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Year : 2018  |  Volume : 7  |  Issue : 11  |  Page : 21-24

A Review of indications and outcome of total abdominal hysterectomy at a tertiary public health facility in Southern Nigeria

Department of Obstetrics and Gynaecology, College of Medical Sciences, University of Benin, Benin City, Nigeria

Date of Web Publication3-Jul-2018

Correspondence Address:
James A Osaikhuwuomwan
Department of Obstetrics and Gynaecology, University of Benin, Benin City
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/nnjcr.nnjcr_49_16

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Objective: Ours' is a major referral center in southern Nigeria which now offers an organized cervical cancer screening and treatment program. Total abdominal hysterectomy is a commonly performed procedure in this center, and this study is aimed at ascertaining its frequency, indications, and safety in line with current reproductive health best practice. Methodology: A descriptive study of consecutive patients who had total abdominal hysterectomy for various benign and malignant indications during the period from January 2009 to December 2013 was conducted. Data extracted from the case files included age, parity, indications for surgery, and postoperative complications. Data were analyzed using Computer Programs for EPIdemiologist (PEPI) and presented in frequency tables. Results: Total abdominal hysterectomy accounted for 13.4% of all major gynecological operations. Majority of the women were in their fifth decade of life (88.5%) and parity of 5 and above (50%). The most common indications were uterine fibroids (50.4%) and cervical intraepithelial neoplasia (17.1%). Postoperative morbidity was recorded in 46 (18.3%) cases, and these were significantly more in premalignant/malignant cases (P < 0.05). The most common postoperative complications were pyrexia (9.5%), wound infection (7.5%), and anemia (6.3%). There was no mortality. Conclusion: Total abdominal hysterectomy is a common procedure in this center; we can hypothesize that the triad of uterine fibroids, age ≥45, and a high parity increases its likelihood in this center. While the most common indication still remains uterine fibroids, we also note increasing cases of hysterectomy for cervical dysplasia/malignancy (courtesy cancer screening services). Although not complication free, overall the procedure is relatively safe and should be offered to selected patient as appropriate.

Keywords: Cervical cancer, Nigeria, screening, total abdominal hysterectomy, uterine fibroids

How to cite this article:
Oseki C, Osaikhuwuomwan JA. A Review of indications and outcome of total abdominal hysterectomy at a tertiary public health facility in Southern Nigeria. N Niger J Clin Res 2018;7:21-4

How to cite this URL:
Oseki C, Osaikhuwuomwan JA. A Review of indications and outcome of total abdominal hysterectomy at a tertiary public health facility in Southern Nigeria. N Niger J Clin Res [serial online] 2018 [cited 2024 Mar 4];7:21-4. Available from: https://www.mdcan-uath.org/text.asp?2018/7/11/21/235861

  Introduction Top

Total abdominal hysterectomy is one of the most frequently performed gynecological surgeries for both benign and malignant conditions. It is an operation involving the removal of the uterus including the cervix through the abdominal route.[1],[2] Depending on the indication, patient's age, and desire for fertility, the ovaries,  Fallopian tube More Detailss, upper portion of the vagina, and pelvic lymph nodes may also be removed. Traditionally, all cases of hysterectomy were done as open procedures, but more recently, minimal access procedures such as laparoscopic hysterectomy and laparoscopically assisted vaginal hysterectomy have been introduced, especially for the management of benign gynecological conditions.[3]

Laparoscopic procedures for hysterectomy, though not commonly performed in developing countries, are associated with less intra- and postoperative complications and shorter duration of hospital stay when compared with open procedures. It is, however, more expensive and only a few gynecologists in developing countries have the required expertise to perform such procedures.[3] Total abdominal hysterectomy seems to be the preferred procedure than subtotal hysterectomy because of the risk of development of carcinoma of the cervix, irritating vaginal discharge, and infrequent cyclical vaginal bleeding from the cervical stump as well as cervical prolapse in the latter.[4],[5] In this part of the world where there are limited organized cervical screening programs, total abdominal hysterectomy is usually the procedure of choice except when it is technically difficult. This is because of its significant importance in optimizing the reproductive health outcome of women in low-resource settings.[3],[6]

Total abdominal hysterectomy accounts for 3.4%–20% of major gynecological operations;[7],[8],[9] its incidence varies from country to country being influenced by cultural, economic, and social factors.[2],[10],[11] In the United Kingdom, about 20% of the women must have undergone hysterectomy before the age of 60 years mainly for uterine fibroids and menstrual disorders.[12] It accounted for between 10.2% and 14% of gynecological surgeries in different studies done in Nigeria.[13],[14] Data from studies done in Nigeria showed that the most common indication for total abdominal hysterectomy is uterine fibroids. This is usually carried out in married, multiparous women who have completed their family sizes and are in their fourth and fifth decades of life.[11],[13],[15]

