Episode 9.1 Cesarean Hysterectomy
Discover how cesarean hysterectomy, once a procedure shrouded in fear, has evolved into a life-saving operation with contributions from pioneering figures like Eduardo Porro and Lawson Tate. In this episode, we are joined by gynecologic oncologist Stuart Winkler, who shares invaluable insights into both unplanned and planned cesarean hysterectomies. Explore the primary indications for these critical surgeries, from uncontrollable bleeding in unplanned emergencies to managing known conditions like placenta accreta in planned scenarios. You’ll gain a deep understanding of the strategic decision-making required, especially in resource-limited environments, to ensure the best outcomes for patients.
Navigate the complexities of performing cesarean hysterectomies under challenging circumstances, particularly when severe hemorrhage threatens patient safety. We delve into surgical tips and techniques, emphasizing the significance of early and careful bladder dissection, effective use of energy sealing devices, and confident decision-making. Our discussion highlights innovative strategies for uterine preservation in placenta accreta spectrum disorders, offering creative solutions when complete resection isn’t feasible, and exploring new protocols that balance operative blood loss and patient fertility.
Finally, take a journey through the historical evolution of cesarean hysterectomy with us, as we trace its transformation from a fearful, last-resort measure to a cornerstone of modern obstetric care. Learn about the pivotal technological advancements that have shaped current practices, such as preoperative arterial occlusion techniques, equipping today’s surgeons with a wide array of tools to tackle even the most complex cases. This episode promises a comprehensive blend of historical insights and practical advice, making it an essential listen for both seasoned professionals and those new to the field.
00:00:01 Cesarean Hysterectomy
00:09:14 Surgical Tips for Cesarean Hysterectomy
00:17:42 Advanced Techniques in C-Hysterectomy
00:23:56 Surgical Tips for Planned C-Hysterectomy
00:31:36 Surgical Techniques for Hemorrhage Control
00:41:38 Uterine Preservation in Spectrum Placenta
00:53:37 Evolution of Cesarean Hysterectomy
Links Discussed
Transverse versus vertical skin incision for planned cesarean hysterectomy: does it matter?
Uterine conservative treatment for placenta accreta : new standard?
Transcript
Announcer: 0:01
Welcome to Thinking About OBGYN. Today’s episode features Howard Herrell and Stuart Winkler discussing cesarean hysterectomy.
Stuart: 0:15
Howard Stuart. What are we thinking about on today’s episode?
Howard: 0:19
Wow, you did that well.
Stuart: 0:21
Thanks, I’ve heard it on here before. I was practicing in front of a mirror and I was getting all ready to be your co-host this week. Excellent.
Howard: 0:29
Yeah Well, today we’re going to talk mostly about cesarean hysterectomy. So welcome to this episode. Our listeners will our loyal listeners will recognize Stuart Winkler, who’s a gynecologic oncologist.
Stuart: 0:51
And we try. If we have him on here, we try to make him only talk about obstetrics. So that’s why I picked cesarean hysterectomy. Yeah Well, I like to show up after the baby’s out, ideally, but I do still take a little bit of OB call every now and then. But yeah, let’s focus on the hysterectomy part today.
Howard: 0:58
I appreciate that.
Stuart: 0:59
Thanks.
Howard: 1:00
Well, we’ll assume all the babies were delivered safely, that’s all cool, so fair enough. I think there’s really two types of cesarean hysterectomies that we should center our conversation around, and maybe the differences between them, because there’s different scenarios. So what I mean is the first type is more in my belly wick, that unplanned hysterectomy following a cesarean or even following a peripartum hysterectomy, after a vaginal delivery, and that she’s had bleeding, she’s had a complication. So in a hospital like mine, a small hospital, we don’t have gynecologic oncology, we don’t have other subspecialists maternal fetal medicine, we don’t. Maybe a hospital doesn’t have interventional radiology or other special services and we certainly don’t have a dedicated see his team or somebody to call. So there’s that type of hysterectomy. And then there is the planned cesarean hysterectomy. That’s scheduled, it’s done with intentionality and in most cases it’s done at a place that has these other services or even a dedicated team. So we have kind of two different subjects here.
Stuart: 1:59
Yeah, I think that’s a really good kind of distinction between both of those. And you’re right, you’re probably better suited to talk about the unplanned ones. Usually, when I get involved, it’s either late in the game on an unplanned one, unfortunately, and those can be really tough situations or it’s with ones where we have a plan going into the case for a cesarean hysterectomy and we have some time to deal with all that.
Howard: 2:22
Yeah, a lot of potential preparations that we’ll talk about for those cases where we have foresight, I guess, so we can talk about the unplanned one first then.
Stuart: 2:31
Sure, yeah, that sounds good.
Howard: 2:33
All right, well, and then we can see where a little bit of planning might be beneficial in some cases.
Howard: 2:38
So, and we certainly don’t mean to go in to do any cesarean hysterectomy without forethought and many of the indications these days are hopefully discovered or at least you have a heads up or some idea before you get to the time of delivery. But I’m talking about that 2 am cesarean with, say, an undiscovered invasive placenta or just uncontrollable bleeding. That’s failed conservative treatments, uterotonic surgical correction, whatever. I also think in this episode we can develop maybe four tips, for I’ll do four tips for these unplanned ones, these middle of the night ones, and I have some ideas there, and then maybe you can give us four tips for the planned ones, and if they overlap that’s okay.
Stuart: 3:16
It’s a really important tip then Two for the price of one they’re getting. The listeners are double their money’s worth on this episode.
Stuart: 3:21
So that’s good. Yeah, I think that sounds great. So let’s start just for a second though, before we get into the planned versus unplanned, let’s just talk about an overview about indications for cesarean hysterectomy and then, after we do that, I’ll give you a little vignette for an unplanned hysterectomy and you can walk us through how you’d manage that. So really, in the unplanned setting, the first, second and third most common indications for a cesarean hysterectomy are going to be bleeding, bleeding and bleeding. The underlying etiologies are those that are familiar to us as causes for postpartum hemorrhages for all obstetricians. So we’re talking about things like uterine atony, fibroids, or maybe some sort of anatomic distortion of the uterus, some coagulation disorders, obstetric emergencies such as uterine rupture and the distortions that can come from that, maybe even surgical bleeding from extensions that otherwise can’t be controlled, or unsuspected placenta accreta spectrum. So things like that.
Stuart: 4:17
In the planned C-Hyst setting, the most common indication is placenta accreta spectrum. By far and away Much less commonly, we can see we can plan a C-Hyst for things like gynecologic cancer, so cervical cancer classically, is what we would talk about there as doing a cesarean radical. Also, occasionally the uterus again could be massively distorted by fibroids and maybe you would go into the case planning a hysterectomy, although that’s pretty rare. In general, a C-Hyst should not be done for things like to satisfy parity or any sort of family planning reason, or to treat menstrual disorders. There’s just other, more opportune times to do those sort of procedures. But actually at least one retrospective review that we looked at cited these sort of less common reasons as reasons that some people do see HIST. So that’s interesting.
