Objective: To determine the outcome of subtotal abdominal hysterectomy in terms of intraoperative and postoperative complications in women with benign uterine conditions.
Design: Descriptive study.
Place and Duration of Study: The Sheikh Zyed Women Hospital Chandka Medical College, Shaheed Mohtarma Benazir Bhutto Medical University Larkana from March, 2008 to February, 2009.
Patients and Methods: The study included 60 women, who underwent subtotal abdominal hysterectomy due to technical difficulties during surgery in benign uterine diseases. Inclusion criteria were menorrhagia and pelvic pain, dysfunctional uterine bleeding, repeated pelvic infection refractory to medical treatment, fibroid uterus and ovarian cyst with adenomyosis of uterus. Patients over 60 years of age, uterine prolapse and suspected cancer of cervix were excluded. Detailed history was taken and examination done. Routine investigations including ultrasound were carried out. Subtotal hysterectomy was performed by clamp-cut and ligate method.
Results: The mean age of patients undergoing hysterectomy was 44 years and parity between 4-10. Most common complaint was excessive menstrual loss. Fibroid was found in 15 (25%) cases, dysfuntional uterine bleeding in 18(30%), pelvic pain and menorrhagia in7(11.6%), ovarian cyst with adenomyosis in 12(20%) and repeated pelvic infections refractory to medical treatment in 8(13.4%).There was no injury to adjacent vicera during the procedure .Early complications like temperature was noted in 5(8.3%) and late complications like cyclical menstrual bleeding in 1 (1.6%) and vaginal discharge in 3(5%) patients. All cases were followed-up 3 and 6 monthly and urinary, sexual and bowel functions were found to be unaffected during this period. There was no mortality associated with the procedure. The histopathology of specimen revealed fibroid followed by adenomyosis to be the commonest pathology.
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Conclusion: Subtotal abdominal hysterectomy resulted in less operative time, rapid recovery, fewer short-term complications but infrequently caused cyclical bleeding and vaginal discharge.
Keywords: Menorrhagia. Dysfunctional uterine bleeding. Adenomyosis, Subtotal abdominal hysterectomy.
Until the late 1930s, the standard type of abdominal hysterectomy was subtotal, leaving the cervix behind to decrease the risk of peritonitis with its attendant high mortality. With the discovery of antibiotics, careful attention to antisepsis, and other medical and surgical advances, many gynaecologists performed total abdominal hysterectomy in the United States and the United Kingdom , although the subtotal approach is more simple technique require less times and still remained popular, in Scandinavian countries. With the advent of laparoscopic hysterectomy, many surgeons, wanting a simpler approach and for a variety of other reasons, have returned to performance of subtotal hysterectomy.1The advantages and drawbacks of total and sub-total hysterectomy remain a topic of debate. Subtotal hysterectomy may be useful in preventing severe complications when total hysterectomy is technically difficult. Furthermore, conservation of the uterine cervix may decrease vaginal erosion in genital prolapse repair when synthetic meshes are used. 2The type of technique does not appear to determine the persistence or development of problems related to sexual activity (frequency of intercourse, sexual desire, and achievement of orgasm). There are no apparent advantages to subtotal hysterectomy compared with total hysterectomy with respect to bowel or bladder function. Hysterectomy is the frequently performed operation in gynaecology. 3Total abdominal hysterectomy involves the removal of both the body of uterus and cervix, whereas subtotal abdominal hysterectomy means conservation of cervix. Hysterectomy disrupts the local nerve supply and anatomical relations of pelvic organs. 4The main branches of plexus passing beneath the uterine arteries may be damaged during division of cardinal ligaments, the vesical innervation which enters the bladder base may be damaged during blunt dissection of bladder from uterus and cervix. Subtotal abdominal hysterectomy is technically easier as there is lower incidence of vesicourethral dysfunction, also the uterosacral and cardinal ligaments remain intact, thus preserving pelvic floor support. 5There is less perioperative blood loss, less postÂoperative infections and haematoma and no complications like vault granulation. The lifetime contemporary risk of carcinoma of cervix with 3 normal papanicolaou smears is 0.05%. Injury to the urinary tract is less frequent (0.5 -3%) after subtotal abdominal hysterectomy. 6The purpose of study to determine the outcome of subtotal abdominal hysterectomy in terms of intraoperative and postoperative complications in women with benign uterine conditions.
