Today my daily rant will be about hysterectomies. I hate them. I hate them even worse than I hate c-sections. In case you don’t understand about hysterectomies, I will explain the fundamental mechanics of an abdominal hysterectomy to you. That is because these are worse than vaginal hysterectomies.
First you make a smiley face cut with the knife, about two fingerwidths above that pubic bone you can feel in the midline. This of course causes instantaneous bleeding, since people insist on bleeding when they are cut. Then we use a little electric knife, called a Bovie, that zaps electricity onto the bleeding vessels and fries them. The smell is somewhat like barbecue. The zapper never works as well as you hope it will. Then you cut and zap and cut and fry until you get down to a sheet of thick gristly stuff called fascia.
You open the fascia in the midline (the sheet goes all the way across the front of the inside of the belly), usually with the Bovie zapper (my favorite surgical instrument). Then you used curved scissors called Mayos to extend that hole in the fascia out to the side. How far to the side? Just until you reach the damn hidden blood vessel that begins to pump everywhere when you hit it. There is one on each side in case you manage to miss one of them. You zap those pumpy little suckers until they stop bleeding on you.
Underneath the fascia are the rectus muscles. Those are the famous “six pack” muscles that no one really actually has. Especially our patients, who have fat layers fists deep before you can reach the fascia. Your next task is to peel the fascia off the muscles underneath. You can do this somewhat by just flat digging with your fingers and peeling it yourself. This is colloquially known as “blunt dissection”. You then peel down the rest of the fascia using those scissors and that good old Bovie, because yes, there are bleeders in there too. You gotta spot em and zap em before they get you. Then you separate those two bands of rectus muscles in the midline from each other. Good old blunt dissection again. A lot of surgery is just bluntly digging around, but there is a reason for this. Things tear neatly along tissue planes, and a lot of times the blood vessels don’t tear along with them. Less bleeding. Less barbecue smell.
Then you are looking for a layer underneath called the peritoneum. It is often obscured with yet another layer of good old fashioned fat. Once you shove the fat out of the way, you find a thin spot in the peritoneum and pop through it with your finger, or elevate it and snip into it with some little metzenbaum scissors. This gains you access to the good old abdominopelvic cavity. So you have just now actually gotten into the belly. All that blathering up above is just preparing you to get into that cavity, so you can see how monotonous this can get.
Another thing to consider: if the patient has had any previous belly surgery, you will encounter scar tissue on the way in. Various tissue planes will be stuck and distorted, and you will not be able to use blunt dissection nearly as much. This part will than take much longer than it takes to describe.
Once you enter the thin layer of peritoneum, you extend that opening out using the “finger fractionation technique.” Think blunt dissection with aggressive pulling out to the sides. Surgery is a lot rougher than anyone realizes. That is why we try to warn you that you don’t need a hysterectomy unless you really really need one. That is also why we put you to sleep when you have it. So you don’t feel all the pulling and hear all the swear words (and the really bad music on the only real radio station we can get down there). So now we are FINALLY in the belly.
Now it’s time to shove everything out of the way. We use something called a retractor, that pulls the whole opening out from side to side. Kind of like those lip stretchers they use when you get braces. Then we use soft white towels called laps to shove your intestines up into the upper part of the abdominal cavity as we can get them to go. Otherwise, the damn things pop out and get in the way all the time. And they are NOT supposed to be a part of this procedure. Neither is the bladder. We then attach something called a bladder blade to the retractor, which pulls the bladder away from the uterus so we can see it. AT LAST. The uterus is in sight. All that just to SEE the damn thing.
Once you see the uterus, you immediately attack it by grabbing it with a vicious looking instrument which is a clamp with sharp teeth called a Lehey tenaculum. It is also used for thyroid surgery, so go figure. You pull the uterus up out of the pelvis with the toothy thing so you can see better. The uterus is unfortunately still attached by all its little blood vessel attachments, which is what we are about to do something about.
