A hysterectomy is a surgery to remove theuterus. Hysterectomies are performed for a variety of gynecologic conditions such as uterine fibroids, heavy periods, endometriosis, chronic pelvic pain, uterine prolapse and gynecologic cancer. 

During a hysterectomy, the uterus is removed. Obgyns often recommend fallopian tube removal (bilateral salpingectomy) to reduce the risk of ovarian cancer. Some women will also need the removal of the ovaries (oophorectomy). Hormonal changes only occur when the ovaries are removed.

Gynecologists perform hysterectomies through a variety of techniques. The size of the uterus, surgeon experience, the patient’s body type, and the prior surgical history help determine the proper surgical approach. Techniques include:

1. Vaginal hysterectomy
2. Abdominal hysterectomy 
3. Laparoscopic hysterectomy 
4. Laparoscopic-assisted vaginal hysterectomy 
5. Robotic hysterectomy robotic

What are the advantages of robotic hysterectomy?

Contrary to the name, robots do not perform the surgery. A human gynecologic surgeon attaches a surgical system to intraabdominal ports. While sitting at a surgical console, the surgeon controls the robotic arms while monitoring the surgical field in a 3D view..

Through 4–5 small incisions, the surgeon detaches the uterus from the surrounding tissues. Robotic surgery is a minimally invasive surgery that allows for faster recovery, reduced pain, and shorter hospital stay.

The American College of Obgyn acknowledges this type of hysterectomy’s growing popularity but recommends robotic hysterectomy be reserved for more complex cases that can not be safely completed through other minimally invasive techniques.

Experienced robotic surgeons prefer the precise control of the surgical arms allowing complex cases to be completed in a minimally invasive fashion. Patients benefit from small incisions, a short hospital stay, and a faster return to work, exercise, and everyday activities.

How long will I be in the hospital?

Surgeons perform robotic hysterectomies as an outpatient procedure or as an inpatient surgery with an overnight stay. Various factors, such as the patient’s underlying health status, surgical complexity, and physician preference, help determine the surgical plan.

Most robotic hysterectomy patients are able to leave the hospital much faster after a traditional abdominal hysterectomy. 

Can family visit me?

A trusted family member should drive you to and from the hospital or ambulatory surgery center for a robotic hysterectomy. Families are welcome to stay with you before and after surgery. Hospital visitor policies for overnight stays vary from region to region due to the Covid-19 pandemic.

Does my procedure require an anesthetic?

Laparoscopic robotic surgery requires general anesthesia meaning patients will be temporarily put to sleep. The surgeon may also inject a local anesthetic into the incisions to decrease postoperative pain.

What’s the procedure when I check-in?

Most surgeries will involve a preoperative visit with your surgeon to go over the procedure’s risks and benefits in detail. Your surgeon answers questions regarding your upcoming surgery. The surgical consent form is reviewed, signed, or updated with any changes.

Because robotic hysterectomies will eliminate the possibility of child-bearing, your doctor will ask questions to make sure you are confident you will not want children in the future.

In most settings, patients will receive a preoperative phone call by a nurse or medical assistant one to two days before surgery. If any blood work or preoperative testing is required, it will be scheduled and confirmed.

After arrival at the hospital or Ambulatory Surgery Center, the staff will guide you to the preoperative holding area to change into a surgical gown and store your valuables. You will meet the nursing team who will provide care during your stay. An IV will be placed at this time.

The anesthesia team will come to interview you and answer questions. Typically your surgeon will also come and review any last-minute questions.

What happens in the operating room?

After the preoperative evaluation, the team will guide you to the operating or procedure room. You will move from the mobile bed to the operating table. Once you are positioned comfortably and safely, the anesthesiologist will give you medication through your IV to help you go to sleep.

The OR nursing team will cover your body with sterile drapes and prep the abdomen for surgical sterility. The team then performs a “surgical time-out.” A surgical safety checklist is read aloud, requiring all surgical team members to be present and attentive.

The gynecologic surgeon will insert a speculum into the vagina to allow visualization of the cervix, the opening of your uterus located at the back of the vagina.

Once the speculum is in place and the cervix visualized, the surgeon inserts a device called a uterine manipulator into the cavity of the uterus. This step facilitates the surgeon’s ability to safely operate and avoid injury to surrounding tissue such as the bladder, rectum, intestines, and ureter.