Total abdominal hysterectomy is not a totally risk-free procedure as complications could occur early or late. Early complications include pyrexia, hemorrhage, anemia, wound infection, pelvic hematoma or abscess, urinary system morbidity including bladder and ureteric injuries, pulmonary embolism, and anesthetic complications. Late complications include intestinal obstruction from bands and adhesions and vault prolapsed.[11],[13],[14]

Recently, our center, which serves as a main referral center for facilities from within and other neighboring states, upgraded its cervical screening and treatment strategies, thus increasing the potential pool of patient, in which total abdominal hysterectomy may be an effective intervention. This study, therefore, intends to evaluate the current incidence and indications for total abdominal hysterectomy and its associated complications.

  Methodology Top

This was a descriptive study of cases of total abdominal hysterectomy carried out at the University of Benin Teaching Hospital, Benin City, between January 2009 and December 2013. This hospital serves as a major public referral center in the Niger Delta Region of Nigeria.

Approval for the study was obtained from the hospitals' Ethics and Review Board. The records in the gynecology ward and theater operation registers were assessed to obtain the case note numbers of the patients, and the case notes were retrieved from the medical records' department. Relevant data extracted from the patients' case notes included age, parity, indications, and complications of hysterectomy and these were analyzed using Statistical Package for Epidemiology (PEPI) and presented in frequency tables and charts. Statistical significance was done using Chi-square and Fisher's exact test as appropriate. P < 0.05 was considered statistically significant.

  Results Top

During the period under review, there were a total of 1992 major gynecological surgeries done. Out of this, 267 were total abdominal hysterectomy giving an incidence of 13.4%. Only 252 case files with complete data were analyzed giving a retrieval rate of 94.4%.

[Table 1] and [Table 2] show the demographic distribution of patients. Their ages ranged between 33 and 66 years, with a mean age of 44.54 years and standard deviation (SD) 3.07. The majority of patients who had total abdominal hysterectomy were age 45 years or more. The parity ranged between 0 and 7, with a mean parity of 3.86 ± 1.38. Majority of the patients who had total abdominal hysterectomy were grand multiparous, accounting for 50% of cases followed by women of parity 3–4 (31.7%). Five women were nulliparous, accounting for 2.0% of cases.
Table 1: Distribution of patients by age

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Table 2: Distribution of patients by parity

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Indications for total abdominal hysterectomy are shown in [Table 3]. The most common indication was uterine fibroids which accounted for 50.4% of cases. Other indications were cervical intraepithelial neoplasia, ovarian tumors (benign/malignant), endometrial hyperplasia/carcinoma, and endometrial polyps, accounting for 17.1%, 15.1%, 7.5%, and 5.9%, respectively. Sixty (23.8%) patients had total abdominal hysterectomy for a premalignant/malignant condition.

Analysis of associated morbidities [Table 4] shows that the mean blood loss at surgery was 593.25 ml and SD 148.66, with a range of 300–1100 ml. There were 46 patients with recorded postoperative complications giving a crude morbidity rate of 18.3%. Some patients had more than one morbidity. Pyrexia, wound infection, and anemia were the most common postoperative complications, accounting for 9.5%, 7.5%, and 6.3%, respectively, of all cases. Four patients had relaparotomy for intraperitoneal bleeding, intestinal obstruction, and pelvic abscess, accounting for 1.6% of cases, whereas 8.7% of patients remained on admission beyond 10 days. There was no mortality recorded.
Table 3: Indications for total abdominal hysterectomy

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Table 4: Associated morbidities

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[Table 5] shows the complication pattern in relation to the indication for total abdominal hysterectomy, either for a benign or malignant condition. For patients who had total abdominal hysterectomy for malignant conditions, the most common complications were pyrexia (P < 0.001), wound sepsis/breakdown (P < 0.001), prolonged hospital stay beyond 10 days (P < 0.001), anemia (P < 0.002), and relaparotomy (P < 0.043).
Table 5: Complication pattern according to indication for total abdominal hysterectomy

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  Discussion Top

Total abdominal hysterectomy accounted for 13.4% of major gynecological surgeries in this study. This is comparable to findings in similar studies done in other centers in the region.[13],[14] It is, however, lower than figures reported in developed countries.[16] Documented reasons for the lower figures in developing countries include fear of surgery, complete cessation of menstruation if premenopausal, cultural, religious, and social beliefs/misconceptions such as loss of sex drive, loss of femininity, sexual rejection by spouse, and cultural beliefs such as reincarnation without the uterus, thus making total abdominal hysterectomy relatively unacceptable in our women.[10],[14] On the other hand, a small family size, less cultural ties, higher literacy levels as well as better health-seeking behaviors, early detection, and treatment of premalignant gynecological conditions among others are reasons for a higher incidence of total abdominal hysterectomy in developed countries.[12],[17]

