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Hysterectomy: GKS: Recommendations
for pre-and postoperative treatment
GKS 27.9.2007
Anna-Mari Heikkinen
KYS naistenklinikka
Hysterectomy: Preoperative recommendations
Thrombosis prophylaxis
Antibiotic prophylaxis
Other
Hysterectomy: Postoperative recommendations
Thrombosis prophylaxis
Sick leave
Other
Käypä Hoito

”Laskimotukos ja keuhkoembolia” 2004, new
version coming
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Preoperative prevention of venous
thromboembolism
”Leikkausta edeltävä arviointi ja hoito” will be
published 2007-2008
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Special preoperative guidelines (cardiac stents,
varfarin treatment etc.)
Hysterectomy and prevention of venous
thromboembolism: References
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Käypä Hoito: Laskimotukos ja keuhkoembolia
2004
Prevention and Treatment of Venous
Thromboembolism: International Consensus
Statement 2006
ACOG Practice Bulletin: Clinical
Management Guidelines for Ob/Gyn Number
84, August 2007
Hysterectomy and the risk of venous
thromboembolism
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Gynecologic surgery without prophylaxis: 1540%
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FINHYST 1996: Thromboembolism AH 0,2%
VH 0,2% LH 0,3%
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FINHYST 2006: Only 2 cases of pulmonary
embolism reported! Not a single venous
thromboses of the lower limb were reported.
Hysterectomy and prevention of venous
thromboembolism : Methods of choice
Early mobilization!
Graduated compression stockings (GCS)
Intermittent pneumatic compression (IPC)
LMWH
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Thrombin inhibitors
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Enoxaparin (Klexane®) 40 mgx1
Dalteparin (Fragmin®) 5000 IUx1
Ximelagatran (Exanta®)
Melagatraani (Melagatran®)
Bivalirudin (Angiox®)
FX infibitor: Fondaparinux (Arixtra®)
Hysterectomy and prevention of venous
thromboembolism: LMWH treatment
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12 h preop, continuing >12 h after postop.
OR: 6-12 h postoperatively
Duration: Immobilization (hospitalization or 7-10 days?)
Prolonged: 1 month
Tiny / obese patients
Hysterectomy and prevention of venous
thromboembolism: Estimation of risk
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LOW RISK: Risk of TE 2-3%
No prophylaxis (early mobilization)
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Duration of operation less than 45 min
< 40 years
No risk factors
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MODERATE RISK: Risk of TE 10-20%
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HIGH RISK: Risk of TE 40-80%
GCS (IPC) + LMWH 1 month
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Cancer
Previous TE (idiopatic/recurent)
Coagulopathy
Severe medical illness/complication
6 w postpartum
Hysterectomy and prevention of venous
thromboembolism: Moderate risk
A. LMWH during hospitalization
B. LMWH during hospitalization, 7-10 days if
risk factors
C. LMWH 7-10 if risk factors,
GCS if no risk factors
IMMOBILIZATION ----- HOSPITALIZATION
Risk factors
7-10 d prophylaxis: 1-2 p
4 w prophylaxis: > 3 p
5p History of TE, coagulopathy, cancer, severe trauma
3p Immobilization, paresis, pregnancy, puerperium
1p Infection/complication
Age > 60y
BMI > 30
Smoking
OC, HT, SERM
Inflammatory bowel disease
Heart failure, MCI
Venous disorder (varicosis, thromboflebitis)
Central venous catheterization
Ac/chr medical illness increasing risk of TE
When no LMWH prophylaxis?
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Uncomplicated operation and cure
< 40-60y patient, no risk factors
Early mobilization, short hospitalization
Intermittent pneumatic compression (IPC)
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Level 2 evidence
Possible indications during hysterectomy
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High risk patient: LMWH + IPC
Moderate risk patient, prolonged immobilization:
LMWH + IPC
Moderate risk patient, contraindication for LMWH
Other medications affecting coagulation
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ASA (50-100mg): Stop 1 week preop
Plavix®: Stop 1 week preop
Marevan®: Stop 4-5 d preop. Bridge therapy!
KÄYPÄ HOITO: Leikkausta edeltävä arvio ja
hoito (2007 -2008)
FINHYST: Thrombosis prophylaxis
FINHYST 1996: AH 37,5% VH 47,1% LH 21,9%
FINHYST
2006
+
LMWH
Duration
specified
Duration
(mean)
Hospitalization
If LMWH given
AH
(908)
72%
97%
41%
4,3
4,0
LH
(1002)
60%
97%
40%
3,1
2,2
VH
(1517)
65%
97%
44%
3,2
2,5
≥60years: Prophylaxis 79%
Postoperative bleeding complication: 2,7%
-Prophylaxis given -> bleeding 3,0%
-No prophylaxis -> bleeding 2,1%
Hysterectomy and prevention of venous
thromboembolism :GKS recommendation
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LOW RISK: No prophylaxis (early mobilization)
 Duration of operation less than 45 min , <40 years patient, no risk
factors
MODERATE RISK : ”Normal hysterectomy”
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GCS alone if no risk factors
LMWH always > 60 yr, or < 60yr and at least 1 risk factor
7-10 days prophylaxis according pre- and postop. risk factors
HIGH RISKI: GCS (IPC) +LMWH 1 month
 Cancer
 Previous TE (idiopatic/recurent)
 Coagulopathy
 Severe medical illness/complication
 6 w postpartum
Hysterectomy and risk of infections
UTI: 5-10%
AH:
 wound infection 3-5%, pelvic cellulitis 10-20% without AB-proph.