PATIENTS AND METHODS
The study was conducted over a period of one year from March, 2008 to February 2009 in Gynaecology and Obstetric Department of sheikh zyed women hospital Chandka medical college, Shaheed Mohtarma Benazir Bhutto University Larkana. All the patients in the study were selected from the consultant's OPD. Patient's age, parity, weight, menstrual history and presenting complaints were noted. All of them gave history of treatment in various clinics / hospitals. The inclusion criteria were menorrhagia and pelvic pain, dysfunctional uterine bleeding, repeated pelvic infections refractory to medical treatment, fibroid uterus and ovarian cyst with adenomyosis of uterus. Exclusion criteria were age over 60 years, uterine prolapse, suspected cancer of cervix and symptomatic urinary incontinence. A complete general, physical and pelvic examination was performed. Investigations including ultrasound were performed and findings were noted. Diagnostic curettage was done and malignancy excluded. All the patients were counseled about the disease and the surgical procedure they had to undergo and also the technical difficulty the surgeon could face during surgery. All patients were admitted couple of days prior to surgery especially for correction of anemia. Patients with haemoglobin of under 10 gm% were either transfused blood or were given intramuscular iron therapy. Blood for the day of surgery was arranged for all patients as a routine, although it was transfused only when it was indicated depending upon blood loss during surgery. Anaesthesia fitness was obtained in all patients.The operation for subtotal abdominal hysterectomy was identical for total abdominal hysterectomy until ligation of uterine arteries. The bladder was tried to be freed as much as possible from the cervix but due to technical difficulties and adhesions it was not possible to separate it as in total hysterectomy. The uterus was removed above the level of internal os to avoid bother some cyclic menstrual bleeding from remnant of endometrium. One healthy ovary was left in perimenopausal women, while bilateral salpingoÂoophorectomy was performed in postmenopausal women. All specimens after surgery were sent for histopathology. Duration of operation was calculated from the time from incision of the skin to the closure, while the blood loss was assessed by counting swabs and measuring the volume of blood collected by suction. All patients received single dose of intravenous prophylactic antibiotic Intravenous line was maintained with 18-gauge cannula and a 16-gauge foley's catheter was used to catheterize the bladder before surgery. Analgesia administered was same in all patients and foley's catheter was removed after 24 hours. Haemoglobin level was repeated on third postoperative day. The average hospital stay was 4 - 6 days. All the patients were followed 3 and 6 monthly and are still being followed. The analysis was performed by using SPSS version-10. Frequency and percentages were computed for presentation of all categorical variables.
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A total of 205 hysterectomies were done during the study period and only 60 patients underwent abdominal hysterectomy due to various benign conditions. The mean age was 44 years, parity between 4 - 10 and weight 54 - 76 kgs. The most common complaint was excessive menstrual loss unresponsive to medical treatment. Fibroid uterus was found in 15 (25%) cases, dysfunctional uterine bleeding in 18 (30%), pelvic pain and menorrhagia in 7 (11.6%), ovarian cyst with adenomyosis in 12 (20%) and repeated pelvic infections refractory to medical treatment in 8(13.3%) cases.(table1) The duration of operation was 30 - 50 minutes and blood loss was lesser than 250 mls in 47(78.3%) patients. Only 8(13.3%) of the patients were transfused blood during surgery. Hospital stay was 4-6 days and haemoglobin level on 3rd post operative day mean was 10.5 gm/ dl. Bilateral salpingo-oophorectomy was done in 25 cases while right sided ovary was removed in 19 and left sided ovary was removed in 11 cases. Pre-operatively the haemoglobin level was raised by blood transfusion. There was no injury to the adjacent viscera in either of the cases. Early complications like temperature was noted in 5(8.3%) cases while wound infection, urine infection and wound haematoma were not seen in any of the patients. Late complications like cyclical menstrual bleeding was seen in 1 (1.6%) and vaginal discharge in 3 (5%) patients. The commonest pathology found on histopathological examination of the specimen was leiomyoma, followed by adenomyosis as shown in Table 2. The results of 3 - 6 monthly follow-up about the sexual activity, bowel habits and urinary complaints were satisfactory till the last follow-up and all of them are still under follow-up.