Howard: 5:05
Yeah, I read something that said the appetite for that sort of just purely elective varies by country. But yeah, if a woman just has hey, I have abnormal uterine bleeding before I was pregnant why don’t you just take it all out? That’s probably not the best thing to do.
Stuart: 5:19
Yeah, we can do our counseling there and hopefully guide the patient towards a good decision there. All right, so let’s talk a little bit about your vignette, and this is going to sound a little bit like a board exam question, and they always tell you that you don’t have a consultant or your resources aren’t available. But in your case, Howard, I think this is actually the fact, the case at your hospital, and I think that’s true for most obstetricians, honestly. Okay, so you’re doing a repeat C-section at 2 am on a patient with no prenatal care who came in. She came in labor and wanted a repeat C-section. She’d only had one early ultrasound at an emergency department. Maybe she had a couple of other ER visits, but really she’s not had a good ultrasound.
Stuart: 5:57
You do put the ultrasound on and you see that there’s a low anterior placenta but she’s contracting like every two to three minutes and she’s already three centimeters and you determine that really a VBAC is not a good option for this patient and you take her to the OR and when you get there you look at her lower uterine segment and you notice some dehiscence of the previous cesarean scar at the base, and the base of the placenta is visible through a translucent layer of serosa. There’s some hypervascularity as well in the loader uterine segment. Remember, there’s no maternal fetal medicine specialist, no oncologist available in the hospital. You’re really on your own. So what do you do? All right, Well perfect.
Howard: 6:36
So and I’ll say a couple of things. One is that it is most people do practice in the United States in a setting without all of these services. I think residents get a distorted view of learning in a tertiary or quaternary center and then many of them the majority of them go to a practice setting where all those resources are not immediately available. There’s not going to be a cesarean hysterectomy team available that you can call and manage this patient, and many of them are not going to be stable for transport. I remember reading one of those throwaway journal summaries of legal cases that they put in there, and it was a story about a lawsuit over a scenario like this where the patient needed a hysterectomy but for bleeding, I think and the doctor didn’t feel comfortable after. I think it was a cesarean, and so he just packed the abdomen and put her on a helicopter to fly her to the tertiary center. That said send us your hysterectomies, we have a hysterectomy team, and she died on the helicopter.
Stuart: 7:28
That’s awful. I love and hate reading those legal reviews in those journals. It gives you pause sometimes. But, yeah, maternal levels of care and specialized teams are really great and I think they really are important for planned surgeries and I’ll talk about that in a few minutes. But these emergent cases are different and you really do have to be prepared with what you have given your resources at your hospital and really you’re the one who knows that best.
Howard: 7:52
Yeah, and you’ve made this into a placenta accreta spectrum case. But it could have been a lot of different things. This could have been a primary C-section, or it’s uncontrolled bleeding, or surgical bleeding that you’ve not been able to repair, or something like that. Just a badly damaged uterus, maybe during a VBAC, and she had a uterine rupture or something. And the scenario you’ve mentioned give or take a few details has happened to me several times. It’s not weird or bizarre, and there have been a few times in my career where I’ve diagnosed a placenta accretive spectrum disorder on ultrasound right before I had to take somebody to the OR.
Stuart: 8:23
Yeah, and ultrasound is far from perfect, but we know that many of these cases aren’t diagnosed until the time of delivery. But sometimes that’s all you have before you go back.
Howard: 8:33
All right, so yeah. So let’s get into the vignette and from that I’ll develop my four tips.
Howard: 8:38
Okay, All right, let’s hear it and I’ve in in just I don’t know how many. We don’t have to shop talk, but I’ve done about 30 cesarean hysterectomies and probably half of them were not planned. They were in this situation you’re discussing and in the other half we knew going in that there was invasive placenta. Most of those maybe all of the planned ones, I think were for placenta spectrum disorders and I’ll say before we get going that I think these cases are actually easy and fun.
Stuart: 9:05
All right, all right, I heard you guys getting hate mail and it’s probably comments like this that they get that comment. So I don’t think I’m allowed to agree with you that they’re fun. But I will say that it’s not necessarily the surgery that’s the hardest part. I think we all are surgeons, whether or not we admit it. We really are the experts in bleeding in most hospitals, even as journalists, obgyns. But maybe it’s not the surgery so much, but where the problem is that mistakes tend to compound and really, if you make little mistakes and this is a preview of one of my four tips but if the surgery is difficult for you, then maybe you need to practice more or have some mentorship or things to be more confident in it and just learn how to do it, because really no surgery is difficult once you know how to do it.
Howard: 9:52
Yeah, yeah, okay. Well, you’ll get more hate mail than me, but yeah, it’s the circumstances of why you had to do the C-HIS that made all of this difficult. Even most of the extraordinary blood loss that you sometimes see reported with these cases occurs leading up to the decision to do the surgery the hemorrhage that was occurring and all that. And too many times we start to do these cases after the patient is really already an extremist, and now you’re starting to do this surgery.
Stuart: 10:19
Yeah, yeah, I think they could already be working on DIC or something like that. I can’t remember the exact quote from the Art of War, but there’s a great quote in there about like death is in the delay, and I think that’s really true here. A lot of times I think when we delay we can get ourselves behind the eight ball and then it becomes that much harder to dig ourselves out. But you’re right, a lot of that blood loss is before we even get to the OR Exactly.
Howard: 10:43
So actually my first tip then, is to be definitive and make the decision to proceed early is reasonable. Part of what empowers you to make a definitive decision early is feeling comfortable doing the surgery, not having a lot of anxiety about getting into this situation, not being scared of what you’re going to have to do. But the goal is not to make the decision after 30 or 60 minutes or whatever, of him pawing back and forth and doing over analysis about whether you should do the cesarean hysterectomy. The patients who get in trouble are often not the ones who get C-Hyst. They’re the ones who didn’t have a decision made soon enough and they’re already in deep trouble. And, like you said, when you get called into a case already proceeding, that’s probably never a good situation.
Stuart: 11:26
Yeah, yeah, you’re right, you’re right, yeah, I couldn’t agree with you more here. And I would add too even if you’re alone, sometimes you have somebody you can call, and we all, particularly in a younger patient maybe, who has desired fertility. It’s a big deal to make that decision to remove the uterus. Sometimes just a phone call to a partner and be like hey, here’s what I’m dealing with, let me talk you through this with a couple minutes and maybe that can help you make that decision if you don’t have the confidence to do it. But OK, so in this case you’re already back in the OR, you see this placenta staring at you and you make the decision immediately and I would say rightly so to deliver the baby and then deliver the uterus. Yeah.
Howard: 12:06
So if I haven’t already, of course I’m going to get her type and cross her blood. I may not have any idea until I open her abdomen what’s going on, but get her type and cross her blood and even though I may not have a subspecialist available, as you said, I could call a partner in even just a general surgeon or vascular surgeon, like just somebody. Another pair of hands, somebody who’s not emotionally in the situation is helpful too, and so just anybody may be helpful. Surgery is surgery, ultimately. And obviously, letting the team know that we’re potentially going to deal with a large amount of blood loss and to bring in whatever equipment we might need, including a hysterectomy tray, an energy sealing device like the Ligature Impact, for example, any extra stuff from the operating room that’s available is helpful in this situation too.
