LONG TERM

COMPLICATIONS
OF

HYSTERECTOMY
 INTRODUCTION
DEFINTION
20% will have procedure by 55yrs
Reasons –Uterine fibroid and menstrual abnormalities
Developing Countries-
-28% of all major gynecological operations in UCH
-Life threatening conditions
Perception of the procedure
- freedom for the patient in developed country
Developing country Ist hysterectomy was
performed – Charles
procedure aversion clay –patient died
-sexual rejection 1843
-Loss of feminity -A year later- did
another patient died
-Preference for
15 days after (fell
perpetual while changing linen
menstrual flow from the hands of the
-Reincarnation potters )
theory Ist successful total
was done by
-Outlet of bad blood Richardson- 1929
 Types of hysterectomy
Based on route
– Abdominal
– Vaginal
– Laparoscopic assisted vaginal hysterectomy
– Laparoscopic supravaginal hysterectomy
– CASH procedure(Semm)
-classical abdominal semm( serrrated edge macro-
morcellated) hysterectomy
- laparoscopic supracervical hysterectomy
-coring out of the cervical canal by serrated
resection device
-Laparoscopic Doderlin hysterectomy
- detachment of the adnexae by laparoscope
- anterior colpotomy/completion per vagina
 Based on portion removed
Subtotal
Total
Panhysterectomy – misnomer
Radical hysterectomy
-Type 1 simple extrafascial hysterectomy with out dissection of the ureters
from its canal
Type 11 modified radical hysterectomy (Telinde’s)
- uterine ligated medial to the ureter
-cardinal ligaments resected from the medial halve
-Pelvic lymph node dissection
-Upper vaginoplasty
Type III Wertheim meig’s operation
- cardinal ligament divided at the pelvic side wall
-uterosacrals –side of the rectum full dissection of ureter except for
attachment to bladder and lateral over the lower 2 cm
Type IV
Upper ¾ of vagina removed, resection of internal iliac
Type V
Excision of inflitrated bladder, ureter, rectum or bowels
 complications
Disruption of the ultimate anatomical
relationships of the uterus, bowel ,bladder
and vagina to one another
Subsequent alteration of functions above
organs
Beneficial /detrimental effect
Detrimental effects on long term
- Psychological
Long term detrimental effects cont.
Anatomical considerations:
Changes in bowel, sexual and urinary
functions
- Disruption of the pelvic plexus of nerves
 Level of disruptions
Main branches passing beneath the uterine
arteries- Damaged during division of the
cardinal ligament
Blunt dissection of the bladder off the uterus
and cervix- vesical innervations
Paravaginal vaginal disruption of the pelvic
neurons
Plexuses around the cervix
 Urinary system
-urinary incontinence –bladder neck
-increased vesical sensitivity lasting up to 6months
-There may be a degree of vesicourethral dysfxn b/4
surgery
-conflicting results
Gastrointestinal
-surgeons increased constipation
irritable bowel syndrome
-Draw back of supportive studies –retrospective and
tasking of patient memory
-Manometric studies showed no change in sphincter
function
-Proctometrograms- increased rectal compliance
volume
COMPLICATIONS CONT.

Increased incidence of enteroceles 40% and perineal

decent 25% on defecography
-Weakness of the pelvic floor muscles- rectal and
vaginal prolapse
Prolapse of the vaginal vault
Vault granuloma formation
-prevention is dependent : cuff-open or closed
-choice of suture plain catgut or chromic
-most important is appropriate apposition of the edges
-Treatment Silver nitrate/electrocautery
Intestinal obstruction –adhesions and vault herniation.
Female sexuality
– Disruption of the innervation around cervix/upper
vagina
– Lubrication and orgasm
– Internal orgasm (cervical orgasm)
– Stimulation of nerve endings of the uterovaginal
plexuses
– Cervical mucous
– ALL theoretical
– In reality sexual response is tied toward
psychological and physical factors
Not conclusive
 Residual ovarian syndrome
-occurs following hysterectomy with
conservation of the ovaries
-occurs in 3-10% 0f patients
-common in women <35yrs
occurs when the ovarian pedicles are tied to
the vault
Presentation –cyclical unilateral pain which may
be disturbing. Associated dense adhesions on
the ovarian capsules preventing normal cyclical
volume changes
Hx of previous pelvic surgery present in10% of
cases and endometriotic cyst-10%
Complications cont.

Ovarian remnant syndrome

-Variant of residual ovarian syndrome
-occurs after difficult total hysterectomy and
B.S.O
-Normal premenopausal FSH levels
Development of cervical cancer
-Potential site of cancer
-2-6% of all cases
-0.5 -1.0% risk after 10 years of subtotal hysterectomy
Chronic vaginal discharge and dyspareumia
 Psychological complications
Post hysterectomy depression
-association with psychology –Derived from hysteros
-etymological association- hysteria
Reasons
-postulated to cause emotional crisis,
-loss of reproductive potentials
-diminished sexuality

some earlier studies done could not find definite

association. Others found
Non reliability caused by faulty research approach, design
and population size used ,retrospective and had poor follow
up.
Recent studies have found pre-hysterectomy rates to be .>
than the general population 16-58% against 6-14%
Post hysterectomy depression cont
It was also noted that patients with depression
may in fact be having depression prior to the
procedure.
Some may have worsen of depression if the
reason the procedure was done did not solve the
problem.
How to reduce such?
- proper patient selection
-psychological evaluation and hormone
replacement theraphy
 Risk factors to depression
Age < 40 and older age Fear and negative
Desire to have children expectations about the
procedure
single, divorced, or
separated Threatened to lose one’s
femininity
Low socio economic
class Nervous and overanxious
premorbid personality
Low educational level
Previous or present
Lack of family support
psychiatric illness
and friends
Absence of organic
Vulnerable to stressful life
pathology
situations
Post hysterectomy syndrome
Reported in 70% of patients after
hysterectomy
Believed to be due to hysterectomy
induced premature ovarian failure
Occurs with 2-5 years of surgery
Hormonal assay confirm relatively low
level of syndrome in patients on Hormone
replacement syndrome
 conclusion
Results of hysterectomy are good
provided the indications are good
Complications are more if reason for
procedure are not wrong.