Anesthesiology

Radical Hysterectomy and Abdominal Hysterectomy - Procedures

Jump to Section

What the Anesthesiologist Should Know before the Operative Procedure

Hysterectomy is the surgical removal of the uterus. Removal of the uterus may be combined with the removal of the ovaries and/or fallopian tubes. The procedure may be done for a benign condition such as bleeding, endometriosis or leiomyosarcoma. Alternatively, this procedure may be part of a more extensive surgical procedure for treatment of malignant neoplasms of the uterus, ovary, cervix, or fallopian tubes. Total hysterectomy is the removal of the uterus and cervix while a subtotal hysterectomy does not include the removal of the cervix. Radical hysterectomy involves the complete removal of the uterus, cervix, upper vagina, ovaries, fallopian tubes, and parametrium. Radical hysterectomy may also be combined with resection of the lymph nodes, the bowel, and/or the spleen.

1. What is the urgency of the surgery?

Emergent- An emergent hysterectomy is unusual except when a gravid uterus is experiencing postpartum bleeding generally due to uterine atony, uterine rupture, placenta accreta, etc.

Urgent- Uncontrolled menorrhagia or sepsis due to an infected uterus may require an urgent hysterectomy.

Elective- Most hysterectomies are electively scheduled for benign conditions such as: uterine leiomyosarcoma, menstrual disorders, urinary incontinence, pelvic floor relaxation abnormalities, pelvic pain/endometriosis, or infection. However, some hysterectomies are performed to treat malignancies (cervical, ovarian, and endometrial), and delaying surgery can affect the oncological prognosis and outcome.

2. Preoperative Evaluation

Women may receive a hysterectomy at any age. However, most hysterectomies are performed on women who are in their 40s and 50s. If the indication for the surgery is benign, then the patient is usually young and healthy. However, patients with malignancies or urinary incontinence often have other comorbid disease states. Regardless, each woman will require a thorough history and physical exam, and each comorbid disease state should be evaluated prior to surgery.

Medically unstable conditions warranting further evaluation include:

Abnormal uterine bleeding - Evaluate for anemia

Cardiovascular disease - Angina, recent myocardial infraction, heart failure, coronary artery disease, significant arrhythmias, valvular disease, recent stroke or TIAs may be underdiagnosed in women. Therefore, all patients' functional status should be determined prior to surgery.

Pulmonary disease - COPD or acute asthma exacerbation, pulmonary hypertension, and obstructive sleep apnea are a few pulmonary diseases that should be screened.

Neurological - Recent head trauma or new-onset seizures should be evaluated.

Renal - New-onset renal failure require further workup.

GI - Bowel obstruction should be evaluated prior to surgery.

Metabolic - Severe electrolyte abnormalities, marked hypoglycemia, significant hyperglycemia, hyperthyroidism, or severe hypothyroidism require further workup.

Musculoskeletal - Recent trauma should be evaluated prior to surgery.

Delaying surgery may be indicated if an unstable medical condition is present and further evaluation or medical optimization will improve patient outcomes.

3. What are the implications of co-existing disease on perioperative care?

a. Cardiovascular system

Acute/unstable conditions: If a thorough history and physical exam suggests the patient has unstable angina, a recent myocardial infarction, decompensated heart failure, significant or new onset arrhythmia, or moderate to severe valvular dysfunction, then these issues should be evaluated and managed prior to surgery. This evaluation may include an EKG, cardiac enzymes, stress test, echocardiogram, and/or coronary angiography. A consultation with the patient's pre-existing cardiologist or a new cardiologist may be necessary to choose the appropriate evaluation and management plan prior to surgery. The management plan may be altered based on the urgency of the surgery.

Baseline coronary artery disease or cardiac dysfunction: A complete history and physical exam should be performed. Any changes in the patient's cardiac symptoms and functional status should be assessed. Prior cardiac tests and evaluation should be obtained prior to surgery including a recent evaluation by the patient's cardiologist. Any recent change in the patient's cardiac condition may require a new evaluation including repeat diagnostic testing.

Pacemakers/AICDs: The following information should be obtained: indication for placement, manufacturer, mode, current battery status, magnet response, dependence on the device (pacemaker dependent?, how often does the AICD fire?), and date last assessed.

Valvular disease: A complete history and physical exam should be performed. Any changes in the patient's cardiac symptoms and functional status should be assessed. Prior cardiac tests and evaluation should be obtained prior to surgery including a recent evaluation by the patient's current cardiologist. Any recent changes in the patient's cardiac condition may require a new evaluation including repeat diagnostic testing. A baseline echocardiogram should be performed, or a prior record should be obtained before surgery.