 Postop. fever 16-36%
 FINFYST 1996: AB-proph. 78.9%; UTI 4,2%, operation-side
infection/fever 6,0%
VH:
 pelvic cellulitis 35% without AB-proph.
 Postop. fever 7-55%
 FINFYST 1996: AB-proph. 79,5%; UTI 7,3%, operation-side
infection/fever 5,4%
LH:
 Postop. fever 10%
 FINFYST 1996: AB-proph. 92,3%; UTI 2,6%, operation-side
infection/fever 5,9%
Antibiotic prophylaxis
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ACOG Practice Bulletin (Ob Gyn July/2006):
Always antibiotic prophylaxis before
hysterectomy
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> 30 prospective clinical trials
2 meta-analysis
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Hysterectomy and antibiotic prophylaxis
GKS recommendation
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Single-dose AB during induction of anesthesia (< 60min but always
before incision)
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Cephalosporins!
 BMI < 30:cefuroxim 1.5g
 BMI > 30: cefuroxim 3g
 Allergic reactions to B-lactam AB:
 clindamycin 600mg
 or vankomycin 1g + tobramycin 120mg / netilmycin 150mg
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Second dose:
 Lengthy operation (3 h after incision)
 Blood loss > 1500ml
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Metronidatzol useless
FINHYST 2006: Postoperative infections
Abdominal
Laparoscopic
Vaginal
Pelvic infection: hematoma/abcess
0,5%
2,9%
2,0%
Wound infection
2,2%
2,1%
2,6%
1,5%
0,7%
1,4%
0,9%
1,5%
0,9%
Urinary infection
Fever for unknown cause
FINHYST 1996 vs. 2006:
Less infections in all groups!
Abdominal
Laparoscopic
Vaginal
1996
2006
1996
2006
1996
2006
Infections all
10,5%
7,8%
13,0%
6,9%
9,0%
5,5%
Antibiotic
prophylaxis
79%
96%
80%
98%
92%
97%
Year
FINHYST 2006: Antibiotic prophylaxis
Usage (%)
Abdominal
TAH
96
SAH
93
LH
98
LAVH
97
96
Laparoscopic
98
Vaginal
97
ABDOMINAL
UNSPECIFIED
CEFUROXIME ALONE
METRONIDATZOLE ALONE
CEFU + METRO
OTHER COMBINATION
OTHER AB ALONE
LAPAROSCOPIC
VAGINAL
0%
20 %
40 %
60 %
80 %
100 %
Reasons to NOT give routine prophylactic
metronidatzol
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Interactions: Varfarin!!
Bacterial resistance
Costs
-> indicated only if bowel injury
Costs of prophylaxis
(examples of hospital prices /dose)
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Klexane 40 mg
3.80€
Fragmin 5000 IU
3.60€
Kefuroksiimi 1.5:
1.80€
Metronidatsoli 500 mg 3.10€
Klindamysiini 600 mg
5.50€
Siprofloksasilliini 200 mg 14.00€
Vankomysiini 1 g
5.60€
Tobramysiini 120 mg
6.40€
Netilmysiini 10 mg
7.00€
Postoperative treatment
Moller C et al 2001: Variation in
recommendations for hysterectomy and
vaginal surgery patients in Denmark
 Sick leave: 4 w (1-8 w) work without heavy
lifting, 6 w (2-12 w) work with heavy lifting
 Lifting restrictions : 2-15 kg, 2-12 weeks
 No sex intercourse: 4 w (0-12 w)
SICK leave after hysterectomy
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No evidence based medicine
Persson et al. 2006. Rand. multicenter trial
AH (n=56) vs. LH (n=63)
Sick leave 14 days
Final sick leave:
AH: 33.5vrk LH: 26vrk
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FINHYST 2006: Convalescence period
AH
LH
VH+prol
VH
Post op hospital days (mean)
3,9
1,9
2,7
1,8
Sick leave days (mean) doctors
32,2
22,0
35,0
25,0
Sick leave days (mean) patients
36,2
25,3
38,3
28,0
Inadequate sick leave
38,6%
38,2%
26,5%
32,9%
Workers receiving extra days %
32,2%
30,9%
22,5%
25,4%
Number of extra days (mean)
11,1
11,0
11,9
11,9
Too long sick leave
0,8%
1,3%
0,7%
2,4%
Sick leave days (mean) if sick
leave was reported adequate
32,6
21,7
36,8
25,8
FINHYST 1996: Sick leave
(mean)
34,4
21,5
34,0
Postoperative recommendations
(HUS, TAYS, TYKS, OYS, PKKS, KYS):
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Sick leave:
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AH: 4 w
LH: 2-3 w
VH: 2-3 w
VH+prolapse: 3-6 w
No sex intercourse: Postop. control or 4 w
Postop. control: 4/6
Other very specific restrictions: Preop peräruiske
kaikille, istumakielto laskeumissa 2vi, ei saunaan
1vi, ei ammekylpyjä/uintia, ei kovia löylyjä, alapesu
vähintään 2x/vrk, ei tampoonia, ei raskaita töitä 1-2
viikkoon, PAPA 5v välein, gyn tutkimus vuosittain, ei
pyöräilyä ennen jt, ei autolla ajoa 2 viikkoon jne…
Sick leave after hysterectomy:
GKS recommendations
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LH: 2-3 weeks
AH: 4 weeks
VH, no prolaps surgery: 2-3 weeks
VH + prolaps surgery : 4 weeks
Hysterectomy: Other GKS recommendations
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No pubic hair shaving, shortening if
necessary
No bowel preparation
No routine abd. cavity drainage
No lifting restrictions (no heavy work during
sick leave)
No sexual intercourse during sick leave
No other specific restrictions to patient
guidelines
No routine postoperative control
KIITOS!