The surgeon will mark the surgical sites with a small marking pin. A small camera is inserted through an incision into the belly button. Air inflates and distends the abdomen to allow visualization of the pelvis. Three or four secondary ports are placed to allow the robotic arms to function. 

The robot is then positioned over the body and attached to the ports. The laparoscopic camera is positioned to show the pelvic anatomy. Small instruments are passed through the additional ports. Scissors are attached to one robotic arm and a grasping device in the other. This allows the surgeon to operate with both hands. 

The surgeon then moves away from the patient to the surgical consult to control the robot. 

As the surgeon takes her seat, she adjusts the camera and robotic arms’ position to begin the surgery.

Many surgeons recommend complete removal of the fallopian tubes (bilateral salpingectomy) at the time of surgery as this technique reduces the risk of ovarian cancer.

The fallopian tubes are located and grasped with one instrument. Using the other hand, the surgeon clamps and cuts the tubes from the adjacent anatomy.

The surgeon travels down the sides of the uterus freeing it from the connecting tissues. The round ligament and utero-ovarian ligaments are clamped, cauterized and then cut. At each step, the surgeon will take precautions to control and avoid bleeding. 

Towards to lower end of the uterus lies important anatomy. The surgeon will separate the bladder from the lower uterine segment to allow visualization of the cervix. 

The surgeon will focus attention on the uterine arteries. These two blood vessels are the main blood supply to the uterus and travel over the ureters, which are the tubes connecting the kidney to the bladder. 

Once the uterine arteries are controlled, the surgeon can safely separate the uterus from the vagina. 

The surgeon makes a circular incision just below the cervix freeing the uterus. The uterus is delivered through the vagina and sent to the pathologist to analyze the tissue. 

The surgeon then sews the edges of the vagina closed to form the vaginal cuff. 

The surgeon examines all of the surgical sites for bleeding. When safe, the Obgyn removes the operative ports and sews the surgical incisions closed. 

Once the procedure is complete, the surgical team completes a post-procedure review. All instruments and equipment are counted and verified. When finished, the anesthesiologist will begin to wake the patient up for transfer to the recovery room.

How long will I be in the operating room?

Once the patient enters the operating room, a series of safety steps must occur. This process takes about 20 minutes.

The operative time for robotic hysterectomy varies. The surgeon’s experience, surgical technique, patient body type, uterine size, and patient’s previous surgeries are all factors.

In general, patient should expect 1–2 hours of total operative time.

When can I go home?

Postoperative recovery time will vary from person to person. Some surgeons will recommend an outpatient procedure while others prefer an overnight stay. The patients underlying health status, surgical complexity and physician preference are all factors. 

To be able to go home, each patient must meet specific discharge criteria. The patient’s vital signs must be stable. The patient must be alert, oriented, and able to walk with assistance. Postoperative nausea, vomiting, and pain must be controlled as well as confirmation of no postoperative bleeding.

The nursing team will go over discharge instructions, and the plan for postoperative pain management options will be confirmed.

What is the usual recovery time

Most women should be able to return to normal daily activities within a few weeks of surgery. The nursing team will help patients walk and move around a few hours after surgery to reduce blood clots’ risk, improve lung function, and expedite bowel function return.

Most patients will require pain medication like NSAIDs and narcotics for a time. Many experience discomfort in the right shoulder due to air irritating the nerves of the diaphragm.

Light bleeding, spotting, and brown or black discharge is common and expected. Sanitary napkins are safe to use.

What aftercare is required?

You should speak with your physician regarding the resumption of exercise and sexual activity. Most can return to basic activities in one to two weeks. Sexual activity is typically restricted for 6–8 weeks to allow the vaginal cuff to heal.

Your doctor will schedule a postoperative examination 1–2 weeks after the procedure to evaluate the incisions.

Danger Signals to look out for after the procedure

You should call your doctor if you experience heavy vaginal bleeding, fevers, severe nausea or vomiting, worsening abdominal pain, or the inability to pass gas.

If you experience heavy bleeding, abdominal or pelvic pain, a fever, or pain that increases over 24 hours, call your physician. After any surgery, contact your physician if you meet any of the following criteria:

• Pain not controlled with prescribed medication
• Fever > 101
• Nausea and vomiting
• Calf or leg pain
• Shortness of breath
• Heavy vaginal bleeding
• Foul-smelling vaginal discharge
• Abdominal pain not controlled by pain medication
• Inability to pass gas

What preparations should I make for aftercare at home?