Rhythm Disorders: A complete history and physical exam should be performed. Any changes in the patient's cardiac symptoms and functional status should be assessed. Prior cardiac tests and evaluation should be obtained prior to surgery, and a recent evaluation by the patient's current cardiologist should be included. Any changes in the patient's cardiac condition may require a new evaluation such as repeat diagnostic testing. A baseline EKG should be obtained prior to surgery.

Perioperative Risk Reduction Strategies

Monitoring: Standard ASA monitors are required. Additionally, invasive monitoring such as an arterial line, CVP, PA catheter and/or TEE may be indicated. Depending on the patient's functional status, invasive monitors may be necessary prior to induction of anesthesia.

Induction: Anesthetic goals include preventing large fluctuations in blood pressure and heart rate.

Maintenance: Hemodynamic goals depend on the patient's specific cardiovascular abnormality. For example, severe coronary artery disease hemodynamic management should focus on improving myocardial oxygenation and reducing myocardial work (i.e., low heart rate, good oxygenation, and high diastolic blood pressure).

Emergence: Anesthetic goals should be accomplished without large fluctuations in hemodynamics.

Type of anesthesia: Spinal anesthesia, with its rapid-onset sympathectomy, may be relative contraindicated with valvular lesions such as severe aortic or mitral stenosis.

b. Pulmonary

COPD

Preoperative Evaluation:

  • History - Current respiratory symptoms, recent exacerbations or URIs, smoking history, medications, oxygen usage, and functional status should be reviewed. Available pulmonary function tests and/or arterial blood gases should be examined.

  • Physical exam - A thorough physical exam should be done focusing on the pulmonary exam. Room-air saturation should be obtained. If the patient exhibits chronic hypoxia, then the patient should be evaluated for pulmonary hypertension with concomitant right heart dysfunction.

Perioperative Risk Reduction Strategies:

  • Medications: Continue current pulmonary medications perioperatively, particularly if the patient is taking an inhaled beta-agonist and/or anticholinergic therapies.

  • Current pulmonary exacerbations should be treated prior to surgery.

  • If general anesthesia is performed, then ventilation should be adjusted for the degree of pulmonary dysfunction. Maximal expiratory time will decrease the likelihood of gas trapping, barotrauma, or rupture of emphysematous bullae. If laparoscopy is performed, then ventilation can be problematic, and allowing some hypercapnia may be unavoidable.

  • If regional anesthesia is chosen, airway manipulation and mechanical ventilation is avoided, thereby reducing the risk of bronchospasm. However, regional anesthesia may anesthetize accessory muscles that may be critical to patients' respiratory effort. Also, regional anesthesia is often problematic during laparoscopy due to the length of surgery, steep Trendelenburg position, and degree of insufflation.

Reactive Airway Disease (Asthma)

Preoperative Evaluation:

  • History - Current respiratory symptoms, recent exacerbations or URIs, smoking history, medications, reactive airway triggers, and functional status should be obtained. Any available pulmonary function tests and/or arterial blood gases should be reviewed.

  • Physical exam - A thorough physical exam should focus on the pulmonary exam, and room-air saturation should be performed.

Perioperative Risk Reduction Strategies:

  • Medications: Continue pulmonary medications, particularly inhaled beta-agonist and/or corticosteroids perioperatively.

  • Current pulmonary exacerbations should be treated prior to surgery.

  • If general anesthesia is performed, ventilation should be adjusted to accommodate the degree of pulmonary dysfunction. If a laparoscopic approach is selected surgically, ventilation can be especially problematic and allowing some hypercapnia may be unavoidable.

  • If regional anesthesia is chosen, airway manipulation and mechanical ventilation is avoided, thereby reducing the risk of bronchospasm. However, regional anesthesia may anesthetize accessory muscles that may be critical to patients' respiratory effort. Also, regional anesthesia is often problematic during laparoscopy due to length of surgery, steep Trendelenburg position, and degree of insufflation.

Pulmonary Fibrosis

Preoperative Evaluation:

  • History - Current respiratory symptoms, recent exacerbations or URIs, smoking history, medications, oxygen use, and functional status should be obtained. Any available pulmonary function tests and/or arterial blood gases should be reviewed.

  • Physical exam - a thorough physical exam should be done focusing on the pulmonary exam. A room air saturation should be performed.

Perioperative Risk Reduction Strategies:

  • Medications: Continue current pulmonary medications.

  • Any current exacerbations should be treated prior to surgery.

  • If general anesthesia is chosen as the anesthetic of choice, ventilation should be adjusted for the degree of pulmonary dysfunction, i.e. allow for a maximal exhalation time to decrease gas trapping and the risk of barotrauma. If laparoscopy is performed, ventilation can be problematic, and allowing some hypercapnia may be unavoidable.

