PRENATAL CARE

PERIPARTUM HYSTERECTOMY Jacob Trisusilo Salean Resident Obstetric GinecologyDr. Soetomo Hospital- Airlangga University

Hysterectomy is more commonly performed during or after cesarean delivery but may be needed following vaginal birth. During a 25-year period, the rate of peripartum hysterectomy at Parkland Hospital was 1.7 per 1000 births (Hernandez, 2012). Most of this increase is attributed to the increasing rates of cesarean delivery and its associated complications in subsequent pregnancy (Bateman, 2012; Bodelon, 2009; Flood, 2009; Orbach, 2011). Indication

Major complications of peripartum hysterectomy : Increased blood lossGreater risk of urinary tract damage. Komplikasi utama dari peripartum histerektomi meliputi peningkatan kehilangan darah dan risiko lebih besarkerusakan saluran kemih. Kehilangan darah biasanya cukup karena histerektomi sedang dilakukan untukperdarahan yang sering adalah deras, dan prosedur itu sendiri dikaitkan dengan darah yang cukup besarloss. Meskipun banyak kasus dengan perdarahan tersebut tidak dapat diantisipasi, mereka yang tidak normalimplantasi sering dapat diidentifikasi antepartum. Persiapan pra operasi untuk plasenta akreta adalahdibahas dalam Bab 41 (hal. 807) dan juga telah digariskan oleh Society for Maternal Fetal-Kedokteran (2010) dan American College of Obstetricians dan Gynecologists (2012c).4Supracervical or total hysterectomy is performed using standard operative techniques. For this, adequate exposure is essential. The bladder flap is deflected downward to the level of the cervix if possible to permit total hysterectomy. Peripartum Hysterectomy TechniqueThe round ligaments are clamped, doubly ligated, and transected bilaterally.

The posterior leaf of the broad ligament adjacent to the uterus is perforated justbeneath the fallopian tube, uteroovarian ligaments, and ovarian vessels.

The uteroovarian ligament and fallopian tube are doubly clamped and cut bilaterally.The lateral pedicle is doubly ligated.

The posterior leaf of the broad ligament is divided inferiorly toward the uterosacralligament.

The bladder is dissected sharply from the lower uterine segment.

The uterine artery and veins on either side are doubly clamped immediatelyadjacent to the uterus and divided. A third medial clamp will prevent back bleeding. B&C. Thevascular pedicle is doubly suture ligated.The round ligaments are divided close to the uterus between Kocher clamps and doubly ligated(Fig. 30-13). Either 0 or No. 1 suture can be used in either chromic gut or delayed-absorbablematerial. The incision in the vesicouterine serosa that was made to mobilize the bladder is extendedlaterally and upward through the anterior leaf of the broad ligament to reach the incised roundligaments. The posterior leaf of the broad ligament adjacent to the uterus is perforated just beneath thefallopian tubes, uteroovarian ligaments, and ovarian vessels (Fig. 30-14). These structures togetherare then doubly clamped close to the uterus and divided, and the lateral pedicle is doubly ligated(Fig. 30-15). The posterior leaf of the broad ligament is divided toward the uterosacral ligaments(Fig. 30-16). Next, the bladder and attached peritoneal flap are further deflected and dissected asneeded from the lower uterine segment and retracted out of the operative field. If the bladder flap isunusually adhered, as it may be after previous hysterotomy incisions, careful sharp dissection may benecessary (Fig. 30-17).Special care is required from this point on to avoid injury to the ureters, which pass beneath theuterine arteries. To help accomplish this, an assistant places constant traction to pull the uterus in thedirection away from the side on which the uterine vessels are being ligated. The ascending uterineartery and veins on either side are identified near their origin. These pedicles are then doublyclamped immediately adjacent to the uterus, divided, and doubly suture ligated. As shown in Figure30-18, we prefer to use three heavy clampsHeaney or Ballantineto incise the tissue between themost medial clamps, and then ligate the pedicle in the clamps lateral to the uterus.6Even if total hysterectomy is planned, we find it in many cases technically easier to finish the operation after amputating the uterine fundus and placing Ochsner or Kocher clamps on the cervical stump for traction and hemostasis. To remove the cervix, the bladder is mobilized further if needed. Total HysterectomyThis carries the ureters caudad as the bladder is retracted beneath the symphysis and will prevent laceration or suturing of the bladder during cervical excision and vaginal cuff closure.7The cardinal ligaments are clamped, incised, and ligated.

A curved clamp is placed across the lateral vaginal fornix below the level of thecervix, and the tissue incised medially to the point of the clamp.The lateral angles of the vaginal cuff are secured to the cardinal and uterosacralligaments.A running-lock suture approximates the vaginal wall edges.

The cardinal ligaments, the uterosacral ligaments, and the many large vessels these ligaments contain are clamped systematically with Heaney-type curved or straight clamps (Fig. 30-19). The clamps are placed as close to the cervix as possible, taking care not to include excessive tissue in each clamp. The tissue between the pair of clamps is incised, and the lateral pedicle is suture ligated. These steps are repeated caudally 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.Immediately below the level of the cervix, a curved clamp is placed across the lateral vaginal fornix, and the tissue is incised above the clamp (Fig. 30-20). The excised lateral vaginal fornix can be simultaneously doubly ligated and sutured to the stump of the cardinal ligament. The cervix is inspected to ensure that it has been completely removed, and the vagina is then repaired. Each of the angles of the lateral vaginal fornix is secured to the cardinal and uterosacral ligaments to mitigate later vaginal prolapse (Fig. 30-21). Following this step, some surgeons prefer to close the vagina using figure-of-eight sutures. Others achieve hemostasis by using a running-lock stitch placed through the mucosa and adjacent endopelvic fascia around the circumference of the vaginal cuff (Fig. 30-22).8

9

Thank You