Reducing the Risk of Total Abdominal Hysterectomy*

REDUOilfG THE lUfU[ GP 'l'O!l'AL ~.BY~QMY* PETER TERZIAN,

M.D.,

AND JOHN P. TIMPANE,

M.D.,

SCHENECTADY,

N. Y.

(From the Department of Gynecology, Ellis Hospital)

now fairly universally agree that if hysterectomy is to GYNECOLOGISTS be performed, complete removal of the uterus is desirable and possible, practically without exception. The risk of total hysterectomy has been steadily decreasing through the past two decades, so that now an operative mortality rate greater than 2 per cent is exceptional. It is not unusual, however, for the postoperative morbidity rate, which is an index of the risk to the patient's life, to be 35 per cent. In the past seven years, numerous studies dealing with and seeking to prevent postoperative morbidity have been published. 1 - 6 As outlined so well by Johnson and Burman," the morbidity rate following total abdominal hysterectomy varies generally between 27 and 41 per cent. The criteria for diagnDsing morbidity vary somewhat from author to author, some considering the temperature beginning on the :first postoperative day, others beginning twenty-four hours after operation, and still others beginning after the first postoperative day. Our criteria are similiar to, but not identical with, those of the Joint Committee on Maternal Welfare/ 2 being an oral temperature of 100.4° F. or over, on any two consecutive days after the first postoperative day, temperatures to be taken four times daily. Practically all studies on morbidity emphasize the importance of exact surgical technique. Some of the most recent studies emphasize the importance of the preoperative vaginal preparation. Cron, Stauffer, and PaegeV studying a rather large series, found that the use of a Zephiran vaginal pack and a penicillin vaginal suppository reduced their morbidity rate for total abdominal hysterectomy from 45 to 21 per cent. Several other studies8 • 9 • 10 verify the importance of careful preoperative vaginal preparation. Unfortunately, some of these studies.combine the results in vaginal hysterectomy and in minor procedures, so that the presumed beneficial results with total abdominal hysterectomy are obscured. A recent study of 518 consecutive hysterectomies from this hospital,B of which 483 were total abdominal hysterectomies, revealed that 36 per cent of the latter patients had morbid postoperative courses, The outstanding cause of the fever was pelvic infection with or without absc~ss or peritonitis. We have become accustomed to designating this complication "parametritis," because the seat of the inflammatory process is the pedicles of the cardinal ligaments and the closely adjacent parametrial structures (uterosacral pedicles, pedicles of the uterine vessels, the perivaginal fascia, broad ligaments, and •Presented at a regular meeting of the Northeastern New York

cological Society in Schenectady, N. Y., April 16, 19(53.

826

Ob~:~tetrical

and G-yne-

Volume 69 Number 4

REDUCING RISK OF TOTAL ABDOMINAL HYSTERECTOMY

827

adnexal pedicles). We believe that the cause of the elevated temperature is often wrongly attributed to cystitis, because of the proximity of the bladder and the frequent finding of pus cells in the urine. Very often we have noted that a rapid return of the body temperature to normal is associated with a sudden increase in the reddish-brown, malodorous vaginal discharge which undoubtedly had been loculated in the subvesical paran1etrial space. With due attention to the foregoing considerations, we formulated a study whereby, with the cooperation of the Gynecological Group of Ellis Hospital, a routine for total abdominal hysterectomies was established. All factors which could contribute to elevating postoperative temperature were analyzed. The surgical teehniqlle was perfected and standardized as completel:r as possible. The preoperative preparation was standardized, and patients were taken at random in the various groups. The degree of intrinsic risk was evaluated for each patient. The postoperative care was standardized. The only significant difference among the several groups of patients was the type of preoperative vaginal preparation given. The results were compared after about forty patients were treated by each method, and the method affording the best results was subjected to a second test, including a second group of forty patients. The results were then analyzed statistically. Basic Considerations