  • If regional anesthesia is chosen, airway manipulation and mechanical ventilation is avoided, thereby reducing the risk of bronchospasm. However, regional anesthesia may anesthetize accessory muscles that may be critical to patients' respiratory effort. Also, regional anesthesia is often problematic during laparoscopy due to length of surgery, steep Trendelenburg position, and degree of insufflation.

Cystic Fibrosis

Preoperative Evaluation:

  • History - Current respiratory symptoms, recent exacerbations or URIs, smoking history, medications, amount of secretions, and functional status should be obtained. Any available pulmonary function tests and/or arterial blood gases should be reviewed.

  • Physical Exam - A thorough physical exam should be performed. Room air saturation should be obtained.

Perioperative Risk Reduction Strategies:

  • Medications: Continue current pulmonary medications perioperatively.

  • Any current infectious exacerbations should be treated prior to surgery.

  • If general anesthesia is performed, ventilation should be adjusted for the degree of pulmonary dysfunction (i.e., allow for a maximal exhalation time to decrease gas trapping and the risk of barotrauma). If a laparoscopy is performed, ventilation can be problematic, and allowing some hypercapnia may be unavoidable. Suction of secretions intraoperatively is to be expected.

  • If regional anesthesia is chosen, airway manipulation and mechanical ventilation is avoided, thereby reducing the risk of bronchospasm. However, regional anesthesia may anesthetize accessory muscles that may be critical to patients' respiratory effort. Also, regional anesthesia is often problematic during laparoscopy due to length of surgery, steep Trendelenburg position, and degree of insufflation.

Pleural Effusions/Pulmonary Metastasis

Preoperative Evaluation:

  • Patients with ovarian cancer can present with pleural effusions and/or metastatic lung disease.

  • History - Current respiratory symptoms and functional status should be obtained. Any available pulmonary function tests, CXR, and/or arterial blood gases should be reviewed.

  • Physical Exam - A thorough physical exam should be done focusing on the pulmonary exam. A room air saturation should be obtained.

Perioperative Risk Reduction Strategies:

  • Medications: Continue current pulmonary medications perioperatively.

  • A decision should be made about whether the pleural effusions should be treated prior to induction of general anesthesia, immediately after induction, or postoperatively. The patient's current respiratory status will guide this decision.

c. Renal-GI:

Perioperative Evaluation:

  • Assessment of volume status: In elective cases, the patient should be appropriately NPO. The last oral intake and dehydration status should be determined by history and physical examination including vital signs (i.e. hypotension, tachycardia, orthostatic hypotension), skin turgor, mucus membranes, urine output and laboratory values such as sodium, BUN/creatinine. Patients will most likely have taken a bowel preparation and may have an additional fluid deficit. An actively bleeding patient may present with dehydration and may be hemoconcentrated. A chronically bleeding patient may present with a severe anemia and some degree of compensation.

  • Chronic Renal Insufficiency: The etiology of renal insufficiency and baseline creatinine should be determined. If the patient is on dialysis, the time of last dialysis and recent potassium should be ascertained. Intravenous fluids and exogenous sources of potassium (such as Lactated Ringers solution) should be closely monitored.

  • GI: In elective situations, the patient should be appropriately NPO. If the patient presents with a bowel obstruction, hiatal hernia, very large uterus, or massive ascites it may be judicious to perform a rapid sequence induction or decompress the obstruction prior to induction of anesthesia. In emergency situations, a rapid sequence induction should be performed.

d. Neurologic:

Acute Issues:

  • Patients with acute neurological conditions such as stroke, TIAs, or newly discovered brain tumors should be further evaluated prior to surgery.

  • Chronic disease: A thorough pre-operative evaluation should be performed.

  • History: Evaluate for a history of stoke, TIAs, paralysis, weakness, seizure disorder, multiple sclerosis, dementia and chronic pain. Consider if the patient has any contraindications for a neuraxial technique if it is being considered for the primary anesthetic or post-operative pain management.

  • Physical: A physical exam should be performed and document any immobility, weakness, or areas of decreased sensation.

Perioperative Risk Reduction Strategies:

  • Patients with impaired mobility may require awake positioning prior to induction of anesthesia to avoid risk of further injury.

  • A history of carotid artery disease may require a higher blood pressure to maintain a baseline blood pressure within 20% of baseline. An arterial line for careful titration of blood pressure should also be considered.

  • Older patients may be more likely to have coexisting dementia and/or be at increased risk for post-operative delirium. The judicious use of benzodiazepines and the use of shorter-acting anesthetic agents may be warranted.