Robotic procedures require very little postoperative care. Keep the incisions clean and dry. Sexual activity should be avoided until cleared by your doctor. One may resume a normal diet the day of surgery and begin light exercise the day after the procedure or when you feel ready.

What information should I provide to my doctors and nurses?

It is very important to provide your doctor with an updated list of all medications, vitamins, and dietary supplements prior to surgery. All medication and food allergies should be reviewed. Share any lab work, radiologic procedures, or other medical tests done by other healthcare providers with your surgeon prior to your procedure.

Still have questions?

Read through any existing comments in the section below and if you still need information on this procedure please do leave your questions in the comments section.

The post Preparing for: Robotic Hysterectomy appeared first on Medika Life.

Pudendal and paracervical blocks are single-injection, or single-shot, nerve blocks that involve a one-time injection of local anesthetic adjacent to the nerve or plexus for pain relief. The duration and density of the block depends upon the dose, concentration, and pharmacology of the chosen local anesthetic.

Transvaginal Pudendal Nerve Block

A pudendal nerve block provides anesthesia to the lower vagina, vulva, and surrounding tissues, with some relaxation of the pelvic floor. Blocking the pudendal nerve with an injection of local anesthetic is used for vaginal deliveries and for minor surgeries of the vagina and perineum. The pudendal nerve provides the majority of sensations and functions of the external genitals, the urethra, the anus, and the perineum. It also controls the external anal sphincter and the sphincter muscles of the bladder. 

Pudendal nerve blocks are still used for certain obstetric and gynecologic indications, but they have been displaced by an increase in the use of neuraxial anesthesia (such as epidurals or spinals), especially in the context of treatment for pain in the second stage of labor. The procedure, however remains a useful tool for urgent or emergent deliveries when quick pain control and analgesia are indicated.

Your doctor may use this block when you undergo the following procedures:

• Operative vaginal deliver (forceps or vacuum)
• Episiotomy repair
• Office-based vaginal procedures

What does this procedure involve

The doctor will use two fingers to feel along the inner left wall of the vagina to locate a boney protuberance called the ischial spine. Using a special needle, pain medication can be injected into the nerve root located in this area. The process is repeated on the right side. This will numb the perineum and lower part of the vagina.

Paracervical Nerve Block

Paracervical blocks can provide excellent anesthesia for procedures that involve cervical dilation, uterine aspiration, or instrumentation of the uterus. The paracervical block is not recommended for loop electrosurgical excision procedure (LEEP) procedures because it may not be as dense on the surface of the cervix.

Your doctor may use this block when you undergo the following procedures:

• LEEP (loop electrosurgical excision procedure)
• IUD (intrauterine device) insertion
• Hysteroscopy (diagnostic, polypectomy, myomectomy, IUD removal)
• Colposcopy
• Cervical Biopsy
• Endometrial ablation

What does this procedure involve

There are a variety of techniques to perform a paracervical block. Each surgeon develops a preferred technique. In a basic paracervical block, anesthetic medication is injected into the upper and lower portions of the cervix. Typical medications are Lidocaine and Mepivacaine. This technique works quickly to numb the cervix.

More complex procedures require a deeper paracervical block to provide anesthesia to the cervix and upper uterus. There are many techniques. The doctor will inject medication in different areas of the cervix to allow the anesthetic to be absorbed into the surrounding nerve bundles. The procedure is done slowly to avoid injecting into any blood vessels. After the injections are complete, the surgeon will wait 10-15 minutes to allow it to take effect before proceeding with other procedures.

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• Pain, which may radiate down an arm (for cervical spine) or around the chest (for thoracic spine)
• Weakness
• Numbness of the extremities

To diagnose and treat these symptoms, your doctor may use nerve root injections.

Purpose of diagnostic nerve root injections: 

If your physician can’t determine the specific cause of your pain using diagnostic imaging, such as an MRI or CT scan, temporarily numbing the suspicious spinal nerve root may help to identify the source of the pain.

Purpose of therapeutic nerve root injections: 

Injection of a steroid along the nerve root may be used as a treatment to help reduce irritation and swelling, thereby relieving pain. The steroid usually starts to work two days to two weeks after the injection. The pain relief varies for each individual, from no relief to long-term pain relief.