Certain constant and variable factors apply to each of the operations reported in this series. The constant factors are : the preoperative enema; preoperative catheterization; the skin preparation; the incision (low midline as a rule; occasionally a Pfannenstiel) ; the use of dry skin towels; catgut technique; fresh gowns, gloves, drapes, and instruments for closure of the abdominal wound; and the withholding of antibiotics before development of morbidity. The variable factors to be considered in each of the operations in this series are: the patient; the surgeon; the preoperative vaginal preparation; ligation of bleeding points (some operators being meticulous, others less particular); insertion of drains in the vault (a drain was used in practically every case in this series; in some instances the cul-de-sac was drained as well as the subvesical area) ; the technique of suturing the vaginal cuff; treatment of the adnexa; technique of peritonization; details of wound closure; appendectomy; and coincidental vaginal plastic operations. A most important variable factor in any major operation is the patient. In this series, we have graded patients according to surgical risk. Patients with the least potential risk were placed in Class I, those with the greatest risk, in Class IV. The grade of risk was advanced one class for each of the following factors: a subcutaneous fatty layer more than 4 em. thick; extensive peritoneal adhesions; endometriosis of the pelvic peritoneum of moderate or marked degree; large myomas; the presence of pelvic malignancy; very severe cervicitis; chronic inflammation of the tubes or pelvic peritoneum; uterine bleeding at the time of operation; the presence of diabetes mellitus;

828

TERZIAN AND TIMPANE

\111

t. ()[,. t.

~

. \ fll

(j_vncc.

i!' .1 () ~ ~

and the coincidental performance of vaginal plastic procedures. As \vill he seen, the distribution of patient risk in each group is approximately equal. making statistical evaluation simpler. The most important extraneous risks must admittedly be i11trodltced at the time of operation. These will be considered now. Catheterization, even by a registered nurse, always carries the risk of contamination of the bladdet· with subsequent serious upper urinary tract infection. The hands, nose, throat, and hair of the operator and assistants are always possible sources of contamination of the field. The skin cannot be sterilized; our prepa1·a.tion consists of applications of Pyxol* and tincture of Zephiran. t The laparotomy drapes can be a source of contamination by inadequate sterilization or by becoming moistened with blood or other liquids. Instruments and sponges can be unsterile. The vagina can hardly be sterilize({. Poor hemostasis can lead to the formation of pyrogenic hematomas. '!'issues can be isolated from their blood supply by poor surgical technique. Excessive trauma necessitates absorption of small or large portions of crushed tissue, with consequent pyrexia. The rislr of perforation of bov:c1, bladder, or ureter constantly besets the gynecologist. 'l'he choice of suture material is of some importanee. There will always be a certain percentage of hysterectomies that are performed without adequate indications. rrhis percentage will of course affect the results in any series. because the pathology present in such eases is minimal; and therefore the risk is less. W P p1·idt> ourselves on feeling that such procedures are at a minimum in this serieR. Technique Several different routines for vaginal preparation were tested, with about 40 patients in each group. After the completion of this series, the preparation giving the best results (Type IV, Table IV) was l'etested in another series of about 40 patients. The alcohol and Pyxol basins were proved to be sterile. The skin was alw·ays prepared by the resident. Dry skin tov.rcls \vere altv-a:rs us-ed, and care was taken to cover the wound edges with these towels before insertion of the self-retaining retractor. A:fter completion of the intraperitoneal procedures, including insertion of the drain and appendectomy if necessary, the skin towels were removed, gowns and gloves were changed by surgeon, assistants, and nurse, fresh towels were applied around the wound, and a fresh set of sterile instruments was used for closure. The technique of hysterectomy was essentially that described by Cornell and co-workers. 6 Hemostasis should be emphasized, and trauma minimized. The most important arteries encountered, in decreasing order of importance, are the cervicovaginal branches of the uterine, the appendiceal, the ovarian,and finally, the uterine. Peritonization is important in the prevention of adhesions, as emphasized by Phaneu£. 11 Our closure technique was continuous chromic No. 1 sutures for the peritoneum, two or three pieces of continuous chromic No.1 catgut for the anterior rectus sheath (with no eviscerations), continuous chromic No. 000 for Scarpa's fascia and suhcutaneons tissue, and Michelclips for the skin. *Pyxol is a 2 per cent solution of concentrated Pyxol (a coal-tar derivative) in a mixture of three parts 95 per cent alcohol and two parts acetone. tZephiran is an antiseptic quaternary ammonium salt. Admittedly there are many completely satisfactory methods of preparing the skin.