  • Patients with multiple sclerosis, due to the pattern of relapsing symptoms, may exhibit an exacerbation of their symptoms in the perioperative period due to surgical stress. The symptoms can also be exacerbated in the setting of hyperthermia.

  • Medications for seizures and chronic pain may be continued up until the time of surgery.

  • Patients with a VP shunt are safe for open abdominal procedure. However, the patient's position (head down) combined with abdominal insufflation will affect the ability of a VP shunt to function. Therefore, it may not be appropriate to have these patients undergo laparoscopic hysterectomy.

  • If the patient has a deep brain stimulator it should be turned off prior to surgery due to the use of monopolar electrocautery.

e. Endocrine:

Diabetes Mellitus

Preoperative Evaluation:

Patients will either have with a pre-existing diagnosis of DM, or a thorough history can be used to assess the risk of DM.

  • History - The patient's baseline medications for DM should be obtained, including the use of insulin. The medications and interventions necessary for the patient to control her blood sugar can vary from diet control to an insulin pump. Therefore, the patient's average blood sugar range should be determined prior to induction of anesthesia. Further, diabetic patients should also be assessed for associated conditions such as coronary artery disease.

  • Physical exam - a thorough physical exam should be done.

  • Laboratory - if possible, a recent HgA1C should be obtained from the patient's old records.

Perioperative Risk Reduction Strategies:

  • Medications: Due to the patient's NPO status, the amount of diabetic medications should be altered or not taken on the morning of surgery. Oral hypoglycemic medicines should be held on the morning of surgery, and a preoperative blood sugar should be obtained prior to administration of anesthesia. Generally, short acting insulin is not given, and longer acting insulin is given in a partial dose (generally one half the typical morning dose). Extremely long acting insulin, such as Lantus, should be given in a reduced dose on the night before surgery. If there is uncertainty, the patient's endocrinologist can be consulted.

  • A patient's blood sugar should be assessed during anesthesia, particularly for cases longer than 2 hours to determine if hypoglycemia is present. The obtained blood sugar should be treated with insulin or glucose if necessary.

Thyroid Disorders

Preoperative Evaluation:

  • History - Signs and symptoms of hypo or hyperthyroidism should be assessed.

  • Physical Exam - A thorough physical exam should be done. The patient's thyroid should be assessed for goiters.

  • Laboratory - If possible a recent TSH (thyroid stimulating hormone level) should be obtained from the patient's records.

Perioperative Risk Reduction Strategies:

  • Medications: Continue current thyroid medications perioperatively.

  • If the patient is severely hypothyroid or hyperthyroid the surgery should be delayed if possible until the patient is euthyroid.

Polycystic Ovarian Disease (PCOS)

Preoperative Evaluation:

  • History - The patient should be assessed to see if PCOS is present. If present, the associated conditions such as insulin resistance/DM, obesity, metabolic syndrome, hyperlipidemia, hypertension, and strokes could also be present. Please note that PCOS is associated with an increased incidence of uterine cancer.

  • Physical exam - A thorough physical exam should be done including a cardiac exam.

Perioperative Risk Reduction Strategies:

  • Medications: Continue current hormonal medications perioperatively.

  • Obesity - Obese patients may be at increased risk due to: increased difficulty managing the airway (can be minimized by appropriate patient positioning - reverse Trendelenburg or placing a patient on a ramp), decreased effect of preoxygenation, increased difficulty positioning the patient, increased pulmonary complications postoperative (due to an increased incidence of OSA), and poor wound healing and surgical difficulty.

f. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (e.g., musculoskeletal in orthopedic procedures, hematologic in a cancer patient)

Hematological:

Since many patients are undergoing a hysterectomy due to fibroids or dysfunctional uterine bleeding, anemia is often present. The level and duration of the anemia must be assessed prior to surgery. Severe anemia, i.e. hemoglobin less than 7, especially if acute, may require a blood transfusion prior to surgery. The patient's functional status will help guide the need for blood transfusion.

If the patient is a Jehovah's Witness - her acceptance of blood products, colloids, and cell saver should be determined prior to surgery.

4. What are the patient's medications and how should they be managed in the perioperative period?

All over the counter drugs should be held on the day of surgery. Herbal medications that affect coagulation such as garlic, ginseng, gingko, fish oil supplements, etc. should be held for 7-10 days prior to surgery.

a. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

  • Many patients suffer from iron-deficiency anemia due to menorrhagia and are on iron supplementation, which can lessen the degree of anemia. Iron should be held on the morning of surgery.

  • Many patients are on oral contraceptives that can be continued until the day of surgery. However, these patients will be at increased risk of perioperative DVTs.