Howard: 12:50
And then realizing that since I’m going to do a cesarean hysterectomy, I’m going to do a couple of things right before I do the delivery itself. So first I’m going to go ahead and make a very generous bladder flap or bladder dissection, and I don’t normally make bladder flaps at the time of cesarean, but taking a couple of minutes to push the bladder down just makes a huge difference later on. We’re not bloody right now and, as I said, I don’t normally do it If I have, if I’m doing a case and I have any suspicion at all when I’m starting a C-section that this might end up in a hysterectomy, well, I go ahead and make one and do a nice dissection, and this should mostly be done using sharp dissection, just like you would do in an abdominal hysterectomy. Use your medicine bomb scissors, take down the peritoneum carefully, use sharp and what dissection is needed to push the bladder down. But these tissues are so edematous and friable that you can make a bladder injury pretty easily just using digital dissection here.
Stuart: 13:46
Yeah, yeah, that’s for sure. And of course the bladder can be hard to dissect down. Sometimes there’s abnormal adherence and then depending on the depth of invasion of the placenta and that sort of thing. But you’re right that making this dissection early on overall is going to decrease your risk of bladder injury and make the rest of the case easier. And right now is really the time you can see the best. Once the bleeding starts, once you get on the proverbial clock, if you will, you have to work a lot more quickly and you may not be able to take the time to get the bladder down as you would in this case.
Howard: 14:17
Yeah, and you might learn. You might, in that dissection, see that the placenta is growing into the bladder, but that’s information that I’m going to learn eventually, so we’ll figure that out, and maybe I have to resect part of this bladder as part of the surgery. So it’s something I’m going to learn and know, Okay.
Howard: 14:31
The second thing I want to do is make the incision to deliver the fetus up higher on the uterus, well away from the placenta, not cutting through the placenta, not going in the normal area. So I’ll make a vertical uterine incision near the fundus, even in the fundus, if that’s what I need to do, and deliver the fetus. Now the next step is key Don’t deliver the placenta. Leave the placenta attached, for in this case we’re talking, of course, about an invasive placenta. It’s going to greatly decrease the amount of blood loss that you experience. Now, in most cases, I don’t even close the incision here. I just take a couple of towel clips and approximate the edges, and I’ll also maybe take a couple of towel clips on either side of the fundus and to have something to hold the uterus with and pull it up, and that’s a good job for my assistant.
Stuart: 15:18
Yeah, I think the towel clip trick is a good one, especially if you’re going to work quickly from that point on, and I think it’s fine to not close the uterus again as long as you were working quickly. Obviously, if it’s bleeding you have to address it, and actually I’ve found the energy device can be helpful here as well. I’ve even made the hysterotomy with the ligature before, and it can be tough if the uterus is really thick, but sometimes you can take it down in layers and sometimes that can be helpful. You don’t want to do anything that takes too long, but sometimes a little extra time to save some bleeding can be helpful. One other thing, too, that can be helpful is the use of interoperative ultrasound to map the placenta, and this is particularly important with an anterior placenta, where you really want to avoid making your incision right over where the placenta is, and sometimes just using an ultrasound with a sterile probe can help you identify that.
Howard: 16:08
Yeah, if you use the ligature for the hysterotomy, do you just make a small incision and then put the device in?
Stuart: 16:14
Yeah, I usually make a small incision, kind of all the way through to where hopefully not get into the amniotic sac and then I’ll close the ligature down. Sometimes you won’t get a complete seal that way, but it and then I’ll close the ligature down. Sometimes you won’t get a complete seal that way, but it’s still. I found a little bit as better than nothing at all.
Howard: 16:28
Well, in the intraoperative ultrasound is a great idea, but again in my 2AM scenario I may not have that.
Stuart: 16:33
Right.
Howard: 16:33
But that’s why I make the incision at the fundus and work your way down.
Stuart: 16:36
That’s true, you can figure that out and you’ve obviously looked at the pre-op imaging as it’s ultrasound.
Howard: 16:41
Yeah, exactly so. Okay, so now we deliver the uterus and this isn’t going to take long. This isn’t going to take long because my second tip you’ve already gotten to this a little bit is to use an energy sealing device. Now about I think half the C-HIS I’ve done in my career were without an energy sealing device. Say, the first half roughly and the second half roughly were done with one, and I can tell you it makes a world of difference. So there is a retrospective study we’ll put a link to that found that using the ligature impact or I think that’s what they use, but there’s obviously two or three products like this that it cut the need for transfusion in these patients from 90 to 53% and decreased the operating time total from 140 minutes to 86 minutes and also cut the total length of stay for the patient nearly in half because there’s less blood transfusions, there’s less ICU time, those sorts of things. So it’s just a tremendous advantage and it fundamentally changes the way you do the whole surgery.
Stuart: 17:36
Yeah, I’m a little younger than you so I’ve done about 90% of mine with energy, but you did kind of start off in the dark ages. I think you even told me once that you did one without a hysterectomy tray. Is that right yeah?
Howard: 17:48
A percreta, a percreta as we called them back then yeah.
Howard: 17:51
Back when the dinosaurs roamed the world. But we didn’t have. It was the middle of the night. It was in a dedicated C-section suite. The OR main OR staff people weren’t there. No one knew how to find a hysterectomy tray. It was unanticipated and we used hemostats as clamps and Kellys and whatever as hysterectomy clamps and whatever was on the tray. But yeah, and you grow up fast back in those ages. But now, as you said, we live in the modern age and so you should have an energy selling device pretty much in any OR you’re going to be in nowadays, and so with the ligature or something like that, you can very quickly race down either side of the uterus. You can take all those pedicles in mass without any deliberate opening of the broad ligament and, frankly, you can have the broad ligament down on either side and have it dissected and coagulated and separated down to the level of the uterine artery or cervix, really in just a couple of minutes on both sides.
Stuart: 18:45
Yeah, definitely, and I’ll add here whether you’re using traditional clamps or a ligature or some other energy sealing device, your approach is a little different than what it might be for, say, an abdominal hysterectomy for fibroids or something, and what I mean by that is you don’t want to bounce them off of the uterus like you might with a clamp for a traditional hysterectomy. Your back bleeding is going to be significantly more with a C-Hyst, and also the tissues are a little more edematous, and so what I found is helpful is sometimes you can even pinch the vessels off of the uterus and seal them that way, rather than digging your tips into the uterus. Once you get into bleeding in these cases you really get on the clock, and so everything you can do to try to keep that unintentional bleeding down can really help.
Howard: 19:35
Yeah Well, I’m sorry if I stole one of your tips with the energy sealing device, but remember you got to come up with four. So keep thinking here.
