Abdominal Hysterectomies for Benign Gynecological Diseases in a Nigerian Teaching Hospital

Introduction

Hysterectomy, which is the surgical extirpation of the uterus, is a traditional surgery in gynecological practice and has been associated with many medical, surgical, emotional, and sexual issues. It is a common gynecological surgery in developed countries, and in the United Kingdom up to 20% of women would have undergone hysterectomy by the age of 55 years. ¹ However, in developing countries, most women may not accept hysterectomy for the fear of surgery, loss of reproductive potential, and the need to maintain femininity and retain menstrual function.

In Ilorin, Nigeria, hysterectomy accounted for only 8.5% of all major gynecological surgeries, ² while it was responsible for 10.2% of gynecological surgeries in Ibadan, Nigeria. ³ Hysterectomy can be approached either through the abdominal route, the vaginal route, or as a laparoscopic procedure. The route of choice is usually dependent on the surgeon's preference based on skill and competence. However, current evidence indicates that vaginal hysterectomy offers advantages in regard to operative time, complication rates, requirement for blood transfusion, and early return to normal activities.^4–6 Despite this fact, studies show a preference for the abdominal route by most gynecologists in our environment, even when a vaginal route would have sufficed.^2,3

Although abdominal hysterectomy is safe, the surgery can be complicated by urological injuries, hemorrhage, postoperative sepsis, and febrile morbidity. In Nnewi, Nigeria, hysterectomy accounted for all cases of urological injuries associated with gynecological surgeries. ⁷

In our center, the sole indication for vaginal hysterectomy, as in most centers in the country, is uterovaginal prolapse.^2,8–10 The current study is an audit of abdominal hysterectomies done in our center over a 10-year period.

Materials and Methods

This is a retrospective study of case files of all the patients who had abdominal hysterectomies for gynecological indications between January 1, 1999 and December 31, 2008 in Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria. These case files were analyzed for age, parity, indications for, and complications of surgery. The obtained data were analyzed with epi info statistical package, version 3.3.2. All cases of vaginal hysterectomies as well as obstetric hysterectomies were excluded from the study. Due approval was obtain from the ethics committee of the hospital.

Results

Hysterectomy accounted for 224 of 1370 cases of gynecological surgeries (16.4%). Total abdominal hysterectomy was responsible for 79.1% (177) of all cases of hysterectomy. The modal age range was 51–60 years (43.0%) followed by the 31–40 years age group (21.5%). Ninety-seven (54.8%) of the patients were grandmultiparous, while nulliparity accounted for 10.7% of cases (Table 1). Table 2 shows the indications for surgery. The most common indication was uterine fibroids (41.8%), followed by dysfunctional uterine bleeding (26.3%) and ovarian tumors (14.3%). Postoperative complications were encountered in 43.6% of cases and constitute mainly hemorrhage (13.6%), sepsis (11.3%), and anemia (7.9%) (Table 3). The mortality rate was 4.0%.

Discussion

The rate of hysterectomy as a proportion of all the major gynecological surgeries was low (16.4%). Although our finding is similar to 17.2% reported in Calabar, ¹¹ it is higher than 8.5%, 10.2%, and 9.33% found in Ilorin, Ibadan, and Cameroon, respectively.^2,3,12 These rates are far lower than what obtains in the United States, where it is estimated that at the age of 60 years, up to one fourth of women would have undergone hysterectomy. ¹³ This disparity may reflect differing cultures and attitudes to hysterectomies by the women. Within developing countries, most women may not accept hysterectomy for the fear of surgery, loss of reproductive potential, and the need to maintain femininity and retain menstrual function.

Abdominal hysterectomy, following the trend in Africa, accounted for the majority (79.1%) of all hysterectomies done within the review period. This is not different from reports from other centers in the country.^2,3,11,12,14 The implication is that most patients are subjected to abdominal hysterectomy with its associated increased morbidity, even when vaginal hysterectomy would have sufficed. Lack of skill, traditional teaching, a perception rather than a confirmation that pathologic conditions exist that may exclude the vaginal approach, and misconceptions regarding the safety and suitability of vaginal hysterectomy may be responsible for this. Training of residents for competence at vaginal hysterectomy is advocated to reduce postoperative morbidities and mortalities.

Uterine fibroids and menstrual disorders were the common indications for abdominal hysterectomy from our study. This finding mirrors the practice in the region.^{2,3,11,12,14,15} The reason for this may relate to the traditional teaching supporting the abdominal route for uterine size more than 12–14 weeks. However, studies had demonstrated the safety of the vaginal route, even when the uterine size was more than 14 weeks.^16,17 There is a need to develop the capacity for vaginal hysterectomy for a moderately enlarged uterus.

Our complication rate was significantly high and constituted mainly febrile morbidity, hemorrhage, and sepsis. Hemorrhage usually results from poor ligation of the vascular pedicles as well as dissection in wrong planes. These skills are acquired by adequate training and supervision.

Conclusions

Total abdominal hysterectomy accounted for the majority of hysterectomies and was associated with significant morbidity. Adequate training and more use of the vaginal route is recommended to reduce these complications.