Surgical Techniques in Radical Hysterectomy

Learning Outcomes

• Understand relevant anatomy and procedural aspects of gynecological surgeries.
• Distinguish between minimally invasive and open surgical procedures.
• Familiarize with clinical pathways for obstetrical patients undergoing surgery.
• Identify conditions necessitating gynecological surgeries such as abnormal bleeding, tumors, and infertility.
• Emphasize patient-centered holistic approaches in perioperative care.

Anatomy Overview

• Cervix

  • Supravaginal portion near bladder and ureters; vaginal portion extends into the vaginal vault.
  • Contains internal and external os, protecting the uterus.

• Uterus

  • Pear-shaped organ situated between bladder and rectum.
  • Supported by ligaments: broad, round, cardinal, uterosacral, and levator ani muscles.

• Fallopian Tubes

  • Musculomembranous channels (10-13 cm) delivering ova from ovaries to the uterus.
  • Supported by infundibulopelvic ligament; critical relationships with cecum, appendix, and sigmoid flexure.

• Ovaries

  • Positioned on either side of the uterus, essential for ovum implantation and embryo development.
  • Ovarian cysts may necessitate surgical intervention (cystectomy).

• Vagina

  • Musculomembranous tube functions in menstruation, sexual intercourse, and childbirth.
  • Has anterior wall close to bladder and urethra; posterior wall adjacent to rectum.

Perioperative Nursing Considerations

• Nursing Assessment

  • Comprehensive gynecological history, including Pap smears, HPV, past surgeries, and menstrual history.
  • Assessment of patient’s pain tolerance for post-operative pain management.

• Blood Management

  • Anticipation of blood transfusion needs due to tissue dissection in vascular areas.
  • Preparation of hemostatic agents for surgical emergencies.

• Patient Positioning

  • Surgical position varies: supine with slight Trendelenburg for open surgeries; lithotomy for laparoscopic procedures.
  • Care in positioning to avoid nerve injury; proper process for removing legs from stirrups post-surgery.

Instrumentation and Surgical Counts

• Surgical Approaches

  • Types: Vaginal, Open, Laparoscopic, LAVH (Laparoscopically Assisted Vaginal Hysterectomy).

• Instrument Sets

  • Common instruments for vaginal procedures include weighted speculum, tenaculum, and uterine curettes.
  • Open and laparoscopic procedures require basic laparotomy sets, hysteroscopes, and specialized forceps.

• Surgical Counting

  • Minor counts for vaginal procedures; major counts for open and laparoscopic surgeries, including vault counts if indicated.

Equipment and Surgical Counts

• Equipment Use

  • Forced-air warming blankets to prevent hypothermia; operating table adjustments as needed.
  • Use of endometrial ablation equipment with care around the cervix.

• Surgical Counts

  • Full counts for major procedures, minor counts for closing vaults. Accurate counts essential to prevent retained instruments.

Radical Hysterectomy and BSO

• Radical Hysterectomy (Wertheim)

  • Involves extensive removal of reproductive organs and lymph nodes, requiring deep dissection.

• Bilateral Salpingo-Oophorectomy (BSO)

  • Fallopian tubes and part or all of ovaries removed, with preservation typically for women under 45.

Vaginovaginal Fistula and Exenteration

• Vesicovaginal Fistula

  • Abnormal opening between bladder and vagina leading to urine leakage; post-operative injuries can cause this.

• Pelvic Exenterations

  • Comprehensive removal of pelvic organs, performed for advanced cancers; types include complete, anterior, and posterior.

Obstetrical Surgery Considerations

• Challenges include monitoring both mother and fetus during surgery.
• Importance of fetal heart rate monitoring, rapid anesthetic induction, and tocolytic medication availability.
• Cervical cerclage performed to prevent miscarriage in cases of cervical incompetence; techniques can be vaginal or abdominal/laparoscopic.

Cervical Cerclage Techniques

• Shirodkar Technique
  • Placement of a suture to mechanically support the cervix; can be removed in office around 36 weeks or at time of scheduled C-section.