••• CHAPTER 32^ Hysterectomy^307
❍ What workup should be done before recommending hysterectomy for chronic pelvic pain (CPP)?
Other potential sources of chronic pelvic pain (CPP), many of them nongynecologic, should be ruled out.
Psychiatric, musculoskeletal, gastrointestinal, and urinary tract sources are important to exclude.
❍ What preoperative testing should be done in patients scheduled for hysterectomy?
- A thorough history and physical will reveal special needs as well as help in the evaluation of potential risks.
- Each patient should have normal cervical cytology or complete evaluation of abnormal cytology to exclude
invasive malignancy. - A complete blood count will give the opportunity to correct anemia and identify thrombocytopenia.
- A urine examination for blood and leukocytes is done.
- An EKG is generally done in healthy women over 35.
- A chest film is ordered for smokers and those with suspected pulmonary disease.
- Under special circumstances, intravenous pyelogram (IVP), computed tomography (CT) scan, mammogram,
pulmonary function tests, colonoscopy, cystoscopy, or consultation from other medical specialists may be
needed.
❍ When should IVP be done preoperatively?
When the pelvic disease is extensive or located where the ureters may be compromised, such as with large adnexal
masses or very large leiomyomata, or when extensive dissection is anticipated. Also, IVP should be done in women
with Müllerian anomalies, since urinary collecting system anomalies are common in this group. If a previous pelvic
operation may have injured the urinary tract, a pre-op IVP will help identify this.
❍ When should a “bowel prep” be done before hysterectomy?
All hysterectomy patients should be instructed to eat light meals the day before surgery, and to remain NPO for
8 hours prior to surgery. Enemas may be given at home. A full mechanical bowel prep with electrolyte solution and
antibiotics is reserved for those in whom bowel involvement is suspected: patients with bowel complaints, extensive
endometriosis, or suspected ovarian cancer.
❍ What is the most frequent complication of hysterectomy?
Infection. The most common organisms are those found in normal vaginal flora.
❍ Does pretreatment for bacterial vaginosis (BV) before hysterectomy reduce the rate of postoperative cuff
cellulitis?
No. Even though BV is associated with an increased risk of postoperative cuff cellulitis, pretreatment for BV does
not appear to reduce this risk.
❍ What incisions are appropriate for abdominal hysterectomy?
A midline vertical incision should be used in cases of suspected malignancy to facilitate access to the upper
abdomen. For benign indications, a transverse Pfannenstiel incision is the most commonly used. A Maylard or
Cherney incision may be used if exposure is difficult with the Pfannenstiel.
❍ When performing an abdominal hysterectomy, what should be done before making an incision?
After induction of anesthesia, the bladder is emptied, and a pelvic examination is performed. The abdominal skin
and vagina are then prepped and draped. Failure to perform an examination under anesthesia can result in the
wrong incision being chosen, or an inappropriate operation being done.