Repeat Laparotomy After Abdominal Hysterectomy

Introduction

Hysterectomy is currently the most common major elective gynecologic procedure in the world, with >70,000 hysterectomies performed annually in England alone. ¹ Although hysterectomy is generally considered safe, several possible complications are associated with the procedure. These complications can result in mild-to-severe morbidity and even (although rare) mortality. Repeat laparotomy after total abdominal hysterectomy in the early postoperative period is one of the rarest types of short-term complication. The authors of this study searched MEDLINE^® for the following terms: re-laparotomy and hysterectomy and hysterectomy complications, and, after appropriate articles were found, used the ‘‘related articles'’ button for additional search. There were no published studies on early repeat laparotomy after abdominal hysterectomy in the medical literature.

The objective of the present study was to identify the incidence, indications, management, and outcome of repeat laparotomy following total abdominal hysterectomy in the early postoperative period, in order to try to avoid even these few unnecessary complications and improve the quality of care.

Materials and Methods

This study is based on hysterectomized patients in a tertiary care Mansoura University Hospital, during an 84-month period between January 1, 2004 and December 31, 2010. During the study period, there were 4386 total abdominal hysterectomies. Preoperative relevant past medical history, information regarding previous gynecologic management, and baseline investigations were evaluated. The standard operative care included intravenous antibiotics given prophylactically; all hysterectomies were performed by consultants. Patients were discharged between the 7th and the 9th postoperative days, after the histopathology report was received.

The inclusion criterion was repeat laparotomy after abdominal hysterectomy in the early postoperative period, which was defined as repeat laparotomy during the same hospitalization. Early postoperative complications, and their relationship with indication for hysterectomy, possible risk factors, and management were investigated. There were no exclusion criteria. The charts of the included women were identified through our computerized database of gynecologic operations and the operating theater records.

Results

A total of 4386 total abdominal hysterectomies were performed during a period of 7 years at the Gynecology Unit of Mansoura University Hospital. During the study period, there were 23 women who underwent repeat laparotomy after total abdominal hysterectomy during the same hospitalization period, of 4386 hysterectomies, with an incidence of 0.52%, that is, one repeat laparotomy was performed for every 191 total abdominal hysterectomies. In all these cases a laparotomy (with opening of fascia) was performed. The patients' median age was 49 (range 34–79) years. Fourteen women (60.9%) were operated on for hemorrhage, 3 (13%) for urinary complications, and 6 (26.1%) for peritonitis and protrusion of intestines through the abdominal wound (eventration). One (4.3%) patient died.

Fourteen patients with hemorrhage (60.9% of those with complications and 0.32% of hysterectomies) are presented in Table 1. In 11 cases of acute bleeding, the diagnosis was made with the appearance of signs of hemodynamic compromise; ultrasound examination demonstrated intraperitoneal hemorrhage. The patient was then stabilized with intravenous (IV) fluids and transfused with 2–4 units of packed red blood cells. Repeat laparotomy was performed an average of 8.7±5.9 hours after the primary surgery (range 3–20 hours). Ligation of hypogastric arteries was performed in 2 patients with friable tissues after failed hemostatic sutures. In 3 patients with subacute bleeding (cases 8, 14, and 20), the patients presented with tachycardia, faint pulse, and large increasing subfascial hematoma, necessitating repeat laparotomy 12.7±6.4 hours after the primary surgery following failure of conservative treatment that included administration of hemostatics. One patient presented with mesenteric blood vessel injury causing intestinal segment necrosis; repeat laparotomy was performed to ligate bleeding vessels and for resection anastomosis of intestine. In all cases of repeat laparotomy for hemorrhage, drainage, hemostasis, and re-suturing were performed. Only one death (4.3% of complications and 0.02% of hysterectomies) was recorded in this series of complicated hysterectomies. Shock was detected 9 hours after hysterectomy for advanced ovarian cancer; repeat laparotomy and exploration demonstrated bleeding from uterine pedicle. Pedicle re-ligation and bilateral internal iliac artery ligation were performed. The patient died 10 hours after admission to the intensive care unit with irreversible shock and respiratory distress syndrome.

