Cesarean Hysterectomy Technique
- Author: Meredith L Birsner, MD; Chief Editor: Carl V Smith, MD more...
If a cesarean hysterectomy is planned, the best abdominal entry technique is via midline vertical incision. This allows retractor placement and optimizes exposure to nearby organs and may facilitate access to the upper abdomen. This incision is in general preferable to the Pfannenstiel or low transverse (“bikini cut”) incision most commonly used by obstetricians for cesarean delivery due to the limited exposure afforded by this incision. In rare emergent circumstances, a low transverse incision may need to be converted to a midline vertical incision to enhance exposure, resulting in an inverted T-shaped incision, which is more difficult to close, more painful, less cosmetically acceptable, and may result in a longer recovery time.
Although a hysterectomy can be done laparoscopically or vaginally when performed for gynecologic reasons, a cesarean hysterectomy is only performed through an abdominal incision.
After entry into the abdominal cavity, a typical cesarean delivery is performed. In the case of a suspected placenta percreta, the uterine incision is typically made in a location to avoid the placental edge. Intraoperative ultrasound may be used. After the baby is delivered, the next step is typically delivery of the placenta, which is often when the bleeding occurs. Ordinarily, the placenta easily detaches. If the placenta delivers easily but heavy bleeding or uterine atony is present, medications is administered to stimulate the uterus to contract.
If medications fail to stop the bleeding, bilateral uterine artery ligation (O’Leary sutures) can be performed. This involves finding an avascular area of the broad ligament, perforating it with a large needle and thick gauge suture, and “lasso-ing” the vessel by anchoring the suture into of the uterine myometrium. When performed bilaterally, blood flow to the uterus is reduced. If uterine atony is refractory to these measures, a B-lynch compression suture can be performed ; this is akin to putting binding “suspenders” on the uterus to manually contract it down. If this suture fails to stop bleeding, other measures need to be considered including interventional radiology if readily available, although hysterectomy is often the next step.
If the placenta does not detach with gentle traction, placenta accreta should be suspected and the anesthesiologist and family should be informed, and the hysterectomy should proceed as below. Forcibly detaching an abnormally adherent placenta can have serious consequences usually involving heavy blood loss and damage to nearby organs. After recognizing that the placenta is not detaching, it is kept inside the uterus and the uterine incision is quickly sutured closed using a single running layer with a large suture (ie, loop Maxon) to decrease bleeding prior to starting the hysterectomy.
A self-retaining retractor (Bookwalter, Balfour, O’Connor-O’Sullivan) may be placed at this point to improve visualization.
The hysterectomy may be performed using the standard steps. However, if bleeding is severe, the steps may be performed without suturing/tying off the pedicles (ie, leaving clamps in place) until the uterine arteries have been clamped and bleeding significantly slows. Multiple clamps need to be available.
To begin the standard hysterectomy, the round ligament is identified, clamped (Kocher, Kelly, Heaney clamps), divided, suture ligated, and suspended for traction. The broad ligament is opened with electrocautery; its anterior leaf is opened medially towards the bladder flap (if made during the cesarean delivery) or along the vesicouterine fold, which separates the bladder peritoneum from the lower segment of the uterus. The bladder is then “dissected off” the lower uterine segment (if not done during the cesarean section). The posterior leaf is opened with electrocautery parallel to the infundibulopelvic ligament which contains the large blood vessels that feed the ovaries. Care must be taken to properly identify and protect the ureters as they run parallel to the infundibulopelvic ligament.
The next step is to free the ovaries from the uterus so they are not removed during the hysterectomy. An avascular area is identified in the posterior leaf of the broad ligament and perforated with electrocautery; this is the hole through which the Kelly clamps are advanced. Usually, 2-3 clamps are placed. A long Kelly clamp is placed on the cornu (horn) of the uterus, engulfing the uteroovarian ligament, which attaches the adnexa (tubes and ovary) to the uterus. A second clamp (some providers place 2 clamps laterally) is placed lateral to this clamp, avoiding ovarian tissue. The tissue between the medial and lateral clamps is divided, and the pedicles are suture ligated or a free tie is placed followed by a transfixing suture. The lateral clamp(s) is then removed. The clamp on the cornu is typically left in place to control back bleeding and for traction. This procedure is done on both left and right sides.
Next, the uterine arteries need to be isolated and ligated. The uterine arteries are palpable and enlarged due to the pregnancy. To find the uterine arteries, the tissue surrounding the uterine vessels (parametrium) is delicately “skeletonized” anteriorly until the uterine arteries are identified. Either 1-2 curved clamps (Heaney or Masterson) are placed so that the curved end is perpendicular to the vessels and the vessels are clamped in their entirety. One clamp is often preferred to reduce the chances of injuring the ureter. See the image below.