Let’s assume we are taking the ovaries out too. Let me tell you about how much the body loves its ovaries. It loves them so much that on one side, the artery to the ovary comes DIRECTLY OFF THE AORTA. You know, that huge single artery that carries ALL THE BLOOD to the rest of your body. On the other side, that ovarian artery comes off the renal artery, which is directly off the aorta on that side. Your body LOVES ITS FREAKIN OVARIES, PEOPLE. It does NOT want you to have them. If you mess up clamping off one of those arteries, you get a blood bath. There is also a structure running milimeters from that ovarian artery called a ureter – it carries all the urine from the kidney on that side to the bladder. You don’t want to nick that silly little thing. Unless you want to go to court. You of course can’t really SEE it because it is buried under the peritoneum in the pelvic sidewall. It does not run free at any point. There are also the really huge arteries that carry blood to the legs. If you nick one of those you are REALLY having a bad day. So you see, those ovarian arteries that you need to clamp off to separate the ovaries from their blood supply are like working IN A MINE FIELD. And trying to disarm a Claymore at the same time (I am using war metaphors here for my readers who enjoy war type things. And to show off the fact that I know what a Claymore is.) So you clamp those suckers REALLY close to the ovaries and pray that you don’t have a ureter in there. We use a nifty gadget called a Ligasure, which is another electricity using toy with a clamp and cutters. We clamp the pedicle (another word for blood vessel-bearing blood supply that is in the way of us getting the uterus out) with the nifty Ligasure toy, push the zapper button that fries all the tissue inside the clamp, and push the cutter button that cuts through what you just fried. Big fun. Do not try this at home. The Ligasure is designed to spread very little heat except within the actual clamp. That keeps thermal damage from travelling, oh, say, to the little ureter, which does not function well when fried. And which is millimeters away. Once you have clamped and cut the artery to the ovary (known actually as the infundibulopelvic ligament, which is why we shall refer to it as the artery to the ovary), then we find the same structure on the other side, clamp and cauterize it, while chanting voodoo and offering up various prayers to protect the ureter and the other delicate (and bloody) structures around it.
You are then in slightly safer waters. You clamp and cauterize on each side under the tubes, which are next to the ovaries, and which are coming out with them. There are not too many terrifying structures there, and the arteries are smaller. But they are still there. Then you reach a completely pointless structure called the round ligament, which contains a small blood vessel and seems only to exist to cause pregnant women pain. You cauterize and cut it. See a pattern here? THERE ARE TWO OF EVERYTHING. So if you don’t screw up on one side, you still have ample opportunity to screw up on the other.
By then you are getting closer to the uterine arteries, which carry the main source of blood into the uterus. DO NOT MESS UP WITH THESE. They will retract into the wall of the pelvis and the patient will bleed out while you are looking for them. Now we stop with the Ligasure and start with good old fashioned metal clamps. We start with curved ones called Heaneys. We put a clamp on each side and clamp off (hopefully) the uterine artery on either side. We hopefully avoid the ureters (remember those friendly little guys? They’re ba-ack) which are again within millimeters (and invisible) of the uterine arteries. You just. Don’t. Want. To. Clamp. Them. Then you carefully cut the artery on each side once it it in the clamp and stitch it off. With luck you haven’t clamped only half of the artery and have the other half now bleeding.
Next the bladder must be peeled off the front part of the uterus, before you can proceed any further. If there is no scar tissue, you make a cut in a tissue fold (NOT in the actual bladder, people) and once again, good old sharp and blunt dissection will get your bladder down. If you are lucky. If you are not lucky, you have a hole in the bladder and you will have to call a urologist to come in and help you. He will probably laugh at you later.
Now begins the endless portion of the procedure. The major arteries to the uterus have all been clamped off. Now there is this long turkey-neck-like structure known as the cervix. The uterus is shaped like a pear with a turkey neck coming off the skinny end of it. The turkey neck cervix frequently feels so long that it seems to go all the way down to the patient’s toes. It doesn’t. But it does go all the way down into the vagina. Now we have to use straight clamps (called Kochers – I think I spelled that right) and apply them in an alternating fashion down the sides of the cervix – on both sides because remember there are blood vessels ON BOTH SIDES of all these structures. The clamps are applied and a pedicle is cut with a long knife. DO NOT ALLOW THE KNIFE TO SLIP AND CUT A HOLE IN THE BOWEL OR BLADDER INSTEAD. Each pedicle is stitched off painstakingly with a needle attached to a suture. The needles are curved and designed for the needle to pop off when you are ready to tie the pedicle down. You have to be careful to prevent premature popoff. Otherwise your partners will make fun of you. These pedicles and this long cervix go on forevvvver. When you finally reach the base of the cervix, you are rewarded with a dilemma of how to cut the damn thing out. You can either put curved clamps around the base of the cervix, cut them off and tie them and then cut the rest of the cervix off the top of the vagina, or you can do a tricky maneuver where you cut down on top of the cervix and make it pop up through the hole you’ve cut and cut the cervix off. Either way, LET THE BLEEDING BEGIN.