  • Some patients are placed on gonadotropin releasing hormone analogs or Danazol (a modified testosterone) prior to surgery that can reduce fibroid size, uterine volume, and the degree of anemia.

b. What should be recommended with regard to continuation of medications taken chronically?

Cardiac

  • Beta blockers - Patients on chronic beta blockers should have the medication continued perioperatively with a goal heart rate of less than 70. The patient should be carefully assessed for hypotension. The patient is also at increased risk of bronchospasm. Starting beta blockers in the perioperative period can lower the risk of perioperative cardiac events but increase the risk of strokes and death. Beta blockers should only be started acutely for high risk cardiac patients that require a beta blocker for appropriate medical management of the patient's condition.

  • Antihypertensives - Any baseline medications to control hypertension should be continued except diuretics and ACE inhibitors. Diuretics should be held on the day of surgery due to the NPO status of the patient. ACE inhibitors should be held on the day of surgery given the risk of hypotension with the induction of anesthesia.

  • Statins - Statins should be continued perioperatively. Discontinuation is associated with an increased risk of adverse cardiac events and mortality. Starting statins in high risk cardiac patients may reduce cardiac risk but the appropriate dosage and duration have not yet been determined.

  • ASA - Aspirin is often discontinued seven days prior to surgery due to the risk of bleeding. However, ASA will decrease the risk of myocardial events and CVAs. For each particular patient a risk and benefit analysis should be determined.

  • Clopidigrel (Plavix) - Patients with a stent in their coronary arteries may be on clopidogrel to maintain stent patency. In the preoperative evaluation, it is important to determine when the stent was placed and the type of stent (drug eluting vs. bare metal). A discussion between the patient's cardiologist and surgeon about when to hold clopidogrel and when to restart (increased risk of stent restenosis [i.e., cardiac event vs. the risk of bleeding]) may be necessary. Please note that patients who have received clopidogrel within the past seven days are not candidates for neuraxial anesthesia. Additionally, epidural catheters must be pulled prior to restarting clopidogrel.

  • Warfarin - Patients are frequently placed on warfarin in response to thromboembolic risk (i.e., history of hypercoagulable state, risk of stroke due to atrial fibrillation, or mechanical heart valve). The reason for anticoagulation must be determined to assess length and the duration of ceasing anticoagulation. Sometimes it is necessary to bridge from long-acting warfarin to a shorter-acting anticoagulation agent, such as Lovenox (low molecular weight heparin).

Pulmonary

  • Medications that are used to control daily respiratory symptoms (such as beta2-agonists, anticholinergic bronchodilators, inhaled steroids, and leukotriene inhibitors) should be continued in the perioperative period, including the morning of surgery. Prior to and during anesthesia, an additional dose of a beta2-agonist should be considered, depending on the patient's respiratory state. If the patient has a worsening of her baseline symptoms or an exacerbation, a delay of surgery should be considered until the patient is medically optimized. Optimization often requires administration of steroids or antibiotics. Patients with very poor baseline respiratory status should also be warned that postoperative ventilation may be required.

Renal

  • Baseline drugs should be continued.

Neurologic

  • Patients with neurologic disease (i.e., seizure disorder, migraine headaches, Parkinson's, etc.) should have their medications continued perioperatively. Patients on anticoagulation drugs to prevent cerebrovascular disease should have a risk-benefit assessment made regarding the time of a discontinuation of the drug and its resumption. This decision will require a discussion between the neurologist and the surgeon.

Anti-Platelet

  • See the cardiovascular section for the discussion of ASA, clopidogrel, and Coumadin.

Psychiatric

  • Mood stabilizers, antidepressants, and anxiolytics should be continued perioperatively. However, certain psychiatric drugs result in commonly used anesthetic medications being counterindicated (i.e., MAOI inhibitors and meperidine) or unanticipated responses to commonly used medications (i.e. ephedrine and bupropion).

c. How To Modify Care For Patients With Known Allergies

In general, patients with known drug allergies are managed with medications that avoid offending agents. If the patient's allergy is severe, an anaphylactic treatment kit including epinephrine, steroids, and antihistamines should be considered.

k. Latex allergy- First, identify if the patient has a sensitivity or anaphylactic reaction to latex. (i.e., Does the patient develop a rash from wearing latex gloves or does she have a difficult time breathing when faced with similar exposure.) Then, prepare the operating room with latex-free products.

