Postpartum hysterectomy (Porro)
Postpartum hysterectomy can be subtotal unless the cervix and lower uterine segment are involved. Total hysterectomy may be necessary in the case of a tear of the lower segment that extends into the cervix or bleeding after placenta praevia. • Review for indications. • Review operative care principles and start an IV infusion. • Give a single dose of prophylactic antibiotics:
• If there is uncontrollable haemorrhage following vaginal delivery, keep in mind that speed is essential. To open the abdomen: - Make a midline vertical incision below the umbilicus to the pubic hair, through the skin and to the level of the fascia;
• If the delivery was by caesarean section, clamp the sites of bleeding along the uterine incision:
• Doubly clamp and cut the round ligaments with scissors (Fig P-54). Clamp and cut the pedicles, but ligate after the uterine arteries are secured to save time.
FIGURE P-54 Dividing the round ligaments
• Use two fingers to
push the posterior leaf of the broad ligament forward, just under the tube
and ovary, near the uterine edge. Make a hole the size of a finger in the
broad The ureters are close to the uterine vessels. The ureter must be identified and exposed to avoid injuring it during surgery or including it in a stitch.
• Grasp the edge of the bladder flap with forceps or a small clamp. Using fingers or scissors, dissect the bladder downwards off of the lower uterine segment. Direct the pressure downwards but inwards toward the cervix and the lower uterine segment. • Locate the uterine artery and vein on each side of the uterus. Feel for the junction of the uterus and cervix. • Doubly clamp across the uterine vessels at a 90̊ angle on each side of the cervix. Cut and doubly ligate with 0 chromic catgut (or polyglycolic) suture (Fig P-56).
FIGURE P-56 Dividing the uterine vessels • Return to the clamped pedicles of the round ligaments and tubo-ovarian ligaments and ligate them with 0 chromic catgut (or polyglycolic) suture. • Amputate the uterus above the level where the uterine arteries are ligated, using scissors (Fig P-57).
FIGURE P-57 Line of amputation • Carefully inspect the cervical stump, leaves of the broad ligament and other pelvic floor structures for any bleeding. • If slight bleeding persists or a clotting disorder is suspected, place a drain through the abdominal wall. Do not place a drain through the cervical stump as this can cause postoperative infection. • Ensure that there is no bleeding. Remove clots using a sponge. • In all cases, check for injury to the bladder. If a bladder injury is identified, repair the injury. • Close the fascia with continuous 0 chromic catgut (or polyglycolic) suture. Note: There is no need to close the bladder peritoneum or the abdominal peritoneum. • If there are signs of infection, pack the subcutaneous tissue with gauze and place loose 0 catgut (or polyglycolic) sutures. Close the skin with a delayed closure after the infection has cleared. • If there are no signs of infection, close the skin with vertical mattress sutures of 3-0 nylon (or silk) and apply a sterile dressing. TOTAL HYSTERECTOMY • Push the bladder down to free the top 2 cm of the vagina. • Open the posterior leaf of the broad ligament. • Clamp, ligate and cut the uterosacral ligaments. • Clamp, ligate and cut the cardinal ligaments, which contain the descending branches of the uterine vessels. This is the critical step in the operation:
The upper 2 cm of the vagina should now be free of attachments. • Circumcise the vagina as near to the cervix as possible, clamping bleeding points as they appear. • Place haemostatic angle sutures, which include round, cardinal and uterosacral ligaments. • Place continuous sutures on the vaginal cuff to stop haemorrhage. • Close the abdomen (as above) after placing a drain in the extraperitoneal space near the stump of the cervix.
• If there are signs of infection or the woman currently has fever, give a combination of antibiotics until she is fever-free for 48 hours:
• Give appropriate analgesic drugs. • If there are no signs of infection, remove the abdominal drain after 48 hours. • Offer other health services, if possible. |