Howard: 19:43
But yeah, absolutely, this is just game changing, I think, for people and it takes away. These devices give people so much security and confidence, I think anyway, and I think that’s true in benign hysterectomy as well, but it’s definitely true here. I think it’s way more important here than it is even in benign hysterectomy. Now, hopefully, I already have a decent bladder flap created. But if I don’t maybe I didn’t know I was going to do one then I’ll usually sail down and get those upper pedicles as fast as possible and then take the time here to finish making a good bladder flap. And if that sometimes involves an incidental cystotomy, then that’s what we’re going to do. If the placenta is invaded into there or that happens, then that’s what we’re going to do. If the placenta is invaded into there or that happens, then that happens and that’s okay, but most of the time it does not.
Howard: 20:30
And now you’re going to have your assistant just really pull the uterus up out of the pelvis at this point and go ahead and put some packing sponge in there to protect the bowel, whatever you want to do, and maybe use a self-retaining retractor, if you have one, and then get the uterines and the cervix elevated.
Howard: 20:47
Your broad ligament dissection should end just near the level of the uterosacral ligaments and then you can take the uterine arteries. Just like with a lot of endoscopic hysterectomy techniques that use energy sealing devices, you can take a couple of parallel bites or, as you said, that idea of just isolating the vessels with your fingers and pulling them away to really get them in the full jaw of the pedicle is a great idea to activate the sealer without cutting it. Make a couple of parallel bites and come back in the middle and take one and cut, but by then the worst part’s over. If you’ve gotten the upper pedicles and you’ve gotten down to the uterine vessels, you hopefully have hemostasis or a decent hemostasis, and you can do that with an energy sealing device within five or six minutes. In other words, get the four major arteries pretty quickly.
Stuart: 21:32
Yeah, absolutely. You can see why the energy sealing device is associated with so much less blood loss, because it replaces all the double clamping and cutting and all that stuff. That just takes a lot of time, and really in these surgeries time is blood.
Howard: 21:49
Oh, I like that. I think that’s our first t-shirt idea. Time is blood, but yeah, and that’s what’s reflected in the data I said earlier. It’s just no reason to spend a lot of time getting those vessels. Now identify the cervix, and I’ll do this with my third tip, which is to pull the uterus down caudad so that you expose the posterior wall of the uterus, down caudad, so that you expose the posterior wall of the uterus, and then just take the bovie, make a vertical incision a little higher in the middle of the torus where the uterus sacral ligaments intersect into the back there, and start a bit higher and then work your way down until you’ve made a hole that exposes the cervix and the vagina and you know exactly the level you should be at with your clamps.
Howard: 22:31
You can usually feel this like in a regular hy at with your clamps. You can usually feel this Like in a regular hysterectomy. You can feel where to put your clamps across. So I don’t always do this, but imagine that you’ve had a patient who’s been laboring and she was maybe even pushing. The cervix has been completely dilated and the cervix is very soft. You’re going to often have a hard time, without doing this, identifying where the level of the cervix should be and where you should put your clamps across.
Stuart: 22:55
So do you always take the cervix when you do these cases?
Howard: 22:59
Yeah, I think I have every time I’ve done one.
Stuart: 23:01
Okay, well, I’ll throw in here that obviously, if you’re really struggling, it is okay to leave the cervix, but most of the time, like you said, you should be able to get it, especially for acne. But most of the time, like you said, you should be able to get it, especially for acne With a previa and with these morbidly adherent placentas, you probably do have to take the cervix to get the bleeding to stop. But for acne, potentially you could leave it if you needed to.
Howard: 23:24
Yeah, there may be circumstances where you should leave it, but I do think the mindset should be to take it. I think sometimes that is not the mindset Like, oh, let’s just get out of here and leave it, and it’s not that difficult to take it in almost every circumstance, so okay, and then I just use regular hysterectomy clamps and cross, clamp across and amputate the specimen out and then, like with traditional abdominal hysterectomy, secure the angles of the vaginal incision so the vagina closed, just what you would do at a regular hysterectomy nothing very fancy here.
Stuart: 23:56
Yeah, I’ll interject one thing here. I’ve actually been in a situation not too long ago where I couldn’t get large, doubly curved clamps quickly, and it was just a situation where straight clamps weren’t going to be a good way to come across the cervix. In this case, another thing you can do is just use the ligature to make your colpotomy cervix. In this case, another thing you can do is just use the ligature to make your colpotomy, so you can either get in posterior, like you were talking about, or a lot of times I’ll put either my fingers or a sponge stick in and sort of feel vaginally while I make a colpotomy and then use the ligature to make a circumferential bite there. So there’s a lot of different ways to do things. That’s one additional option, if you want. I know we worry about that as potentially devascularizing the cuff in some cases, but you know, as we all know, in these cases there’s plenty of blood flow to the cuff.
Howard: 24:40
Yeah, and just take bigger bites. If you’re worried about dehiscence of the cuff, take larger bites, and if you’ve done that, then it’s less of a concern. So definitely an option. And then irrigate, check for bleeding, convince yourself the bladder is okay, whatever that entails. Maybe you black fill the bladder, or maybe you do a cysto if you’re worried, whatever, whatever makes you satisfied and then close her up.
Stuart: 25:02
Okay, all right. So let’s do a little tip review. I think your first one was to be definitive about deciding to do the surgery and decide early. Tip number two was to use an energy-sealing device. Tip number three was the trick with opening the back wall of the cervix and the upper portion of the vagina to identify the lower level of the cervix. What is your tip number four?
Howard: 25:24
Well, my tip number four might be out of order, but I think my tip number four and this is a segue to you really is to make a horizontal skin incision. So I know I should have tip number four and this is a segue to you really is to make a horizontal skin incision. So I know I should have started with that. But of course mine was a surprise case and I was doing a horizontal incision anyway, as a normal cesarean might be. But you can put your two cents in about this, and more and more these days what I see happening is that folks are routinely, if they’re planning on doing a cesarean hysterectomy or have suspicion to do one, they’re routinely making vertical skin incisions and with the intent of then doing a cesarean hysterectomy. And I guess I have to blame gynecologic oncologists for that. But it really just doesn’t add anything to the case.
Howard: 26:04
It certainly the one I just did and I don’t think I’ve ever made a vertical incision in these circumstances. But certainly most of us who are out in the 3 am world are going to have made a Joel Cohen or a Fannin still or something to begin with and had no intention of doing that. But it doesn’t for these benign cases. Now you could add in radical cesarean hysterectomies and things like that, but for these benign cases I just don’t think it adds anything to it. So I made my normal skin incision in this case and I’ve just never found that to be problematic or wished I had had a vertical skin incision, and I’ll put a link to a couple of studies that have retrospectively reviewed this and found no difference in outcomes with a transverse versus a vertical skin incision.
Stuart: 26:48
Yeah, yeah, that’s interesting. I think in oncology we’re in general more comfortable working through vertical incisions. We do a lot of our open cases through vertical incisions. But I would agree with you here. I think that, thinking back on it, although a lot of the cases I’ve been involved with we do use a vertical incision, I might have to think about that a little harder, and I think you’re probably right Most C-his could be accomplished through a transverse skin incision.