Types of nerve root injections

Selective Nerve Root Block (SNRB): This is a diagnostic-only procedure. It tests to see if a specific nerve is causing pain by blocking it with a strong anesthetic. No steroid is used. The anesthetic may cause temporary numbness, tingling, and/or mild weakness in the affected leg. These symptoms and any pain relief only last until the anesthetic wears off.

Nerve Root Injection (NRI): This is a diagnostic and therapeutic injection. Both a strong anesthetic and steroid are used and injected around the nerve and into the epidural space.

Transforaminal Epidural Steroid Injection (TFESI): This is primarily a therapeutic procedure aimed at relieving pain when the physician knows which nerve is affected. A lighter anesthetic and steroid are injected around the nerve and epidural space.

Overview of the nerve root injection procedure

Here’s what to expect during a cervical or thoracic nerve root injection procedure:

• If your pain is in your cervical spine, you will lie face up; if your pain is in your upper back, you will lie face down.
• The injection area is cleaned and numbed before the injection.
• Using fluoroscopic (X-ray) guidance, your physician will determine the appropriate path for the needle.
• Your doctor will insert a thin needle to a point immediately behind the nerve root.
• Next, your doctor will inject a small amount of contrast dye to make sure that the medication will flow exactly where intended.
• Then, your physician will inject a small amount of anesthetic, steroid, or a combination of both, depending on the procedure’s purpose.
• During the injection, you may feel a sensation of pressure in the neck or arm. This typically disappears in a few moments.
• After the procedure, you’ll spend 20 to 30 minutes in the recovery area.

Preparing for the nerve root injection

• While the procedure may take less than 15 minutes, you should allow for at least one hour at the procedure center.
• You need to arrange for a driver to be present and take you to and from the medical facility. If you do not have a driver with you, we may have to reschedule your procedure.
• For diagnostic injections, you should have some pain at the time of the procedure or be able to reproduce it consistently with certain activities or positions. If you are typically pain-free after taking pain medication, please do not take these medications for four to six hours before an injection.
• If you are taking prescription blood thinners such as Coumadin (warfarin), Ticlid (ticlopidine), or Plavix (clopidogrel bisulfate), please inform your docot. These medicines will need to be stopped before the procedure, but only after you receive permission from the doctor who is prescribing these medicines.
• If you develop a fever, night sweats, or an active infection before your procedure, your procedure will need to be rescheduled.

Possible side effects of the steroid

Side effects of steroid injections are usually minimal and go away within one to three days after the procedure. Possible side effects of the steroid include:

• Facial flushing
• Fluid retention
• Insomnia
• Low-grade fever (less than 100° F)
• For women, temporary changes to your menstrual cycle
• Headache
• For people with diabetes, temporary elevation of blood sugar levels

After the injection

• Follow the specific instructions given to you by the health care providers
• Plan to rest for the remainder of the day. You may resume light activity that is comfortable for you, but do not overexert yourself the first day.
• You may be sore from the needle placement for one to two days. If a local anesthetic was injected, you may feel a numbing sensation in your arm for a few hours until the anesthetic wears off.
• For discomfort, apply ice packs to the puncture site for 15 minutes several times a day.
• Do not soak in a tub for 24 hours after the procedure. You may take showers.
• Report any signs of infection or other unusual symptoms to your doctor, including:
  • Redness and warmth at the injection site
  • Increasing pain
  • Swelling or drainage at the injection site
  • Chills, night sweats, or fever that reaches above 100° F

• If you develop a headache:
  • Stay quiet with your head and body flat
  • Drink plenty of fluids
  • Take Tylenol (acetaminophen) or your prescribed pain medication
  • If your headache lasts more than 12 hours or is noticeably worse when you stand up, it may be an indication of a spinal leak and you should notify your doctor. This is very rare and usually gets better without treatment.
• Keep a record of your pain and symptoms after the injection and report your results as instructed by your doctor’s patient care coordinator.

Potential risks of nerve root injections

The risks of nerve root injections are minimal and are similar to any procedure involving a needle placement. These include, but are not limited to:

• Allergic reaction to the anesthetic or contrast dye. 
• Infection
• Needle injury to a blood vessel, which may bleed
• Irritation of the injected area, which could cause temporary worsening pain
• Inability to place the needle at the desired target, resulting in inability to complete the injection

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