The week of hysterectomies

I saw several hysterectomies this week on the gynecology service, each a different flavor. A resident pointed me in the direction of a wonderful resource, the Atlas of Pelvic Surgery, which describes specific surgeries step-by-step with accompanying pictures. Reviewing each procedure ahead of time helped me better understand what was happening in the operating room.


One hysterectomy was a total vaginal hysterectomy, which delivers the uterus through the vagina. This patient had a prolapsed uterus, which basically means that the tissues holding the uterus in place were failing causing the uterus to sink down lower into the pelvis and out the vagina.


Another was a total abdominal hysterectomy, a procedure that removes the uterus through an incision in the lower abdomen. The abdominal approach was chosen, versus a transvaginal approach, because the uterus was burdened by several fibroids, one of them the size of a softball. Attempting to deliver such a large uterus through the vagina wouldn't have been smart.

The most interesting hysterectomy I saw was a laparoscopy assisted vaginal hysterectomy that was converted to an open procedure because of uncontrolled bleeding from the uterine arteries, which were difficult to clamp laparoscopically because of abnormal anatomy.

This turned into a true emergency. The gynecological surgeon never lost his calm, but he also started moving much more quickly than surgeons usually move. Less than 30 seconds after he called out "We're converting to open!" he and the resident made an incision across the lower abdomen and were literally tearing apart the subcutaneous tissue to gain access to the abdominal cavity. The bleeding was stopped, and the rest of the surgery went without further complications.

The attending asked me afterward, "What's the first thing you do in a Code situation?" My answer: check for airway, breathing, and circulation. Not entirely incorrect, but his answer was much more to the point: Take your own pulse.

Seeing three different surgical approaches toward the same end goal, removal of the uterus, was very helpful in terms of understanding the female pelvic anatomy. I also have a higher appreciation for how anatomic variability, both normal and abnormal, determines the course a surgery.