Volume 6~ -t-

H~:lWCIXG

~llmher

RTRK OP 1'0TAL .\RD
After the operation, hydration was 11111intaim·!l, usually orally, hut ofte11 with intravenous liquids. COlw:hing, deep h1·eathing, and moving about in hed were encour·aged. Tht' catheter was left in place during the first night to prevent bladder distention. All patients \nr·e ambulated on the first postoperative day. Skin clips mHl vaginal drain were removed on the fifth day. The patient usually was dischar·gpd on the st•Hnth (lay atH1 a stay of more 1han ten days was unusual.

Material The patients in this series were divided into groups according to the type of vaginal preparation: Type 1, cotton vaginal tampon with cervical end soaked in 10 ml. of ;-; per cent Sulfamylon* inserted the afternoon before operation. Type 2, dry cotton vaginal tampon inserted the afternoon before operation. Type 3, disinfection in operating room with tincture of Zephiran aiHl dry sponging. Type 4, penicillin-streptomycin suppositoryt inserted in posterior fornix the afternoon before operation. rrype .), no pelvic exanlination in hospital, no preoperative vaginal preparation. The results are presented in Tables I to V. In the group with Type 1 preparation, one patient had pyelitis, which is discounted since the surgical procedure per se was not to blame, and one patient had a wound infection, which is preventable, therefore is included in the net morbiditv All other morbiditv waR annarentlv dne to '' nHramPtritis. '' . In the gr:oup ~ith Type 2 pr~parati~~: 2 pat(ent~.h~d p~i~~~~ry atelectasis, and one had a wound infection. The former are discounted in the net rate. 'rABLE

I.

OPERATIVE RISK, CLASS

VAGINAL PREPARATION, TYPE

1. 41

PA'riENTS

NUMBER OF PATIENTS

NUMBER MORBID

PATIENTS MORBID DUIG ~·o PELVIC CO:Iil'I,!('ATlON

0

21

:l

0

Il JII

13

±

I------~------~6------~---

IV

Gross morbidity rate 21lo/c TABLE OPERATIVF~

RISK, CLASS

II.

,,

Net morbidity rate 17%

VAGINAL PREPARATION, TYPE

2.

43

PATIENTS

NUMBER OP PATIENTS

NUMBE!( MORBID

PATIENTS MORBID DUE TO PELVIC COMPI,JrATION

27 S 1

7

±

7 2

~------~------~7~----~------~------~-----

II III TV

U

l

U

----~~~~~~--------------~~--~~~~~~------

Gross morbidity rate 28%

Net morbidity rate 23%

In the third group, 2 patients had pulmonary atelectasis, and one had a wound infection. It is noted that patients who are Class IV risks are often afebrile, probably because the surgeon is more meticulous in these cases. The converse holds with Class I patients. *Sulfamylon is a topical sulfonamide, active in the presence of pus anti blood, chemically 4-aminomethylbenzenesulfonamide hydrochloride. tThe penicittin-streptomycin suppositories originally used by us were custom made by the hospital pharmacist, Mr. W. M. Hartmann, and contained 100,000 units of crystalline potassium pc·nicittin G with 250 mg. of dihydrostreptomycin base, in cocoa butter.

830

TERZIAN AND TIMPANFJ TABLE

III.

3.

VAGINAL PREPARATION, TYPE

OPERATIVE RISK, CLASS

NUMBER OF PATIENTS

I II

4

III

25 14

IV

1

1

.\m

44

J.

Obst. & Gynec. April, 1955

PATIEN~'S --------------··

NUMBER

: - --~~~_I_I) ____ ..

PFJLVW COMPLICATION

2 2

..0.,

In the group with Type 4 vaginal preparation one patient developed acute enteritis coincidentally with her family on the first postoperative day. 'l'wo other patients developed minimal early morbidity not requiring antibiotics, fairly definitely attributable to oozing from areas of severed adhesions. TABLE IV.

4.

