusion in post-abdominal hysterectomy patients a comparison of high versus low dose. Acute Pain 2000 3 131-9. 

In a randomized, double-bhnd, placebo-controUed study of 80 patients who required epidural morphine after abdominal hysterectomy, 40 received intravenous dexamethasone (8 mg) (21). The incidence of vomiting with dexamethasone group was 5% compared with 25% with placebo the total incidence of nausea and vomiting was 16% compared with 56%. 

In a double-blind, randomized comparison of remifentanil (0.25/0.5 micrograms/kg/minute) and alfentanil (50 micrograms and 0.5 micrograms/kg/minute) in 35 patients undergoing total abdominal hysterectomy, remifentanil provided more stable analgesia during anesthesia but caused significantly more hjrpotension (14). 

Kovac AL, Azad SS, Steer P, Witkowski T, Batenhorst R, McNeal S. Remifentanil versus alfentanil in a balanced anesthetic technique for total abdominal hysterectomy. J Clin Anesth 1997 9(7) 532 1. 

Akural El, Salomaki TE, Tekay AH, Bloigu AH, Alahuhta SM. Pre-emptive effect of epidural sufentanil in abdominal hysterectomy. Br J Anaesth 2002 88(6) 803-8. 

In a randomized, double-blind placebo-controlled study of 76 women undergoing abdominal hysterectomy, tramadol 100 mg was a more effective analgesic than ketorolac 30 mg given every 6 hours intravenously (45). However, of those given tramadol 38% had vomiting compared with only 8% of those who were given ketorolac. 

Coetzee JF, van Loggerenberg H. Tramadol or morphine administered during operation a study of immediate postoperative effects after abdominal hysterectomy. Br J Anaesth 1998 81(5) 737 1. 

Ketorolaco frente a tramadol estudio comparative de la eficacia analgesica en el dolor postoperatorio de histerecto-mias abdominal. [Ketorolac versus tramadol comparative study of analgesic efficacy in the postoperative pain in abdominal hysterectomy.] Rev Esp Anestesiol Reanim 2000 47(4) 162-7. 

EUstrom M, Bengtsson A, Tylman M, et al. Evaluation of tissue trauma after laparoscopic and abdominal hysterectomy measurements of neutrophil activation and release of interleukin-6, cortisol, and C-reactive protein. J Am CoU Surg 1996 182 423-30. 

Chou WY, Wang CH, Liu PH, et al. Human opioid receptor Al 18G polymorphism affects intravenous patient-controlled analgesia morphine consumption after total abdominal hysterectomy. Anesthesiology 2006 105(2) 334-7. 

Hemsell DL, Johnson ER, Hemsell PG, et al. Cefazolin is inferior to cefotetan as single dose prophylaxis for women undergoing elective total abdominal hysterectomy. Clin Infect Dis 1995 20 677-684. 

Vaginal or abdominal hysterectomy and high-risk cesarean section (following labor or ruptured membrane only)... 

The 36-year-old female client who had an abdominal hysterectomy is prescribed the estrogen hormone replacement Premarin. The client calls the nurse in the Women s Elealth Clinic and reports she is producing breast milk. Which intervention should the nurse tell the client ... 

A placebo-controlled study in women undergoing abdominal hysterectomy found that a dexmedetomidine infusion started 15 minutes before induction of anaesthesia caused a dose-dependent reduction in isoflurane MAC (by 35% and 47% with dexmedetomidine plasma levels maintained at 0.37 and 0.69 nanograms/mL, respectively). In another study, dexmedetomidine reduced the ED50 dose requirement ofisoflurane for anaesthesia (motor response) in 9 healthy subjects. Dexmedetomidine plasma levels of 0.35 and 0.75 nanograms/mL reduced the requirements for isoflurane by about 30% and 50%, respectively. Subjects who had received dexmedetomidine took longer to wake up. Dexmedetomidine has sedative, analgesic and anxiolytic effects and therefore, like other sedatives, may reduce the dose requirements of anaesthetics. However, it may also affect the distribution of thiopental and possibly other intravenous anaesthetics. 

Caumo W, Hidalgo MPL, Schmidt AP, Iwamoto CW, Adamatti LC, Bergmann J, Ferreira MBC. Effect of pre-operative anxiolysis on postoperative pain response in patients undergoing total abdominal hysterectomy. Anaesthesia (2002) 57, 740-6. 

Sandler AN, Baxter AD, Katz J, Samson B, Friedlander M, NormanP, Koren G, Roger S, Hull K, Klein J. A double-bUnd, placebo-controUed trial of transdermal fentanyl after abdominal hysterectomy. Analgesic, respiratory, and pharmacokinetic effects. Anesthesiology (1994), 81, 1169-80. 

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