Howard: 27:12
I think if you’re doing a radical cesarean hysterectomy or something like that or you’re a few who knows, they’re going to have to re-implant a ureter. But if you knew you were going to have to re-implant a ureter, I think that’s the concern. But folks can check out the couple of studies that have looked at this and and think about that. Okay, well, now we turn the tables on to you, so you have the benefit. Well, not always you get the call in the middle of the night too, but hopefully in your scenario you’re going to have the benefit of prospection and a planned approach to a complicated hysterectomy. Maybe in your case you’re doing this for a cancer diagnosis or, more likely, as you said, you’re doing it for a placenta accreta spectrum disorder. So we need your four tips and I think I’m going to center you a bit with some questions that you can give us your opinions on.
Stuart: 27:59
Okay, yeah, that sounds great. I will answer your questions and let my four tips emerge. I will say, though, that my first tip, going into these planned CCHIS, is that there really needs to be one person in charge. This is a procedure that absolutely needs a captain of the team or I’m in the Air Force, so I should probably say pilot and if you can imagine both a pilot and a co-pilot simultaneously trying to land a plane, that is sort of the situation you can be in if you’re operating with a co-equal surgeon. I’m not saying there may not be some difference in skill, but there absolutely needs to be somebody in charge of these.
Stuart: 28:40
In your vignette, obviously, you’re the leader of the team at 2 am because you’re the only one there, but in these multidisciplinary teams, you have a lot of people with a lot of opinions. In the surgery, there are a lot of people with a lot of opinions. In the surgery, there are a lot of people with a lot of opinions, and you really do need a clear coordinator who understands the thing from soup to nut, so to speak, and I think that usually makes the most sense to either be the OBGYN who’s a part of the planning or, in my case, a lot of times the GYN oncologist. So that’s my tip number one. So just lead the team. All right, let’s hear some questions.
Howard: 29:19
Okay. So I’ve got a few keyed up for you here. So in planned cases, my first question is do patients benefit from preoperative placement of ureteral stents?
Stuart: 29:29
So in general I would say no, I don’t really think they provide a lot of benefit. There was actually a recent systematic review and medical analysis that looked at this. The authors looked at about a thousand cases of patients who had a planned C-Hyst for morbidly adherent placenta or placenta accreta spectrum disorder. When comparing those who had preoperative stents versus those who didn’t, the rates of genitourinary injury were really not different. It was about 25% in each group. In my personal experience, if I have a case where I’m really concerned about bladder invasion, I do tend to have urology there as part of the team and if they prefer to put stents in preoperatively I don’t argue with them. But no, for these cases I don’t routinely replace them.
Howard: 30:15
Yeah, I will say too, if you injure the bladder, usually the area where the bladder gets injured here is going to be very near the ureteral orifices, and so if it’s already open you can go ahead and put stents in there and help guide your repair and make sure the ureter orifices are not involved in the repair. But yes, I have done it both ways in the past and for a long time I’ve had privileges to displace my own stents and so I had done that. But the literature, as you said, I think it says only if you have some special urgency for them. Okay, so we talked about this incision thing and obviously that is a cultural difference, I think, between generalists and gyn-oncologists, for example. But certainly some patients need them extend to the broad ligament.
Stuart: 30:59
They may benefit from a vertical midline just to give better access to the posterior pelvis, maybe a uterus that isn’t going to elevate as much. You mentioned how important it is to be able to pull the uterus up and out and sometimes you lose your ability to the posterior pelvis. So there could be a benefit there of a vertical midline. Maybe a percreta that’s growing into the broad ligament as well. I will say, sometimes patients with a lot of central obesity can present a challenge. Now we know that wound healing is going to be worse for a vertical midline.
Stuart: 31:43
In those cases I’ve actually found that a vertical midline can be helpful. Of course the issues with wound healing afterwards, but I wouldn’t say that would be a hard and fast rule. And then other ones patients with maybe a complex surgical history. I did one recently, without giving too many details, a patient who’d had a prior bowel resection, an infection and such, and so in that case I did a vertical midline because I thought I was going to get into a lot of adhesions, and I was right. And so being able to do that, being able to really have more control of the bowel, I think was helpful. But you know, I think those cases are the exception, not the rule.
Howard: 32:19
Yeah, and I guess there could be a situation too where you already have a good suspicion that it’s growing into a ureter or something like that. You need those things. So I will say though, remember for my generalist colleagues who are probably starting out with their version of a low transverse incision of Pfannenstiel, Joel Cohen, you can always can expand that to a Maillard or a Churney type incision and get more space. The gene oncology world used to use those sorts of incisions and do all kinds of things, and so this is why we learn those other incisions too is because you might need that at 3 am. Okay. Well, one think one of the more difficult or I don’t know, controversial things is about preoperative arterial occlusion. So what’s the role of preoperative internal iliac artery balloons? How about the infernal aortic artery balloon occlusions or even just uterine artery embolization after the fetus is delivered?
Stuart: 33:08
Yeah. So these are really great questions. I have experience with all of these approaches, and some of that’s from fellowship where I worked with a lot of different attendings, but I’ve also done a few different approaches in my own practice. I don’t really think there’s a right answer. If you have an approach that you do like, you can probably find literature to support it and that’s not really the way we should do things, but it’s the way it’s done. Sometimes we will link to a nice Gray Journal expert review by John Kingdom and colleagues and this reviews some of the literature on these approaches.
Stuart: 33:37
Now, none of these balloons or occlusion devices are without risk and they definitely can have their downsides In most cases I think it’s really unclear if they’re really true upsides. We’ll talk about that a little bit more here in a minute. Internal iliac balloons are focused but they don’t address the collaterals and I think that’s a downside to those. And those are balloons that are actually fed endoscopically into the internal iliac right. So they go typically up the external iliac artery and then to the common and then are floated down into the internal iliac and then inflated there.
Howard: 34:13
Inflated right after you deliver the baby.
Stuart: 34:15
Right, exactly, yeah, yeah, not before you might run into some issues. Yeah, right, after you deliver the baby. I think those can limit you depending on how far those balloons go down, and it can just depend on the IR dock placing those. It can limit your ability to tie off the root of the anterior branch of the internal iliac. So there could be a potential downside there if you needed a little bit more permanent control. But you can find retrospective data to support their use. But the prospective trials, at least the ones that I’ve looked at, really don’t show a difference in overall blood loss. So that kind of begs the question what if you go higher and temporarily occlude the aorta? We talked about the collateral. So what if you could get around that by doing an actual aortic balloon? And so actually at my institution, which actually happens to be a level one military trauma center, we have a lot of experience with using these things called ROBOA catheters and they were actually developed by military surgeons and they were initially for battlefield applications. But our trauma surgeons are very experienced with these and they can be used to temporarily occlude the aorta to help control massive hemorrhage. They prevent more blood flow than the internal iliac balloons and some data suggests that they may result in less hemorrhage, especially when the collaterals are complex. So percreta cases. But these comparisons are really hard to do. The major head-to-head comparisons have a lot of confounding when it comes to these PAS cases Also, they go through a seven French catheter which puts a pretty good-sized hole in the femoral artery and it can require some skill to place these.