All those little tiny stupid vessels that don’t even have names are now bleeding. Now you have to get popoff suture and painstakingly tie your way around the now open hole at the top of the vagina. It takes dozens of sutures to make the bleeding stop. And you are now digging down in a deep dark hole where you can barely see and having to use long and unwieldy instruments to reach where you are going. After you have stopped the bleeding (see – takes forever) it is now time to close the open top of the vagina, somewhat like closing the toe of a sock. You now use a running suture that the needle does not pop off of (without some difficulty) and close the whole thing with a running, locking suture. Locking is to cut down on more bleeding. At this point, voila, the uterus is out. But you are nowhere near done. Because you have to reclose everything you have opened, layer by layer.
First you irrigate the area of the closed vagina with clear water so you can make sure there is no active bleeding. Once you assure yourself of this (which sometimes takes a while, and some more stitches), then you can cut the sutures you have been holding to help elevate the vagina out of the pelvis, and you can pull out all eight million of those little white lap towels you used to hold the bowel back. You take out the retractor. You replace the bowel in its anatomic position. You make a big deal out of replacing the bowel in its anatomic position. It is then time to close the peritoneum.
All the bowel you have released is in your way. Your surgical assistant is only now half paying attention to you because she is doing a count. You have to count all your instruments on the way out, one count for every layer you close. The first count was done when you closed the vagina. You now need an instrument to hold back the damn bowel, because it is on the loose and wants to become part of the party. You push it back with something called a malleable (metal strip that holds the bowel back) or a fish (a plastic bathmat looking thing shaped like a fish, with a retrieval string tied to it). You then quickly close that hole in the peritoneum you made (remember “finger fractionation”) with some more running suture. Just as you reach the end of the hole, you pull out the malleable or fish (some call it a flounder – we decided in surgery today that it looks like a trichomonad – a little Gyn humor) and voila – ze bowel is gone back to where it belongs.
We then irrigate with more clear sterile water and buzz any bleeders with the magic Bovie, or failing that, stitch them off with a not-so-magic suture. Now it is time to close the fascia. Wait for it, boys and girls: the closure of the fascia is the most important layer of all the closures. That will be on the test. It is always on the test. Just remember it. Not skin. FASCIA. The fascia is the tough gristly stuff, and it is the strongest stuff that you will be stitching together. If you mess up the closure, your patient will stand up tomorrow and all her bowels will fall out. I am so not kidding.
Then you rinse everything out yet again and look for more bleeders. Time for the magic zapper thingie. Once everything is dry, it it time to close the skin. The skin closure is important because it is the only part of all this work that the patient will ever see. We usually do a subcuticular closure, which is a side by side stitching just under the skin edges. Then we put on Dermabond, which is skin glue. What it is actually is is sterile Super Glue. Then we cover up the whole thing with a dressing and voila! Instant hysterectomy. Although the damn thing actually took two hours and you are exhausted. The patient, however, is feeling great because she has been asleep the whole time.
So imagine this: your patient breezes in and she has had a couple of heavy periods, and you are trying to work out possible simple, noninvasive methods of treatments, maybe some birth control pills or some nice progesterone, and she blurts out, “I just want my hysterectomy.” She doesn’t want to try any medical therapy. She just wants her hysterectomy. Her mother had one, her sister had one, and it is her God-given right to have herself one too. You think about the two hours ahead of you, of the “just hysterectomy” and realize she has no clue what kind of brutality her body will be subjected to, or what kind of misery the doctor will be subjected to, and despite your trying to explain that having a hysterectomy is kind of a big deal, SHE JUST DOESN’T CARE. She wants her hysterectomy. You take a deep breath, and you sigh, and you say, “I’ll get the paperwork to the scheduler,” and you know you are in for yet another morning of misery and stress.