Three patients (13% of complications and 0.07% of hysterectomies) presented with anuria 5 hours after operation (Table 2). Two cases of bilateral ureteral ligation and 1 case of unilateral ureter ligation with a solitary functioning kidney were found by cystoscopy and retrograde ureteric catheterization. The patient underwent an emergency operation; careful examination showed ureters tied in the ligatures applied to uterine vessels on both sides. The ligatures were cut to free the ureters on both sides. The uterine vessels were freed and dissected of ureters before clamping again. Ureters were explored and managed by end-to-end anastomosis or ureteroneocystostomy.

Six patients (26.1% of those with complications and 0.14% of hysterectomies) presented with infections (Table 3). One patient had a localized pelviabdominal tender mass. The diagnosis of pelviabdominal abscess was made by computed tomography. At first, a conservative approach was attempted, and when no improvement occurred, a repeat laparotomy and drainage were performed on day 12 after the primary surgery. Cases 5 and 10 presented with acute peritonitis. General supportive measures such as vigorous intravenous rehydration, correction of electrolyte disturbances, and antibiotics did not improve the condition, which required laparotomy to perform a full exploration. Necrosis of the intestinal segment in 1 patient with peritonitis necessitated resection anastomosis, lavage of the peritoneum, and drainage. Three patients (9, 17, and 21, Table 3) presented with an infected abdominal wall causing disruption of the subcutaneous tissue and rectus sheath (eventration). The diagnosis was made with signs of protrusion of intestines through the abdominal wound on the 5th to 7th post-hysterectomy day. Systemic antibiotics were given and medical treatment involved application of local antiseptic. Debridement and secondary re-suturing were performed. The postoperative period after repeat laparotomy was uneventful in all 6 cases.

Discussion

This is a descriptive survey of the incidence, indications, and management of repeat laparotomy following hysterectomy in a tertiary care Mansoura University hospital over an 84-month period. The incidence of repeat laparotomy in the present survey is 0.52%; Hemorrhage was the leading cause for repeat laparotomy (60.9%) following abdominal hysterectomy, whereas urinary complications was the least common (13%). Management during repeat laparotomy was obviously dependent on the underlying cause; we had one death among patients with complications.

Hemorrhage was the major complication encountered in these patients (60.9% of those with complications). Maresh et al. reported that the most serious postoperative complication of hysterectomy is hemorrhage, which occurs in 1%–3% of patients. ¹ The lower incidence of hemorrhage (0.32 of hysterectomies) in this study compared to the previous mentioned study may be explained by restriction of cases with complications to patients who needed early repeat laparotomy only, rather than those who may have needed it later. The uterine pedicle site was the most common bleeding site (35.7%) followed by the vaginal vault angle (28.6%), rectus muscle (21.4%), infundibulopelvic pedicle (7.1%) in 1 patient, and intestinal mesentery (7.1%) in 1 patient. Reasons for delayed bleeding after surgery may be the result of faulty technique used to accomplish immediate hemostasis (loose superficial sutures), delayed bleeding from small retracted vessels, or hypotension with anesthesia which corrected after surgery. During hysterectomy, several measures may be taken in order to reduce the need for a subsequent repeat laparotomy for delayed bleeding. It has been suggested that the surgeon should perform blunt dissection of the rectus muscles, and, especially, should secure hemostasis at critical sites such as the uterine pedicles, vaginal vault angles, infundibulpelvic pedicle, and rectus muscles. Careful pelvic exploration should be done before sheath suturing. Both the surgeon and the anesthetist should be aware of the patient's blood pressure during exploration before wound closure. The critical period for expression of substantial postoperative bleeding is the first 9 hours after hysterectomy (Table 1). Therefore, special care should be taken to observe hemodynamic signs and hemoglobin levels in the patient during this period.

