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Wertheim’s Hysterectomy in Nursing Home Setup : Observations in 100 Cases

 

Parag Anop Shah

 

Introduction
Cancer of the cervix is the third commonest female cancer for those in the age group of 35 to 65 years. Out of all cervical cancers seen in the world, 14% occur in the developed countries and 86% occur in the developing countries.1

In 1912, Ernest Wertheim published his report on radical hysterectomy. It is to the credit of Sir Victor Bonney, who brought the high operative mortality of 30% to as low as 9% and made surgery an acceptable modality of primary therapy.

Radiotherapy with its current improved technology has tremendously brought down the complication rate and enhanced the survival rate. This led to complacency on part of the Gynaecologist towards this radical procedure demanding a greater surgical skill. Thus Wertheim’s hysterectomy once considered the Acme of pelvic surgery went into disuse to such an extent that many postgraduate students have never seen this surgery in the tenure of their residency.

Cure rates following Radical surgery and Radiotherapy for carcinoma cervix are almost comparable. However in one review of available world data the results for patients treated by surgery alone are better than patients treated by radiotherapy alone.2

Complications from treatment with surgery are related to anaesthesia and injury to other organs such as the bladder, ureter and the bowel. There is also risk associated with blood transfusion and infection. These complications usually occur early and are remediable. Radiation complications can occur years later and are difficult to fix.Besides in the developing country such as ours Radiotherapy facilities are limited, crowded and expensive. Not only the patient but the accompanying relative who usually is the only earning member is put to inconvenience for more than a month. Surgical treatment on the other hand is accomplished in a single sitting with added advantage of accurate staging.

Material and Methods
Between the years 1995 and 2002 one hundred Wertheim’s hysterectomy with extraperitoneal lymphadenectomy were performed by the author in various Nursing homes.

Clinical evaluation included a thorough pervaginal bimanual examination, complete haemogram, blood sugar, BUN, S. Creatinine, S. Electrotyes, HBsAg, HIV, X-ray Chest, ECG and cervical pap smear/biopsy. IVU, CT Scan or MRI was not mandatory, although performed in a few cases by the treating Gynaecologist. Patients with associated major medical conditions (ASA IV and V) requiring multidisciplinary and intensive postoperative care were referred for further treatment under an Institution.

Discussion
Routine advocated bowel preparation included a mild laxative a day prior and simple enema before the surgery to clear the rectum. Preoperative povidone iodine vaginal pessaries were advised for bulky, proliferative tumours.

Preoperatively the bladder was catheterized. The choice of anaesthesia was left upon the Anaesthetist and the patient. Spinal anaesthesia was the preferred choice in 89 patients, 9 patients had epidural anaesthesia and two general anaesthesia.

The abdomen was opened by an infraumbilical midline incision. After the linea alba was incised, extraperiotoneal space was created by blunt and cautery dissection taking care not to open the peritoneum. All fibro-fatty-lymphatic tissues along the iliac vessels (common, external and internal) were removed. Similar sharp dissection was carried out in the obturator fossa. Haemostasis was achieved by a combination of ligation, cautery and packing. Bilateral Internal iliac artery ligation was performed in continuity as a routine.

Peritoneum was now opened and the disease assessed. Radical hysterectomy as described by Te Linde was then undertaken.3 While performing a Radical hysterectomy cervix was removed by staying as far away from it and the cancer as possible, in contrast to a simple hysterectomy where cervix is removed by staying as close to it as possible. All along the surgery the ureter was carefully identified and retracted medically while performing the extraperitoneal lymphadenectomy. However the ureter was retracted laterally while dissecting the uterosacral ligament and the ureteric tunnel. A sufficient length of Vagina was mobilized and a long cuff of vagina excised along with the specimen. The edges of the vaginal wall were sutured and the vagina left open to drain outside. No attempt was made to reperitonealise the stumps. No tube drain was kept in the peritoneal cavity. Abdomen was closed in monolayer using 1/0 polypropylene.

Results

  1. Age : The youngest patient was 38 years of age while the oldest was 64 years. However, 88% of our patients were between 45 and 50 years.
  2. Clinical assessment : 68% of the patients had FIGO stage I B disease. While 32% had FIGO stage II A disease. There was no difference of opinion on the findings of clinical staging by the treating Gynaecologist and the operating surgeon.
  3. Hb and Blood transfusion requirements : 49% of patients had preexisting anaemia. Hb levels were brought upto 10 gm% before surgery. Average blood loss was 250 ml (min. 100 ml and max. 450 ml). Average one unit of blood transfusion was administered postoperatively (min. nil and max. three).
  4. Operative time : Average operative time was 180 minutes (range 90 minutes to 240 minutes) depending upon the obesity status and degree of involvement.
  5. Morbidity : Three patients had ureteric injury in the lower part of the ureter. All underwent primary repair. Stenting was done in all the cases. In two cases ureteric stent was used and in one case an Epidural Catheter. Stents were removed after four weeks. There was no increased morbidity because of the ureteric suturing. One patient had rectal tear, which was sutured in two layers. Two patients had partial burst abdomen which needed secondary suturing. Five patients had superficial surgical wound infection which were treated conservatively. Two patients had prolonged excessive lymphatic discharge from the open vaginal stump which stopped spontaneously in two weeks.

Mortality : There was no perioperative mortality in the series.

Histopathology : Eighty six patients had squamous cell carcinoma while 14 patients had adenocarcinoma. Pelvic lymph node involvement was seen in 26% of the cases. Six patients had vaginal cut margin close to the tumour (less than 1 cm). All patients with positive lymph nodes or close vaginal margins were advised adjuvant Radiotherapy.

Conclusion
There is a general doubt in the mind of practising gynaecologists whether they are justified in operating upon cases of carcinoma cervix in a Nursing home setup. This study shows that Wertheim’s Hysterectomy is feasible in a Nursing home setup without compromising on the quality of patient care, surgical technique and radicality of the procedure. Institutional care no doubt provides better monitoring and equipment facilities but it is costly, psychologically depressing to the patient, involves prolonged waiting period and puts not only the patient but also the accompanying working member of the family to inconvenience. In our situation Nursing home care provides tremendous convenience to the patient. There is one to one interaction between the patient and the physician. The reassurance and positive attitude provide tremendous psychological benefit in the postoperative period which are difficult to document in any scientific study. With accurate clinical assessment and proper selection of cases (ASA I to III) the incidence of perioperative mortality is nil and perioperative morbidity is negligible and easily manageable. It also provides a variety from routine for the practising Gynaecologist.

Acknowledgement
To all the nursing home owners and practising Gynecologists along with whom the surgical procedures were carried out.

References

  1. Saraiya SB. Guideline for cancer screening for women in India. The Journal of Obstetrics and Gynaecology of India 1998; 48 (6) : 189-94.
  2. Pettersson F. Annual report of treatment of the results of treatment of Gynaecological cancer. FIGO 1979-1981. Vol. XX. Stockholm : FIGO, 1987.
  3. Piver MS, Rutledge FN, Smith JP. Five classes of extended hysterectomy for women with cervical cancer. Obstet Gynecol 1974; 44 : 265-71.

 


Hon. Consultant Surgeon, Nowrosjee Wadia Hospital, Parel, Mumbai.

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