VAGINAL PREPARATION, TYPE

40 PATIENTS

OPERATIVE RISK 1 CLASS

NUMBER OF PATIENTS

NUM.BER MORBID

PATIENTS MORBID DUE TO PELVIC COMPLICATION

I II III

6

2

21

1

1 1 1

0

n

2

IV

Gross morbidity rate 12%

0

1

Net morbidity rate 5%

·'------

The group that had Type 5 vaginal preparation was not carried beyond 33 patients because in it more freqll€D.t and more severe morbidity was encountered than in any other group. The principle to be determined was whether examination of the patient in th.e hospitaLby the house staff (usually two members) increased operative risk by disseminating infection from the cervix or other sites into the pelvic lymphatics. This series proved to the satisfaction of the Gynecological Group that examination by the house staff was not deleterious. One patient in the group developed pulmonary atelectasis, another a wound infection. TABLE V.

VAGINAL PREPARATION, TYPE

OPERATIVE RISK 1 CJ,ASS

NUMBER OF PATIENTS

I II III

13

IV

11

7 2

Gross morbidity rate 27%

5.

33

PATIENTS

NUMBER! MORBID _ ---~1~---

4 3

1

PATIENTS MORBID_DUE TO PELVIC COMPLlCATION

1

3 3 1

Net morbidity rate 24%

As a comparison, 49 consecutive total abdominal hysterectomies performed by general surgeons at this hospital during the same period were analyzed. The surgical risk distribution could not be determined with complete accuracy, but was judged to be similar, from the pathological reports, with 15, 19, 12, and 3 patients in Classes 1, 2, 3, and 4, respectively: T-he gross morbidity rate in this l!roun was 27 ner cent. and the net rate 22 ner cent. with 2 wound infections~ one~ deep thrombophlebitis, and one pyelonephritis., When the results of these studies became apparent, the Gro11p elected· to use the penicillin-streptomycin suppository before all contempl-ated and possible total abdominal hysterectomies. This has been done, and, to date1 another series in which this preparation. w~ used is avaful.ble fo-r Cl)m.j1Won1 consisting of 40 patients. The gross morbidity rate in th,is grou,p was 15 per cent, and the net rate 8 per cent. There was one instance o£ acute bronchitis,

REDUCING RISK OF 'l'O'l'AL ABDOMINAL HYSTERECTOMY

Volume 69 :-.Jumher 4

831

one of cystitis causing a delayed morbidity, and one of paralytic ileus. The risk distribution in this group was G, 17, 17, and 1 patients in Classes 1, 2, 3, and 4, respectively. A summary of the results in each of these gl'nups is presented in Table VI. TABLE VI.

SUMMARY OF RESULTS WITH DIFFERENT TYPES OF VAGINAL PREPARATION BEFORE TO'TAIJ ABDOMINAL HYSTERECTOI\-iY. 290 PATIENTS GROSS RATE OJ;' MORBIDITY

RATE OF PELVIC MORBIDITY

(%) 28

(%) 23

27 27

22 24

80

20 16

44

14

17 11 6

NUMBER OF PATIENTS

TYPE OF PREPARATION

43 49

2. 6. 5. 1.

Dry tampon Surgeons' cases No preparation Sulfamylon 3. Tincture of Zephiran 4. Suppository

33

41

Mortality There was one death during the period of this study, which occurred 47 hours postoperatively, caused by acute adrenal cortical insufficiency in a patient with Sheehan's syndrome and carcinoma of the endometrium ; an autopsy was performed. Analysis We have been impressed by the results obtained in this study. The only legitimate objection is that the series may be too small for complete validity. If we consider the group of 80 hysterectomies performed after vaginal preparation with the suppository, however, only 11 of these patients had a morbid course, and, of these, only 5 had morbidity of pelvic origin. This is a gross morbidity of 14 per cent and a net morbidity of 6 per cent. Considering all the other 210 cases as a group, the gross morbidity was 23 per cent and the net morbidity 20 per cent. The difference between the net morbidity rates is statistically significant, while the difference in the gross morbidity is probably significant. In only 7 cases out of 100 would one expect to get such a difference by chance alone.* Summary