A straight clamp (Kocher or Masterson) is placed medially to this clamp to reduce back bleeding from the uterus. The vessels are then transected such that the straight clamp is left on the uterus and the curved clamp(s) remains on the uterine arteries. Next, the uterine arteries are suture ligated either once or twice at the surgeon’s discretion. The Heaney clamp is then removed. This procedure is done on both left and right sides.
Next, the cardinal and uterosacral ligaments are sequentially clamped, cut, and suture ligated. This is done by advancing a straight clamp downward towards the cervix and vagina, parallel and immediately adjacent to the cervix to prevent damage to the nearby ureter. This “marching down” continues until either the cervix or vagina is reached.
If the surgeon decides to not remove the cervix, fewer bites are required and the hysterectomy is called “supracervical.” In a supracervical hysterectomy, the uterine fundus is “amputated,” often with cautery or scissors, and the remaining part of the cervix (stump) may be sutured closed.
This is often the type of hysterectomy performed during a cesarean hysterectomy. Frequently, particularly if the woman labored and the cervix is dilated and effaced, it is difficult to elucidate the anatomy. To assist in identifying anatomy, some surgeons prefer to “tag” the cervix, either by placing a ring forceps on the anterior lip of the cervix or placing a suture on the cervix. If the cervix is removed with the uterus, the hysterectomy is called “total.” To remove the cervix, the vagina is entered sharply near the level of the external cervical os. Heaney clamps are placed at the left and right corners (cuff angles). Care needs to be taken to not excessively shorten the vagina. The specimen consisting of the uterus and cervix is removed by sharply cutting along the vaginal edges. Next, the vaginal cuff is closed using figure-of-eight sutures.
Finally, the mother’s pelvis is irrigated with warm saline and the vaginal cuff and adnexa are inspected for bleeding. If no bleeding is observed, the abdomen can be closed.
Many surgeons prior to abdomen closure perform cystourethroscopy, using a cystoscope, to ensure that the ureters (which connect the kidneys to the bladder) have not been harmed during surgery. Indigo carmine, an intravenous blue dye, is administered to the mother and after a few minutes, the urine becomes blue. With the cystoscope in the bladder, the openings of the ureters into the bladder (ureteral orifices) are identified, and when the blue dye is seen streaming vigorously into the bladder, the surgeon can feel confident that the ureters remain open on both sides.
If placenta percreta with invasion into the bladder is a preoperative concern, a cystourethroscopy may be performed prior to opening the abdomen for the cesarean section, and if placenta is visualized invading into the bladder, additional specialists maybe called to the operating room for bladder reconstruction if necessary. If confident that the ureters were not injured and cystourethroscopy is not performed, retrograde filling of the bladder with approximately 200-300 mL of saline and methylene blue can evaluate bladder integrity.
Complications and Outcome
Possible complications after cesarean hysterectomy include infections, bleeding, urinary tract injury to the bladder or ureters. Infections can occur in the abdominal wound or within the abdomen and pelvis, as well as in the urinary tract due to catheter presence. Fever after surgery can indicate the presence of infection and should be thoroughly investigated. The urinary tract can be evaluated during surgery and if injured, repair is be performed immediately and the bladder catheter may remain in place after surgery for several days.
If a hysterectomy is performed for uncontrolled uterine bleeding after delivery, the mother could experience disseminated intravascular coagulation (DIC), a life-threatening bleeding condition that occurs after significant blood loss, which can make controlling the bleeding very difficult. DIC requires transfusion of multiple blood products; although it is managed primarily by the anesthesia team, it can make surgery difficult due to the mother’s propensity to spontaneously bleed from multiple surfaces simultaneously. Even if a mother does not experience DIC, blood product transfusion during and or after cesarean hysterectomy is common.
Prevention of venous thromboembolism (VTE) is extremely important following hysterectomy because pregnancy and major surgery are risk factors for development of life threatening blood clots in the leg veins and pulmonary arteries (pulmonary emboli). Mothers are strongly encouraged to continuously wear sequential compression device (SCD) boots while recovering in bed soon after surgery and may be offered compression stockings as well. Certain mothers with additional risk factors such as obesity may be offered blood-thinning medication as added protection against blood clots.
Length of stay in the hospital after surgery depends on the circumstances of the surgery (emergent or planned) and primarily on the mother’s medical condition. If a mother is admitted to a surgical ICU after surgery, her discharge home will likely be extended by several days beyond the average 3-4 day stay after cesarean section. Complications usually delay discharge home.
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