Risk factors for latex allergy include history of congenital urinary tract abnormalities, patients who have undergone multiple surgical procedures, and health care workers. If a latex allergy is present, then latex-containing items should not be used, and latex-free alternatives should be substituted. Medications should be drawn up in a latex free manner (either via a latex free stopper or if the stopper contains latex it should be removed with a bottle cap opener).

d. Does the patient have any antibiotic allergies - Common antibiotic allergies and alternative antibiotics

If the patient is allergic to cephalosporin, gentamycin and metronidazole are alternatives. Note the incidence of cross reactivity of an allergy to penicillin with a cephalosporin is 7-18%.

m. Does the patient have a history of allergy to anesthesia?

Malignant Hyperthermia

  • Documented- avoid all triggering agents such as succinylcholine and inhalational anesthetics.

  • Family history or risk factors (e.g. Duchene Dystropy, Central Core Disease, Myotonia).

  • Proposed general anesthetic plan using a total intravenous technique and non-depolarizing muscle relaxants.

  • Regional anesthesia may be used.

  • Make sure a malignant hyperthermia cart is immediately available. This cart should contain dantrolene, bacteriostatic water for injection, and sodium bicarbonate. Ice should also be readily available.

Local Anesthetics

  • If a patient states that she has an allergy to local anesthetics, clarify if a true allergic reaction has occurred in the past and the class of local anesthetic involved (amide vs. ester). If the allergy is true, then general anesthesia may be indicated.

Muscle Relaxants

  • Allergies to muscle relaxants are rare but possible. If there is suspicion of an allergy and the procedure is elective, preanesthetic testing is indicated. Consider the use of regional or "deep" general anesthesia.

5. What laboratory tests should be obtained, and has everything been reviewed?

Typically, patients require a CBC, pregnancy test, and blood bank sample prior to surgery. Any additional tests are determined by the patient's pre-existing medical conditions and functional status.

  • Hemoglobin levels: Hemoglobin levels may be indicated by the individual patient's comorbidities and type of procedure (i.e., possibility of blood loss) when deciding an appropriate hemoglobin level for the patient. Also consider evidence of inadequate delivery of oxygen carrying capacity to end organs.

  • Electrolytes: Patients taking potassium-wasting diuretics may have hypokalemia. Alternatively, patients taking potassium-sparing diuretics may have hyperkalemia. Hyperkalemia may also be seen in patients with renal insufficiency.

  • BUN/creatinine: This test is indicated in patients with a history of renal dysfunction or evidence of dehydration.

  • Coagulation panel: Coagulation studies are clinically indicated in patients with a history of easy bruising (platelets), bleeding easily or coagulopathy. It is also indicated in patients with a history of liver disease. An INR should be obtained for patients on warfarin.

  • Imaging: Imaging may be obtained for oncology patients as part of a metastatic work-up and should be guided by history of physical exams.

  • Other tests: Pregnancy testing is indicated in all women with the capacity to become pregnant.

  • Diabetics should have a blood sugar determined on the day of the procedure. Additionally, a recent HbA1c will give an assessment of the average plasma glucose concentration over weeks to months.

  • In patients that have a history of hypothyroidism, a recent TSH should be reviewed.

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

Depending on the particular patient, her pre-existing medical conditions, and the surgical plan, either general or regional anesthesia, or a combination of general and regional anesthesia may be preferred. Since most abdominal hysterectomies are performed under a laparoscopic surgical technique, general anesthesia is typically preferred.

a. Regional Anesthesia

Neuraxial

Benefits:

  • Avoids manipulation of a potentially difficult airway

  • Avoids airway manipulation or mechanical ventilation in patients with severe pulmonary disease

  • Less risk of postoperative nausea and vomiting

  • Reduction in post-operative cognitive dysfunction

  • If an epidural catheter is placed, there may be superior postoperative pain control.

Drawbacks:

  • Cannot be performed in the setting of anticoagulation or coagulopathy.

  • Cannot be performed in the setting of infection/bacteremia.

  • Can cause hypotension due to sympathectomy.

  • In patients who can not tolerate sudden hemodynamic changes (such as severe aortic stenosis), spinal anesthesia may be relatively contraindicated.

  • Patients may refuse regional anesthesia.

  • Patients may not be appropriate regional candidates (i.e. inability to communicate or lie still for procedure).

  • In the case of a difficult airway, if a regional is chosen and it is necessary to convert to general anesthesia, then it will be more difficult to approach the airway midway through the case as opposed to the beginning of the case.

  • High levels of neuraxial blockade can reduce respiratory function by eliminating accessory respiratory muscles and the ability to cough, which can be problematic in patient with severe respiratory disease.

  • Risk of post-dural puncture headache worsened if a large bore or cutting needle is used.

Issues:

  • If an epidural is placed to assist for postoperative pain management, restarting of anticoagulation will need to be coordinated with epidural removal after a discussion with the surgical team.