The mean age was 44.5 ± 3.07 years, and this bears a good relationship with figures obtained from similar studies.[7],[18],[19] At this age, majority of the women would have completed their family size; hence, the decision for hysterectomy becomes easy both for patients and their caregivers. Expectedly, the majority (81.7%) of patients were Para 3 and above, and this was comparable to other studies done in Nigeria.[15],[18],[19] The importance attached to childbearing in our environment may be the reason why hysterectomy rate is lower in those with low parity in this study. In contrast, in developed countries where women are less averse to surgery, they could occasionally opt for hysterectomy after one or two children to enable them carry out their normal activities without hindrance from menstruation.[17] In this study, nulliparous patients accounted for 2% of women who had total abdominal hysterectomy, the indication in all being ovarian malignancy. This explains, therefore, that women irrespective of parity may undergo total abdominal hysterectomy if indicated.

Uterine fibroids were the most common indication observed in this study similar to previous studies.[3],[14],[15],[20] We, however, note an increasing trend for hysterectomy for cervical dysplasia, this reflects an increase in awareness and uptake of cervical screening program in the center. Furthermore, because of a dearth of conservative treatment modalities in developing society, as well as the fear of being lost to follow up, total abdominal hysterectomy becomes desirable. Conservative ablative or excisional procedures are alternative treatment modalities to total abdominal hysterectomy in women with cervical intraepithelial neoplasia and are more desirable in younger women who are yet to complete their family size.[15] Ovarian tumors, both benign and malignant, accounted for 15.1% of cases of total abdominal hysterectomy in this study, and this was higher than findings in Nnewi.[3] Although not sited in several other studies done in Nigeria as most were for only benign gynecological conditions, the possible reason for ovarian tumors being a common indication for total abdominal hysterectomy in this study may be adduced to the fact that ours is a gynecology center with referrals from within and neighboring states.

The procedure for total abdominal hysterectomy is not without complications, common among which are pyrexia and hemorrhage.[14],[21] This was corroborated by the findings observed in the study, albeit the crude morbidity rate of 18.3% in this study was lower than figures from other studies,[11],[13],[19],[20] which may indicate judicious surgical approach to patient care in this center; furthermore, we observed that TAH for malignant disease was associated with more complications. This was not observed in previous studies done as most were for benign gynecological conditions.[13],[15] Our observations buttress previous expert opinion that improvement in blood transfusion services, use of more potent antibiotics, advances in control of intraoperative bleeding, better expertise of surgeons, and safe anesthetic techniques have drastically reduced the morbidities and mortality associated with total abdominal hysterectomy in the past.[15] There was no mortality recorded in this study and this correlated with findings in other studies.[13],[15],[19]

  Conclusion Top

Total abdominal hysterectomy is a relatively common procedure in this center, with indications and complications similar to those from other centers in Nigeria and beyond. While the most common indication for total abdominal hysterectomy remained uterine fibroids, we can hypothesize that the triad of uterine fibroids, age 45 and beyond, as well as multiparity, in a patient increases the likelihood for total abdominal hysterectomy. Although increasing cases of hysterectomy for cervical dysplasia/malignancy were associated with increased morbidities, overall the procedure is relatively safe in the center and should be offered to selected patient with credible indications.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Vessey MP, Villard-Mackintosh L, McPherson K, Coulter A, Yeates D. The epidemiology of hysterectomy: Findings in a large cohort study. Br J Obstet Gynaecol 1992;99:402-7.  Back to cited text no. 12
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Murta EF, Carneiro JG, De Freitas MM. Total hysterectomy versus subtotal hysterectomy: Which procedure should be performed during the pregnant-puerperal period? Rev Paul Med 1993;111:354-8.  Back to cited text no. 16
Arowojolu AO. Hysterectomy In: Okonofua F, Odunsi KO, editors. Contemporary Obstetrics and Gynaecology for Developing Countries. 1st ed. Women's Health and Action Research Centre (WHARC): WHARC Pub; 2003. p. 227-39.  Back to cited text no. 17
Abe E, Omo- Aghoja LO. A decade of hysterectomy in a tertiary hospital in urban Niger Delta region of Nigeria. Niger J Clin Pract 2008;11:359-63.  Back to cited text no. 18
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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