Stuart: 35:50
And, like I said, at my institution fortunately I have trauma surgeons who can, but not everywhere does, but I would say probably few places do. Now, one option that you can do this is actually supported by the literature and this is what we do at our institution we place a five French femoral sheath which is quite a bit smaller than the seventh French, and then, if we run into severe hemorrhage, this can be quickly upsized to actually place a ROBOA if you need to. And then, once in place, we would usually inflate it in what we call zone three, which is the infrarenal aorta. There are some trials that look at inflating it even higher, but you can occlude your zone 3 for up to 60 minutes, which should give you time to control hemorrhage. So we do have these available for our suspected increta or percreta cases.
Stuart: 36:39
We don’t do it for all PAS cases and honestly, we really rarely inflate these balloons. I think the last three I’ve done. I haven’t even needed to place the ROBOA, so we’ve just had the femoral catheter only. But there’s other ways. You don’t need a fancy device necessarily to occlude your aorta. There’s other, more rudimentary ways to do that.
Howard: 37:00
Yeah, the abdomen is open, even if it’s not my 3 am solution for aortic occlusion is the fist maneuver. It’s not very high tech. You have your assistant place their fist against the symphysis pubis at the level of the bifurcation, and you can periodically release the pressure to see what’s bleeding and put it back on and let you know where you need to focus. And again, this is, I think, equivalent to being. It would be inferrenal and works very well.
Howard: 37:25
You can do it through the abdomen in postpartum hemorrhage and you can do it much more precisely in a case like this where you have you can put a hand in the abdomen and do it and this was actually studied too, and they found in a, in a sort of retrospective comparison, that the patients who routinely utilize the fist maneuver had about a liter less blood loss than people who they didn’t use it on.
Stuart: 37:44
Yeah, that’s great. Yeah, you can always put pressure. That’s we’re surgeons, that’s our first approach. Right, put pressure, and definitely pressure on the aorta helps. I do think it’s an interesting question whether it would work. I mean, there’s not going to be a head-to-head, I feel like between that and ROBOA but I do think it’s a really good option. I don’t think there’ll ever be a trial necessarily comparing them. One other thing you can do as well I should have mentioned this with the internal iliac balloons, but I tend to have bulldog clamps available and those can be super helpful as well. You can tie off the uterines or the internal iliac. Obviously, you don’t want to tie off the posterior division if you can help it or they’ll get some claudication. But you can definitely tie off the anterior division. But that does take some skill to do and sometimes you can just place a bulldog clamp right on it and then take that off after you’ve have bleeding under control. So that’s another option as well.
Howard: 38:36
Yeah, and I think for most generalist OBGYNs you’ve gotten probably beyond their skillset with that, so but certainly for our oncology colleagues or anybody with that experience. But that’s also. We’re having a vascular surgeon or a general surgeon in your hospital in my scenario. Hey, come in, can you maybe help me with these celiacs for a second? That’s why somebody with that experience could be available, even in a small hospital.
Stuart: 38:59
Yeah, and inexperience there can get you in trouble, particularly if you get into a vessel that you don’t mean to.
Stuart: 39:05
So you’re right, yeah, okay, you didn’t mention uterine artery embolization, yeah, Well, you asked me a very complex question so I had to take it in chunks. So this is a great question. Though, about the uterine artery embolization, I don’t routinely do it, although I did work with attendings and fellowship who did it routinely after every C-Hyst, and they had really good outcomes. But if I’m worried, like I said, I personally do like to do surgical ligation of the internal iliacs, but I do have IR in my back pocket if I need them for these. But ideally, I think if you have the bleeding controlled surgically and we generally know that at the end of the case, I just don’t see a ton of benefit to doing the uterine artery embolization.
Howard: 39:52
Yeah, walk me through the internal iliac ligation.
Stuart: 39:55
Oh, yeah, yeah, I can do that. So the way I like to do that is I’ll open up my peritoneum, lateral to my IP. I’ll identify my ureter. Obviously that’s where it’s going to be crossing over the bifurcation of the common iliacs there. Once you get past that bifurcation of the common, if you go down about two centimeters anteriorly, you’re going to get past the posterior division. You can maybe take it even a little bit further, but if you take it two to three centimeters you’ll get past that posterior division of the internal iliac and you won’t worry about those vessels that go to the glutes.
Stuart: 40:31
So what I do there is I’ll take a right angle typically and I work from lateral to medial to get under the artery and at that point you can take a 2-0 silk and pass it to yourself and just tie it down. Obviously you’re not cutting any vessels, you just tie the silk down over and it just decreases the pulse pressure. Now, when you’re going with that right angle, ideally you don’t want to go from medial to lateral or you can hit the external vane if you’re not careful and that can be a real bugger to try to get to stop bleeding. We’re trying to prevent bleeding here, not cause it, but that’s my approach to actually likening the vessels.
Howard: 41:11
I was in a I can’t remember what it was, but I was in a talk or a meeting with about 20 OBs sometime in the last year and the speaker asked the question basically of how many and these were generalists how many people had done this or felt like they knew how, and one person raised their hand yeah, it might have been me, but it was. Again, this is just something that most journalists are going to need help with.
Stuart: 41:35
Yeah.
Howard: 41:36
Okay, Well, another interesting question. I think about this most of these hysterectomies are for spectrum placenta-increased spectrum disorders, but do they all require hysterectomy? It seems like a while ago that was a dogma, as you do hysterectomy on all these patients, but I’ve done a couple of uterine preserving surgeries where the invasion was limited and I resected it and repaired the uterus and they had future fertility.
Stuart: 42:00
Yeah, I think this is an option, particularly for those focal accretas, and these are a lot of times patients who had prior myomectomies. Maybe it’s like a small little kind of sticky focus of morbidly adherent placenta. The rest of the uterus detaches, but you do have this small area, this kind of small sticky area of invasion. You can resect it, as you said, and of course, if you suspect a credo, you wouldn’t have delivered the placenta in the first place. But sometimes these are usually surprises, right, and I think you just have to be creative here. My residents probably get tired of me saying this, but I tell them a lot of what I teach them in residency is like a classical musician trying to learn to play the notes on the page. But once you get to be a chief and once you get out on your own, you’ve got to take those principles and kind of learn to play jazz, and I think this is a jazz situation.
Howard: 42:50
Yeah, and maybe with MRI and things like that, you’ll have a sense that this is a small one that’s eligible for conservative management. We’ll put some links to some studies about conservative management too. But, as you said a lot of times, it’s unanticipated, you didn’t. It was so small that nobody realized that you try to deliver the placenta and you’re like, oh no, and but it’s a relatively small area, and so then you could consider preservation there. Well, is there a place for leaving placental tissue? I’m not thinking about in the uterus, but I’m thinking about a percreta or something. It’s, I don’t know, my nightmare. It’s invaded the ureter or the big vessel or iliac or something like that, and resecting it doesn’t seem appropriate. So is there a place for leaving it? Or also, what about delayed hysterectomy in the cases of these percretas?