Peripheral Nerve Block

  • NOT INDICATED for complete anesthetic management but certain blocks maybe useful to assist with postoperative pain management, such as the TAP (transversus abdominis plane) block. For more details see the postoperative pain section.

b. General Anesthesia

Benefits:

  • Secure airway

  • Patient will be able tolerate unexpected changes in the surgical duration or plan

  • Tolerated by combative or uncooperative patients

  • Tolerance of positioning (steep Trendelenburg) and insufflation

Drawbacks:

  • Increased risk of nausea and vomiting

  • Increased risk of postoperative cognitive dysfunction

  • No sustained postoperative pain control

  • Can have severe hemodynamic swings on induction and emergence from anesthesia

Other issues:

  • None

Airway concerns:

  • No specific concerns for this patient population but patients with difficult airways are present in this population.

c. Monitored Anesthesia Care - NOT Indicated

We strongly take into account the patient's preference and the surgical approach, duration of surgery, and extent of surgery (including possible postoperative pain control issues). Limited studies have shown no difference in outcome based on a particular anesthetic technique. However, there is new literature showing a reduction in primary tumor reoccurrence with the utilization of regional anesthesia for postoperative pain control or as the primary anesthetic (see references - demonstrated for ovarian cancer). If the surgical plan involves a laparoscopic approach, we tend to prefer general anesthesia. If the surgical approach includes an extensive dissection and a large potential for blood loss we prefer a combined general/ regional anesthetic technique with an epidural catheter that will be used for postoperative pain control.

6. What is the author's preferred method of anesthesia technique and why?

What prophylactic antibiotics should be administered?

Utilize current SCIP recommendation. See Figure 1.

Figure 1.

2009 SCIP Recommendations

What do I need to know about the surgical technique to optimize my anesthetic care?

  • The majority of the blood loss should be finished when the uterus is removed.

  • Radical hysterectomy is generally performed for cervical cancer, and it requires a larger resection to remove lymph nodes and parametrium. This larger resection results in a more significant amount of blood loss. Given the scope of the surgery, radical hysterectomies may not be performed using a vaginal approach. However, radical hysterectomies have recently been successfully accomplished with a laparoscopic approach. Laparoscopy is associated with a shorter duration of hospital stay, less postoperative pain, faster recovery of bowel function, and decreased overall cost.

What can I do intraoperatively to assist the surgeon and optimize patient care?

  • The patient is typically positioned in lithotomy and is at risk for postoperative neuropathy such as peroneal nerve damage due to compression (foot drop), femoral nerve (with exaggerated hip flexion or abduction), and sciatic nerve with external rotation of the leg. There can also be additional nerve injuries due to surgical retraction or resection. Small benign abdominal hysterectomies can be done in the supine position.

  • To assist in surgical visualization, adequate muscle relaxation is necessary.

  • Urine quality (i.e. if tinged with hemoglobin) and quantity should be frequently assessed to determine if urethral damage has occurred during the surgery. The surgeons will occasionally ask for administration of IV dye, such as indigo carmine, to assess for urethral damage and if the concern is high a cystoscopy may be performed during the surgery.

  • The surgeons may request the patient be positioned head down (Trendelenburg) to allow the bowel to be retracted with ease.

  • The surgeons may request the avoidance of nitrous oxide due to the potential of bowel expansion.

  • Care should be taken to maintain euthermia due to increased risk of infection, bleeding, etc. with mild hypothermia.

  • In patients with a history of severe postoperative nausea and vomiting, either a regional anesthetic or a total intravenous anesthetic involving propofol may be indicated.

What are the most common intraoperative complications and how can they be avoided/treated?

  • Possibility for bleeding (increases with the size of the uterus and the extent of the dissection planned).

  • Larger malignant masses can invade the vasculature and increase the likelihood of bleeding.

  • Typical risks associated with any anesthetic and surgical procedure including cardiac and pulmonary complications, allergic reactions, and embolism.

  • Bladder injuries

  • Conversion to another surgical approach or more extensive dissection can entail increased risk.

Cardiac complications:

This risk of cardiac complications depends on the patient's baseline cardiac status. As with any anesthetic, there is always a risk of dysrhythmias, myocardial ischemia or infarction, and hypertension or hypotension.

Sympathetic blockade for a high spinal or epidural can induce hypotension and bradycardia. Hysterectomy should be considered an intermediate risk surgery per the AHA/ACC guidelines with the possible exception of an extensive exploration and resection such as would occur with a large pelvic mass or a placenta percreta.

Pulmonary:

There are no unique complications in hysterectomies that are not also seen in typical abdominal surgery. Patients are at risk of pulmonary aspiration, hypoxemia, and hypercarbia (especially with insufflation and Trendelenburg). Patients are also at risk for postoperative pulmonary dysfunction due to the derangement of the abdominal muscles with the surgical incision.