The mortality rate following total abdominal hysterectomy nowadays is usually less than 2 per cent, but the rate of risk to the patient's life and wellbeing, based on the postoperative morbidity rate, is still rather high, averaging about 35 per cent. It was therefore considered worth while to study methods whereby this rate of risk might be reduced. vV e have done this by a critical appraisal of the individual patient and of the surgical technique m 290 cases. Our results have been found statistically valid. •·For the entire series of 290 cases, the gross morbidity, p = _I)_Q_ = 0.207, 290 and the net morbidity is p' = Then n, = 80, p 1 Sigma

=

p2

-

p,

AA ~

290

11 = SO =0.1375.,

= 0.159. n,. =

210, p, = 0.2333.

- fpq + pq = 5.3,

'f

n,

n2

Similarly, p,' = 0.0625, p 21 = 0.1952, and

p, - p, = 1.8 and P Bigma p, - p 1

=

0.07.

. p,' - p,' = 2.8 and P = 0.01. Srgma p,' - p,'

832

'I'I
'1'TMPANI,~

,\o:

_T. Clb,,J. &

Grnt'l- . •\priL 19~-l\

Conclusions

1. The pelvic murbiJity rate following tuta1 abdominal hysterectom;.· l~,; reducible to less than 10 per cent in auy consecutive series. 2. Part of the risk of hysteredomy is intrinsic in the patient., due to such factors as obesity, metabolic disease, and the type of pelvic pathology. :3. A greater part of the risk of hysterectomy is extrinsic, depending on surgical technique and pre- and postoperative care. 4. An important part of the prt>paration for hysterectomy is the vagiual phase. Our best results have been ohtainefl with the use of a penicillin-streptomycin suppository inserted into tlw posterior fornix of the vagina, twelve to sixteen hours before operation. 5. Simple drying of the vaginal vault is equivalent to no preparation before operation. 6. Sulfamylon and tincture of Zephiran are of some value in preparation of the vaginal vault before hysterectomy. 7. Wound infection is preventable. Grateful acknowledgment is made to the members of the Gynecological Group of Ellis Hospital; namely, Drs. Phillips, Cornell, Meyerhoff, McGrane, 'fischler, Jameson, and Kathan, who cooperated to the fullest in establishing and testing the often tedious routines in the operating room, and of whose patients this series is almost completely composed. The operating-room staff, likewise, under the direction of Miss Rosa Kennedy, R.N., performed many more than their usual duties so that this work might be accomplished. The statistical analyses were performed by Miss Elizabeth Parkhurst, Associate Bio· statistician in the Bureau of Vital Statistics of the Department of Health, State of New York.

References 1.

2. 3. 4.

5. 6.

Leventhal, M. L., and Lazarus, M. L.: AM. J. 0BST. & GYNEC. 61: 289, 1951. Pratt, J. H., eta!.: AM. J. 0BST. & GYNEC. 61; 407, 1951. Danforth, W. C.: AM. J. 0BST. & GYNEC. 52; 218, 1946. Curtis, W. W., Suckow, E., and Huffman, J. W.: AM. J. 0BST. & GYNEC. 59: 989, 1950, Johnson, C. G., and Burman, R. G.: AM. J. 0BST. & GYNEC. 65: 574, 1953. Cornell, J. H., Tischler, L. P., Carpenter, R. J., and Terzian, P~: AM . .T. OBST. &- GYNEC.

66: 138, 1953. Cron, R. S., Stauffer, J., and Paegel, K: AM. J. OBST. & GYNF.C. 63: 344, 1952. Moore, R. M.: AM. J. 0BST. & GYNEC. 64: 387, 1952. Fletcher, P. F.: South. M. J. 43: 715, 1950. Turner, S. J.: AM. J. 0BST. & GYNEC. 60: 806, 1950. 11. Phaneuf, L.: New Eng. J. Med. 247: 39, 1952. 12. DeLee, J. B., and Greenhill, .T. P.: Principles and Pradi<'t' of ObstetrieR, ed. !l, Philadelphia, 1948, W. B. Saunders Con1pany, p. 775.

7. 8. 9. 10.

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