Stuart: 43:36
Yeah, so for those two separate questions. So if you’re asking if it’s okay to remove the uterus and portion of the placenta that you can and sort of leave whatever bit is there, I think you can do that. I’ve done this before and used like an argon beam ablator to help with sort of desiccating that remaining tissue there. You can find some people who will give methotrexate afterwards if there’s retained placenta, particularly retained placenta that has blood flow. But in general that’s a pretty rare situation to be in. One situation that is actually pretty interesting, and one I’ve had more experience with recently, is for these really advanced percreta’s where there’s invasion of the bladder or sometimes deep into the broad ligament, or maybe even I haven’t seen it, but I’ve read of invasion into the bowel.
Stuart: 44:30
In these cases there is growing evidence for a delayed hysterectomy. That may actually be an option. As an answer to your first question too, about if you were needing to cut through the placenta, these delayed hysterectomies are pretty interesting. I think there’s a couple of protocols that are out there there’s one from Vanderbilt and there’s one out of Duke, and we can put links into both of these protocols. I grew up in Nashville, Tennessee. I went to a rival North Carolina residency program to Duke. So so I actually prefer the Vandy protocol.
Howard: 45:04
Oh, okay, so you’re. I see your approach to antenatal space medicine here, yeah.
Stuart: 45:09
I am loyal. What can I?
Stuart: 45:10
say the Duke protocol does incorporate uterine artery embolization with leaving the placenta in situ, and the Vandy protocol does not. That’s probably the biggest difference between the two, and I’ve used the Vandy protocol a couple of times in the last 18 months or so. So basically what they do is they do delivery of the infant and then at that point they make a decision on whether or not they feel like they can safely remove all the placental tissue or whether it would be. Basically the morbidity would be too high and a lot of the calls on that are abnormal vasculature, like completely involving the bladder. That would require not just a small resection but a large resection. Or in my case it was a placenta that was completely invaded into the broad ligament and really to the sidewall and it was just not going to be resectable without a huge amount of operative blood loss. So that’s where you make the call you sew the uterus up, you tie the cord off, usually with silk or something, and then tuck a little portion of the cord back into the uterus, sew the uterus up and basically just complete the C-section with leaving the placenta in place. Obviously you do not give Pitocin and then you watch the patient. So for the Vandy protocol we give 72 hours of broad-spectrum antibiotics. Neither one of these protocols looks at methotrexate because there’s already sort of a natural involution. That, excuse me, and I always emphasize, the standard of care is a hysterectomy for placenta acreta spectrum. But this is an interoperative call that really has been shown by evidence to decrease massive blood loss In my case.
Stuart: 46:51
And the other case I did was one that had severe invasion into the bladder. This is the one I did about 18 months ago and in that case she actually had some hematuria. We had done a preoperative cystoscopy that showed distortion of her bladder mucosa and so we were really prepared to leave the placenta in at that time. Were really prepared to leave the placenta in at that time. We delivered the baby. We kept her in the hospital for seven days afterwards, watched her really closely, gave her antibiotics, discharged her home after her white count had normalized and she hadn’t had any fever.
Stuart: 47:22
So those next few days are not easy for the person in charge. I would be lying to you if I slept well over the next few nights and the plan was to basically go back at six weeks and do her hysterectomy. Now she presented with increasing abdominal pain about four weeks out. We decided to go ahead and go forward with the hysterectomy, but it was a straightforward abdominal hysterectomy. It was incredible. I got in there and it was almost like a normal hysterectomy. The bladder planes were clear. I did a cystoscopy at the end of the case and it was a completely normal cystoscopy. So it really can be a really novel and helpful way to approach these cases. In the case series that was done by Vandy, only 14% of the delayed hysterectomy patients had four or more units of packed red blood cells, while over half of the patients in the standard C-Hyst group did. So there really is a good way there to help with intraoperative blood loss.
Howard: 48:19
And I think knowing about this approach and these protocols is also helpful, because if I open somebody up at 2 am tonight with a surprise broad ligament percreta, I’m going to follow this protocol and then just ship them off to the tertiary center if they’re stable and not tackle that case, that’s going to be safer. So this is a thing that can be done and so we need to be aware of that. Okay, and we’ll have to talk. We should do a whole other episode sometime about management of intraoperative complications, urinary tract, bowel injuries and other things like that. I see that in our future.
Stuart: 48:55
Yeah, I’d love to do that.
Howard: 48:57
Thanks, at least intellectually, it’s fun to talk about. I wouldn’t say I’d love to talk about it, not actually. Yeah, yeah, yeah.
Stuart: 49:00
Theoretical ones are my favorite complications, that’s right, theoretic complications.
Howard: 49:03
Yeah Well, if you operate enough, you’re going to have complications and recognize them, get them treated appropriately and it’s going to be okay. But yeah, I chuckled to myself a bit when you said that personal cell phone number thing, because I can’t tell you how many times I’ve done that.
Stuart: 49:18
Well, because I was like I know she’s going to show up in the ER and the ER doc is going to be like what is going on here? So it’s like just call me, I will, I’ll grease all that, yeah, okay, well, give us your four tips.
Howard: 49:28
Sure, I’ll grease all that, yeah, okay, well, give us your four tips?
Stuart: 49:31
Sure. So I mentioned the first one already, but it would be to have one person in charge, and really this is not an arrogance thing. I can’t emphasize that enough. It’s not about being arrogant, it’s not even about being the smartest person or the best prepared person in the room, but you really just need one person making the calls and calling the shots. You certainly should take suggestions from everyone in the room, but there really does need to be a clear plan and really for my planned out cases, I actually, almost like a stage manager, will write out a one pager and we’ll give it to every team with the order of what we’re going to do, of which teams are involved, the contingency plans for each step and IR, trauma urology. They’re all can be very helpful, but they don’t necessarily understand the big picture and you, as the primary obstetrician surgeon, do All right.
Stuart: 50:23
My second tip would be, for planned cases, just position the patient in low lithotomy. We’ve all been in the situation before where we have to put a patient who’s supine in lithotomy and how unfun that can be. It really does make it easier for all sorts of applications. So if you need to put stents in, it makes it a lot. You basically have to have them in lithotomy to put stents in. I mentioned sometimes I really like Howard’s tip about making the vertical incision posterior to find the cervix. Sometimes what I’ll do too is I’ll put, like I said, put a sponge stick or even my hand in to cut down on top on there and so having that sort of tactile feedback for a cervix that sometimes can be harder to feel through the vaginal cuff I think can be really helpful.
Howard: 51:10
Yeah, or a sizer yeah.
Stuart: 51:11
Sizer Exactly.
Howard: 51:13
Yeah.
