Emergency Hysterectomy

It would be a very unusual situation that would require an emergency hysterectomy. Most bleeding can be controlled with lesser procedures (D&C or hormonal management), and most infections respond to antibiotics.

Hysterectomy consists of clamping across the supporting structures of the uterus and its blood supply followed by removal of the uterus. The most difficult part (and the part which leads to the most complications) is removal of the lowest portion of the uterus and cervix. The reason for this difficulty is the close proximity of bladder, ureters and bowel. In an emergency setting, it is very acceptable to avoid those problems by performing a “supracervical hysterectomy.”

Clamps are placed across the fallopian tubes close to the body of the uterus. Then working stepwise, the parametrial tissues are clamped. When the uterus narrows, (above the level of the bladder and ureters), a scalpel cuts across the lower uterine segment, resulting in the removal of the upper portion of the uterus and the leaving in place of the lower portion of the uterus (primarily the cervix). The raw, cut edge of the cervix and lower uterine segment is sutured for hemostasis.

The advantages of this supracervical hysterectomy are:

  1. It can be performed more easily, particularly by surgeons with lesser amounts of gynecologic surgical training.
  1. It is safer in the short run because it greatly reduces the chance of inadvertent injury to the bladder, bowel or ureters.
  1. It is faster than a complete hysterectomy.
  1. Because the cervix remains in place, there is less chance of long-term vaginal support problems since the supporting structures (cardinal and uterosacral ligaments) remain intact.

The disadvantages to the supracervical hysterectomy are several, but relate more to the elective or semi-elective hysterectomy setting than the emergency hysterectomy performed in an operational setting. Because the cervix remains and may develop cervical malignancy at some time in the future, the patient has not derived maximum benefit from her surgery. If malignancy is present in the uterus, an incomplete procedure has been performed. Further, if infection is present, some infected tissue may be left behind.

In the operational arena, none of these disadvantages seem persuasive, and the advantages in speed, safety and simplicity suggest supracervical hysterectomy is preferable when needed.

Prophylactic antibiotics covering gram negative and anaerobic bacteria is an excellent idea in the operational environment.