In some cases, and usually in those complicated by severe obstetrical hemorrhage, postpartum hysterectomy may be lifesaving. The operation may be done primarily at laparotomy following vaginal delivery, or it may be done coincident with cesarean delivery (termed cesarean hysterectomy). Hysterectomy is performed in 1 in every 200 cesarean deliveries and 1 in every 950 overall deliveries.
The majority of peripartum hysterectomies are done to arrest hemorrhage either from intractable uterine atony, lower-uterine segment bleeding associated with the cesarean incision or placental implantation, a laceration of major uterine vessels, large myomas, severe cervical dysplasia, and carcinoma in situ. Placental implantation disorders, to include placenta previa (see Chapter 26) and variations of placenta accreta, often in association with repeat cesarean delivery, are now the most common indications for cesarean hysterectomy.
Major deterrents to cesarean hysterectomy are concern for increased blood loss and the possibility of urinary tract damage. A major factor in the complication rate appears to be whether the operation is performed as an elective procedure or as an emergency. Morbidity associated with emergency hysterectomy is substantially increased. Blood loss is commonly appreciable because of the indications for the operation. When performed for hemorrhage, blood loss almost always is torrential. Indeed, over 90 percent of women undergoing emergency postpartum hysterectomy require transfusions.
If done following vaginal delivery, most clinicians find it prudent to open the abdomen through a midline infraumbilical incision. After gaining access to the peritoneal cavity, a transverse bladder flap is deflected downward as for a cesarean incision, but extended farther down to the level of the cervix if possible. If done after delivery of the infant by cesarean, the bladder flap is also deflected farther down. Supracervical or preferably total hysterectomy can be accomplished by standard operative techniques. Although all vessels are appreciably larger than those of the nonpregnant uterus, hysterectomy is usually facilitated by the ease of development of tissue planes in pregnant women. The placenta is removed if still in situ, and the cesarean incision, if present, can be approximated with either a continuous suture or a few interrupted sutures. Alternatively, Pennington or sponge forceps can be applied; if the incision is not bleeding appreciably, neither is necessary.
Next, the round ligaments close to the uterus are divided between Heaney or Kocher clamps and doubly ligated. Either no. 0 or 1 sutures can be used. The incision in the vesicouterine serosa, made to mobilize the bladder for cesarean delivery, is extended laterally and upward through the anterior leaf of the broad ligament to reach the incised round ligaments (Figure 20-1). The posterior leaf of the broad ligament adjacent to the uterus is perforated just beneath the fallopian tubes, utero-ovarian ligaments, and ovarian vessels (Figure 20-2). These then are doubly clamped close to the uterus (Figure 20-2), divided, and the lateral pedicle doubly suture ligated. The posterior leaf of the broad ligament is divided inferiorly toward the uterosacral ligaments (Figure 20-3). Next, the bladder and attached peritoneal flap are again deflected and dissected from the lower uterine segment and retracted out of the operative field (Figure 20-4). If the bladder flap is unusually adherent, as it may be after previous cesarean incisions, careful sharp dissection may be necessary.
FIGURE 20-1 The incision in the vesicouterine serosa is extended laterally and upward through the anterior leaf of the broad ligament to reach the incised round ligaments.
FIGURE 20-2 A. The posterior leaf of the broad ligament adjacent to the uterus is perforated just beneath the fallopian tube, utero-ovarian ligaments, and ovarian vessels. B. These then are doubly clamped close to the uterus and divided.
FIGURE 20-3 The posterior leaf of the broad ligament is divided inferiorly toward the uterosacral ligament.
FIGURE 20-4 The bladder is further dissected from the lower uterine segment by blunt dissection with pressure directed toward the lower segment and not bladder. Sharp dissection may be necessary.
Special care is necessary from this point on to avoid injury to the ureters, which pass beneath the uterine arteries. The ascending uterine artery and veins on either side are identified and near their origin are doubly clamped immediately adjacent to the uterus, divided, and doubly suture ligated (Figure 20-5). In cases of profuse hemorrhage, it may be more advantageous to rapidly clamp all of the vascular pedicles and remove the uterus before suture ligating the pedicles.
FIGURE 20-5 A. The uterine artery and veins on either side are doubly clamped immediately adjacent to the uterus and divided. B and C. The vascular pedicle is doubly suture ligated.
A subtotal (supracervical hysterectomy) is occasionally necessary to shorten the operative procedure in the face of torrential hemorrhage or for other technical reasons. To perform a subtotal hysterectomy, it is necessary only to amputate the body of the uterus. The cervical stump may be closed with continuous or interrupted chromic sutures.
To perform a total hysterectomy, it is necessary to mobilize the bladder much more extensively in the midline and laterally. This will help displace the ureters downward as the bladder is retracted beneath the symphysis and will also prevent laceration or suturing of the bladder during cervical excision and vaginal cuff closure. The bladder is dissected free for about 2 cm below the lowest margin of the cervix to expose the uppermost part of the vagina. If the cervix is effaced and dilated appreciably, the uterine cavity may be entered anteriorly in the midline either through the lower hysterotomy incision or through a stab wound made at the level of the ligated uterine vessels. A finger can then be directed inferiorly through the incision to identify the free margin of the dilated, effaced cervix and the anterior vaginal fornix. The contaminated glove is removed and the hand regloved.
The cardinal ligaments, uterosacral ligaments, and the many large vessels these ligaments contain are doubly clamped systematically with Heaney-type curved clamps, Ochsner-type straight clamps, or similar instruments (Figure 20-6). The clamps are placed as close to the cervix as possible, and it is imperative not to include excessive tissue in each clamp. The tissue between the pair of clamps is incised, and suture ligated appropriately. These steps are repeated until the level of the lateral vaginal fornix is reached. In this way, the descending branches of the uterine vessels are clamped, cut, and ligated as the cervix is dissected from the cardinal ligaments posteriorly.
FIGURE 20-6 The cardinal ligaments are clamped, incised, and ligated.
Immediately below the level of the cervix, a curved clamp is swung in across the lateral vaginal fornix, and the tissue is incised medially to the clamp (Figure 20-7). The excised lateral vaginal fornix can be simultaneously doubly ligated and sutured to the stump of the cardinal ligament. The entire cervix is then excised from the vagina.
FIGURE 20-7 A curved clamp is swung in across the lateral vaginal fornix below the level of the cervix and the tissue incised medially to the point of the clamp.
The cervix is inspected to ensure that it has been completely excised, and the vagina is repaired. Each of the angles of the lateral vaginal fornix is secured to the cardinal and uterosacral ligaments (Figure 20-8). Following this, some prefer to close the vagina using figure-of-eight chromic catgut sutures. Others achieve hemostasis by using a running-lock stitch of chromic catgut suture placed through the mucosa and adjacent endopelvic fascia around the circumference of the vagina (Figure 20-9). The open vagina may promote drainage of fluids that would otherwise accumulate and contribute to hematoma formation and infection.
FIGURE 20-8 The lateral angles are secured to the cardinal and uterosacral ligaments.
FIGURE 20-9 The lateral angles are secured to the cardinal and uterosacral ligaments.
All sites of incision from the upper fallopian tube and ovarian ligament pedicles to the vaginal vault and bladder flap are examined carefully for bleeding. Bleeding sites are ligated with care to avoid the ureters.
For further reading in Williams Obstetrics, 23rd ed.,
see Chapter 25, “Cesarean Delivery and Peripartum Hysterectomy.”