Leiomyomas were the indication for hysterectomy in at least one third (7/23) of patients with complications (30.4%). The higher incidence of myomas with complicated hysterectomy may be attributed to the high incidence of abnormal vascular pattern caused by disturbed anatomy with multiple uterine fibroids. Some studies report that myomas and endometriomas are at greater risk for postoperative bleeding.^2,3

To minimize postoperative complications, recent treatment advances could bring hysterectomy rates down further. There are now an increasing number of nonsurgical alternatives to hysterectomy, such as uterine artery embolization, which involves a shorter hospital stay, a shorter recovery time, and fewer major complications compared with surgery. ⁴ Transvaginal ultrasound-guided radiofrequency myolysis and magnetic resonance-guided focused ultrasound surgery (MRgFUS) may be used for symptomatic treatment in some patients with fibroids.^5,6

Three patients (13% of those with complications) presented with urologic disorders. Dandade et al. ³ reported higher incidence of urologic complications (0.5%) with hysterectomy; the lower incidence of urologic complication in this study was attributed to the restriction of the study sample to patients needing repeat laparotomy during primary surgery hospitalization. Risk factors for urologic disorders were disturbed anatomy in 2 patients with cervical and broad ligament fibroids, and adhesions associated with endometriosis and previous laparotomies in one patient. In another study, ureteral injuries during laparoscopic hysterectomy were common, because of the size and location of the ureter; these generally are the result of excessive electrosurgery, and lasering adjacent to the ureter during surgery. ⁷

Bilateral ureteral ligation must be thought if there are complete anuria and renal functional impairment after hysterectomy. ⁸ Intraoperative ureteric injuries may complicate gynecologic, urologic, vascular and general surgery.^9,10 The retroperitoneal course of the ureter and its close proximity to the female reproductive organs make it particularly vulnerable to iatrogenic injuries in gynecologic procedures. The reported incidence rate varies between 0.4 and 2.5% of all gynecologic procedures. ⁹ When these injuries are detected during the initial operation they can be managed successfully in the early stages. When there is delay in diagnosis, many problems can be seen during management.^11,12 Many injuries are missed at the time of operation and some never become symptomatic. ¹³ Five percent of patients remain asymptomatic and may be diagnosed years later with a nofunctioning or hydronephrotic kidney. ¹⁴

Approximately 90% of ureter injuries occur in the distal portion of the ureter where it passes beneath the uterine vessel. ¹⁵ The left ureter has a much closer relationship to the cervix than does the right one, and is therefore more liable to injury. ¹⁶ Five to ten percent of ureteric injuries are bilateral. ⁸ The likelihood of injury tends to be related to the difficulty of operation or the inexperience of the surgeon. Although any gynecologic procedures can cause urinary tract injury, it is more common after abdominal hysterectomy. ¹⁷ Main risk factors are enlarged uterus, pelvic adhesions, and massive hemorrhage. ¹⁸ Endometriosis reduces the mobility of the ureter and distorts the normal anatomy, and this makes it liable to injury.^8,10 To avoid ureteric injuries, awareness of gynecologists must be encouraged, and the ureter should be identified in difficult operations such as for large pelvic mass, disturbed pelvic anatomy, and pelvic adhesions.

Six patients (26.1% of those with complications) presented with infections. Four diabetic patients were initially treated for gynecologic disorders. Infection is a common postoperative complication associated with hysterectomy. Six to twenty-five percent of patients having abdominal hysterectomy develop an infection post-surgery.^2,19 Regardless of the careful precautions taken, approximately one third of patients develop postoperative febrile infection. Use of preoperative and postoperative interventions, such as prophylactic treatment with broad-spectrum antibiotics, can contribute greatly to the reduction of infections occurring with hysterectomies. ¹⁹

Fascial disruption on 5th to 7th post-hysterectomy day was diagnosed in 3 patients (13% of those with complications). A risk factor in all patients was early postoperative wound infection. Ceydeli et al. reported that such disruption occurs predominantly because the suture cuts through the tissues. ²⁰ Fascial incision achieves 55% of its med tensile strength after 20 days. ²¹ In order to minimize the occurrence of post-hysterectomy eventration, proper sterilization, prophylactic antibiotics, and proper suture techniques are advised.

Conclusions

In summary, to reduce the need for early repeat laparotomy after abdominal hysterectomy, several precautions must be taken. Attention must be paid to high-risk patients, prophylactic measures, and proper postoperative follow-up. To reduce the number of hysterectomies and associated complications, less invasive alternate treatment methods can be tried.