Table: I. Cases of undergoing surgery n=60
Dysfunctioning uterine bleeding
Pelvic pain and menorrhgia
Table:II. Histopathoogical findings. N=60
Benign endrometrial polyp
Cystic endrometrial hyperplasia
Table:III Complications of surgery no=60
Cyclical menstrual bleeding
The increasing trend towards subtotal abdominal hysterectomy reflects a more conservative surgical approach in gynaecological surgery.4,5 It is clear from this study that operation method and proper selection of cases is very important to obtain favourable results. The indication for hysterectomy for majority of cases in this study was excessive menstrual bleeding, alone or in combination with pelvic pain. The pathology found in majority of cases was leiomyoma and adenomyosis. There was no mortality associated with hysterectomy in this study. Febrile morbidity was seen in 5(10%) of cases despite antibiotic cover as shown by Hawkins J. The reported incidence of urinary tract injury during gynaecological procedures range from 0.5%- 3%7 in simple hysterectomy for benign diseases and upto 1.6% following laparoscopic cases, which is the most frequent cause of litigation in gynaecological practice. Haemorrhage in such cases range from 0.2- 2% which is a serious complication.8,10 Such injuries are not seen in subtotal hysterectomy as it requires less mobilization of bladder and minimizes the risk of injury to the ureters. It is also associated with lower incidence of wound infection, haematoma and symptomatic vault granulation.9 The life time risk of cervical carcinoma following subtotal abdominal hysterectomy10 may require a second operation to avoid such risk. In this series only those women were selected whose 3 consecutive smears were negative before the surgery. The modern legal theory and practice consider doctors and patients to be partners. Medical practitioners performing surgical procedures are obliged to obtain informed consent. They are also required to inform their patients about indications, course of the operative11
The detrimental effect on sexual function like superficial dyspareunia and vaginal shortening was seen in total abdominal hysterectomy. These were not noted in subtotal hysterectomy group, rather increased sexual activity was noted and also symptoms of disease were cured. Vander et ai. and Vanbeek et ai12,5 reported that 10% of women who had laparoscopic supracervical hysterectomy suffered from vaginal discharge and 25% of cases continued to menstruate. This study showed cyclical bleeding in 2% and vaginal discharge in 4% of cases, in other words subtotal hysterectomy resulted in more rapid recovery and fewer short-term complications, but infrequently caused cyclical bleeding or cervical prolapse.
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The genitourinary functions were not disturbed at all in subtotal hysterectomy rather urinary complaints like frequency of micturation pre-operatively in case of myomas of uterus was reduced. There was higher incidence of abscess and wound infection following total hysterectomy13 which is often attributed to contamination of abdominal cavity by vaginal flora during the procedure. It is not encountered following subtotal hysterectomy. With total hysterectomy much of the time, cost and morbidity are associated with removal of cervix and also the chances of vault prolapse are there with an incidence around 3.6/1000. 14,6The operation time, morbidity and blood loss is significantly less in subtotal hysterectomy.l5
Leiomyoma appears to be the commonest pathology in our study in contrast to other studies done in Karachi, Pakistan16,17, where the commonest pathology was adenomyosis.
The study by Jones et al. states that supracervical hysterectomy by mini-laparotomy can be adopted by gynaecologists as short stay surgery, which is a cost effective alternative for a variety of gynaecological conditions.18 While on the other hand subtotal hysterectomy is not popular in U.K. just because either the gynaecologists do not consider the bladder/bowel/sexual effects important, or that the risk of cancer of cervical stump and/or sheer habit have an over-riding impact on practice.19 The concern that cancer might develop in the cervical stump is no longer considered a justification for routine use of total abdominal hysterectomy. Screening reduces the incidence of invasive cancer20 and the risk of cervical cancer after subtotal abdominal hysterectomy is less than 1% as shown by Thakar et al21 Similar results were seen in the study conducted by Parikh et al., where the incidence of stump cancer was negligible with the advent of papanicolaou smear.22 Many gynaecologists and patients worldwide have questioned the routine removal of the benign cervix. The argument for conserving cervix is less disturbance to bladder, bowl and sexual function. No significant differences were found in the clinical measures including complications. A substantial number of women experienced persistent cyclic vaginal bleedings after sub-total hysterectomy. Neither minor or major postoperative complications, nor serum concentration of sex hormones, were associated with general psychological wellbeing 12 months after the operation. General psychological wellbeing is equally improved after both sub-total hysterectomy and total hysterectomy within 12 months of the operation, and does not seem to be associated with the occurrence of peroperative complications or serum concentration of sex hormones23.Day-by-day recovery of general wellbeing is no faster in subtotal versus total abdominal hysterectomy. Independent of operation method there is an interaction between preoperative psychological wellbeing, postoperative recovery of general wellbeing and the duration of sick leave.s24
There were rapid recovery in Sub-total Hysterectomy short-term complications and few cases of cyclical bleeding and vaginal discharge. The operative time, morbidity and blood loss was less in subtotal abdominal hysterectomy. The quality of life following such procedure was found to be improved, however, long term follow-up needs to be done.