Neurologic:

Aside from positioning injuries, there are no unique neurological complications.

a. Neurologic:

SEE ABOVE

b. If the patient is intubated, are there any special criteria for extubation?

No.

c. Postoperative management

What analgesic modalities can I implement?

  • For open procedures, an epidural can be employed.

  • IV PCA or IV opioids

  • In addition, supplemental non-narcotics, such as IV NSAIDs (ketorolac) and IV acetaminophen, can be used.

  • If a spinal or epidural anesthetic is used, preservative-free morphine can also be used. However, appropriate postoperative monitoring for respiratory depression is necessary for at least 24 hours.

  • TAP (transversus abdominis plane) block has been shown in some studies to reduce the amount of IV narcotics required for pain relief in the first 24 hours after an open surgery. However, the block, like all regional anesthesia, involves the risk of failure, local anesthetic toxicity, bleeding, infection, nerve damage, and peritoneal and bowel perforation (risk reduced if using ultrasound guidance).

What level bed acuity is appropriate?

  • Postoperative bed acuity depends on the pre-existing functional status and co-morbidities of the particular patient and the extent of the intraoperative dissection and blood loss. In most situations, the patient has a stable preoperative condition she would be eligible for a regular floor bed after she is appropriately recovered per PACU standards.

What are common postoperative complications, and what are ways to prevent and treat them?

  • The most common postoperative complications are poor postoperative pain control, postoperative nausea and vomiting, and positioning injuries. The patients, especially with malignancies, are at risk of thromboembolic events and should have DVT prophylactic anticoagulation.

What's the Evidence?

Apfel. "A factorial trial of six interventions for the prevention of post-operative nausea and vomiting". N Engl J Med. vol. 350. 2004. pp. 2441-51.

(A classic article showing the effect of different interventions on the incidence of PONV in a high risk population.)

Carney, J. "The transversus abdominis plane block provides effective postoperative analgesia in patients undergoing total abdominal hysterectomy". Anesth Analg. vol. 107. 2008. pp. 2056-60.

(A recent article showing a decrease in patient reported pain scores and postoperative narcotic use with a TAP block.)

Griffiths, JD. "Transversus abdominis plane block does not provide additional benefit to multimodal analgesia in gynecological cancer surgery". Anesth Analg. vol. 111. 2010. pp. 797-801.

(This recent article shows no difference in patient comfort or postoperative narcotic use with the use of a TAP block.)

Ferguson. "A prospective randomized trial comparing patient-controlled intravenous analgesia on postoperative pain control and recovery after major open gynecologic cancer surgery". Gynecologic Oncology. vol. 114. 2009. pp. 111-6.

(A recent article comparing postoperative pain control using IV PCA vs. epidural PCEA after an open laparotomy. The epidural group of patients had better pain scores both at rest and with activity.)

Lin, L. "Anaesthetic technique may affect prognosis for ovarian serous adenocarcinoma: a retrospective analysis". Br. J. Anaesth. vol. 106. 2011. pp. 814-22.

(A recent reference showing a difference in survival with regional anesthesia in ovarian cancer - an initial pass at understanding the debate with primary cancer reoccurrence in ovarian cancer and regional anesthesia that still needs further data before a definite conclusion can be reached.)

Pierre, S. "A risk score-dependent antiemetic approach effectively reduces postoperative nausea and vomiting - a continuous quality improvement initiative". Can J. Anaesth. vol. 51. 2004. pp. 320-5.

(An article demonstrating how the use of a PONV risk score to guide antiemetic therapy can reduce the risk of PONV.)

Zakashansky, K. "Recent advances in the surgical management of cervical cancer". Mount Sinai Journal of Medicine. vol. 76. 2009. pp. 567-76.

(A basic review of the different surgical approaches to radical hysterectomy including the use of minimally invasive surgery.)

You must be a registered member of ONA to post a comment.

Sign Up for Free e-newsletters

Regimen and Drug Listings

GET FULL LISTINGS OF TREATMENT Regimens and Drug INFORMATION

Bone Cancer Regimens Drugs
Brain Cancer Regimens Drugs
Breast Cancer Regimens Drugs
Endocrine Cancer Regimens Drugs
Gastrointestinal Cancer Regimens Drugs
Genitourinary Cancer Regimens Drugs
Gynecologic Cancer Regimens Drugs
Head and Neck Cancer Regimens Drugs
Hematologic Cancer Regimens Drugs
Lung Cancer Regimens Drugs
Other Cancers Regimens
Rare Cancers Regimens
Skin Cancer Regimens Drugs