Stuart: 51:13
And then if you have to do like a pyelogram or something like that, all those sorts of things are much easier done in in lithotomy position and it’s really it also allows another assistant to get in a little bit closer as well. So I think lots of benefits to having a patient in lithotomy. Number three we’ve already talked about, but it’s to not bounce off of the uterus when you’re taking the vessels. So really respect the back bleeding. And I would actually add too we haven’t really talked about it’s not really a C-Hyst, but if you ever do a hysterectomy for a mole, for a complete mole, it’s actually a similar approach. This is also a pregnant uterus, you have similar vasculature blood flow and so you really want to approach it in the same way. Also, don’t bounce off of the uterus if you do the hysterectomy for a mole.
Stuart: 52:01
And then my final one is this isn’t an absolute, but I do think it’s helpful to have two Yankeur sections available. I as the surgeon, as a lead surgeon, typically like to have one in my hand because I like to do some of my dissection with that, and it’s helpful for my assistant to have another one to deal with sucking, and sometimes you do need to like, if you get into bleeding Now a lot of times, I’ll have one of them hooked up to a cell saver, and we didn’t really talk about that, but that is an option. Potentially, if you do have a lot of massive blood loss After the baby’s delivered, after you’ve suctioned out all the amniotic fluid, you can switch over one of the suctions to a cell saver and then potentially give some blood back to the patient at the end of the case. So that’s another option.
Howard: 52:46
I like that one. I’ve definitely been in a case before where the blood was pulling up in the pelvis faster than one sucker could suck it out, and so that’s a great tip to pressure and find it Like you gotta get it, you gotta see, you gotta get exposure, you gotta get pressure on it and then get ahead.
Stuart: 53:00
And it’s a cheap tip too. I’ve I have been in, I’ve had attendings who insisted on having two ligatures, which I mean, yeah, there is actually a nice benefit to that, but it’s expensive, right. But two yank hours is not expensive, Right.
Howard: 53:13
Yeah, okay. Well, there’s no way that you and I can do an episode together and not do a historical segment.
Stuart: 53:19
No, you’re right. So I think we’ve got a couple minutes and we’re going a little bit long, but yeah, let’s talk about it. Well, let’s talk about the history of cesarean hysterectomy for just a second. Okay, so today we think of the C-Hyst as a dangerous thing that increases risks, but in the early days it was life-saving for women because they were all dying from cesareans and when they died of hemorrhage and infection. And we have all these ideas of antisepsis now, but at that point that really wasn’t a thing. And so cesarean deliveries in the early part of the 19th century and before that were almost always fatal, and the challenge was how to deal with the hemorrhage or the infection that the women would subsequently die of.
Howard: 54:03
Yeah, so that sets the tone for a couple centuries ago, and we typically talk about cesarean hysterectomy in terms of before Eduardo Porro and after Eduardo Porro.
Stuart: 54:13
Right, yeah, so before Porro, this was a time when we were afraid to remove the uterus because we thought it was an essential organ like the lungs or something like that. And the idea was disproven in 1768 by Joseph Cavallini of Florence, who did animal experiments, both pregnant and non-pregnant animals. He did hysterectomies and they didn’t die. So we got our answer.
Howard: 54:37
It’s not the heart that’s not there. Yeah so, and we don’t talk a lot about animal experimentation in that era, but of course it happened. And worse than, animal experimentation happened in the beginning of the 19th century, and so subsequently the Germans in the English they showed that if you were doing an abdominal delivery on an animal, that the outcomes were uniformly better if you just also did a hysterectomy, if you remove the uterus while you were there doing the delivery.
Stuart: 55:03
Yeah, again, we were hampered by this, by a lack of anesthesia and the technology and knowledge that we have today and things like sutures and even a lot of the instruments that we have today. But that was really until the latter part of the 19th century. Now, the first report we have was in 1868 when Horatio Storer of Boston he did do an abdominal delivery of a dead fetus because the outlet was obstructed by an apparently a large fibroid and there was just so much bleeding that he decided to remove the whole uterus. But unfortunately that patient died three days later.
Howard: 55:39
And yeah, and then. So pre-Porro. And then, in 1876, Porro finally reported the case of the first woman who survived a hysterectomy after a cesarean delivery. He had intentionally practiced this on animals. He was working up to this and at that time he washed his hands in carbolic acid. They use chloroform for sedation for the patient all these emerging technologies of the day. And he delivered a living baby girl but was unable to get hemostasis, even with sutures. So he elevated the uterus and put a big ligature at the base of it and cut the whole specimen off, and he did the whole case in 26 minutes.
Stuart: 56:16
Wow, yeah, I’m a little worried about the ureters here, but they were using this thing called the Syntrat constrictor I think that’s how you say it. This is like a snare that they would use. So they pulled out through the wound and they left it on for four days and then they would take it off and essentially slide it out.
Howard: 56:37
Right, yeah, and it was a thing for a while. And then in 1890, Lawson Tate modified the procedure and he actually had the idea of bringing the cervical stump up. Sounds weird, but bringing the stump up to the abdominal incision and sewing it there effectively to create a drain and to have extra peritonealize the drainage from that area, obviously to combat infection. And so then the Tate-Porro procedure became common for the next several years.
Stuart: 57:03
Yeah, so Porro was an Italian and that first patient was actually a rachetic patient with a contracted pelvis. She was 25 years old and only about 144 centimeters tall, or four foot eight, but the interesting thing was that her name was Julia Cavallini.
Howard: 57:19
Oh right, so the same last name as the guy who proved the uterus wasn’t a vital organ.
Stuart: 57:23
Yeah, so this was apparently just a coincidence, but history has some cool coincidences sometimes.
Howard: 57:30
Well, Italy was the epicenter for this stuff. It’s probably a fairly common name there. So well, cesarean hysterectomy was so safe, compared to what we were doing with just C-section that after 1890, it was the standard way of doing deliveries for a little while until Max Sanger came along and really developed what today we would call the classical cesarean technique and showed how to preserve the uterus and how to obtain hemostasis with sutures and things like that. But that’s a story for another time.
Stuart: 57:57
And I’ll just add that since Pora’s first C-Hyst was planned for rickets and she’d not been in labor and then that went a long way to reducing the infection in that case, particularly in an age of before asepsis and antisepsis, but she might have died otherwise from infection in another case.
Howard: 58:15
Bleeding and infection. But, as you said, most of the C-HYSTS are done for bleeding and if bleeding doesn’t get you, we have good antibiotics now. But they certainly didn’t then and infection was a problem, and for a generation. The decision was not when to do the C-HYST soon enough. The decision was when to do the cesarean soon enough, before the patient had prolonged labors and was infected, because those patients just universally died.
Stuart: 58:37
I’m so glad we lived today.
Howard: 58:40
All right, well, this has been fun and we’ll be back. Well, you won’t be back, but you’ll be back in a little bit and maybe we’ll do surgical complications or something like that, and otherwise the podcast will be back in a couple of weeks.
Stuart: 58:51
Thanks.
Announcer: 58:53
Thanks for listening. Be sure to check out thinkingaboutobgyn.com for more information and be sure to follow us on Instagram. We’ll be back in two weeks.
