3. Patient Selection and Preparation
Selection. Since the introduction of C*I*S*H*, selection of the type of hysterectomy has been simplified. C*I*S*H* has virtually replaced total abdominal hysterectomy in our practice. Even in cases of mild to moderate uterine descensus, we prefer C*I*S*H*, as the topography after amputation of the corpus lends itself to pelvic floor suspension and repair with additional vaginal repair if needed. Cervical and endometrial pathology (i.e., cervical dysplasia or atypical endometrial hyperplasia) are contraindications. Abnormal tissue should not be morcellated; therefore vaginal hysterectomy or LAVH may be performed in these cases. Previous cervical intraepitheal neoplasia is not considered a contraindication provided cone margins have been free of disease and subsequent Papanicolaou smears are consistently normal.
Preparation.After obtaining a thorough history and undergoing physical examination, the patients are informed about the various types of hysterectomy and their indications, advantages and disadvantages, and risks/benefits. The patient is involved in the decision-making process.
Physical preparation is simple:
- Cervical cytology must be normal
- Endometrial sampling must be normal, in case of abnormal bleeding (endometrial biopsy and pelvic sonography are performed when appropriate)
- CBC, urinalysis, type and cross-match
- Chemistry profile, electrocardiography, and chest radiography as indicated
- Additional laboratory work and consultation(s) as indicated
- In the case of large leiomyomas encroaching on the pelvic brim, the patients are treated preoperatively with gonadotropin-releasing hormone (GnRH) agonists, usually leuprolide acetate (Lupron) 3.75 mg IM for three months.
The day before surgery the patient is requested to take a bottle of citrate of magnesia, and she must remain NPO after midnight. She is admitted during the morning for surgery. If bowel complications are anticipated, a bowel preparation is prescribed.
P.F. Vietz, M.D.
Westminster, MD. 21157 (USA)