Pre-Operative Visit for Total Hysterectomy and Bilateral Salpingo-Oophorectomy
A patient should expect comprehensive preoperative counseling, risk assessment, imaging studies, and surgical planning during the pre-operative visit for total hysterectomy and bilateral salpingo-oophorectomy.
Essential Preoperative Assessments
Medical History and Risk Stratification
- Family history evaluation is mandatory to identify genetic cancer syndromes (Lynch syndrome, BRCA mutations) that may influence surgical approach and extent 1.
- Comorbidity inventory must be documented, including cardiovascular disease, diabetes, and bone health status, as these impact decisions about oophorectomy timing and hormone replacement 1.
- Geriatric assessment should be performed when appropriate to evaluate surgical candidacy 1.
Physical Examination Components
- Clinical and gynecological examination to assess uterine size, adnexal masses, and pelvic anatomy 1, 2.
- Evaluation of pelvic organ prolapse if present, as this may require concurrent pelvic support procedures 2.
- Assessment of body habitus to determine optimal surgical approach (abdominal, vaginal, or laparoscopic) 1.
Required Imaging Studies
Standard Imaging
- Transvaginal ultrasound is the standard initial imaging modality to evaluate uterine pathology and adnexal structures 1.
- CA-125 and pelvic ultrasound are recommended for preoperative planning when oophorectomy is planned 1.
Advanced Imaging When Indicated
- Contrast-enhanced MRI should be obtained to assess cervical involvement or myometrial invasion in apparent Stage I endometrial cancer 1.
- Abdominal CT scan may be performed to investigate extrapelvic disease when malignancy is suspected 1.
- Chest X-ray is required as part of standard preoperative assessment 1.
Surgical Planning Discussion
Procedure Components to Discuss
- Standard surgery includes total hysterectomy with bilateral salpingo-oophorectomy, which removes the uterus, cervix, both fallopian tubes, and both ovaries 3, 4.
- Peritoneal cytology will be obtained by aspiration of ascites or peritoneal lavage at the time of surgery 3, 4.
- Thorough abdominal exploration will include systematic inspection and palpation of the entire abdomen, liver, diaphragm, omentum, and peritoneal surfaces 1, 3, 4.
Surgical Approach Options
- Laparoscopic approach should be discussed as it is associated with fewer moderate-to-severe postoperative adverse events and shorter hospital stays compared to open procedures 3.
- Vaginal route should be considered as first choice for benign indications when feasible 2.
- Abdominal approach is indicated for large uteri, suspected malignancy, or when extensive adhesions are expected 3.
Critical Counseling Points
Hormone Replacement Therapy Discussion
- Estrogen replacement therapy should be discussed for premenopausal women undergoing oophorectomy, as premature menopause causes detriments to bone health, cardiovascular health, and quality of life 1.
- Timing and duration of hormone therapy must be individualized based on age, cardiovascular risk, and cancer risk factors 1.
Ovarian Preservation Considerations
- Ovarian preservation may be considered in women under 45 years old with less than 50% myometrial invasion, no obvious extra-uterine disease, and no family history of ovarian cancer risk 1.
- Risk of subsequent pelvic lesions is significantly higher (50.7% vs 5.5%) when ovaries are preserved, requiring close follow-up 5.
Cancer Risk Reduction Benefits
- Total hysterectomy eliminates endometrial cancer risk but has not been shown to reduce endometrial cancer mortality 1, 6.
- Bilateral oophorectomy eliminates ovarian cancer risk, providing definitive prevention that cannot be achieved through screening alone 1, 6.
- For Lynch syndrome patients (MLH1, MSH2, EPCAM mutations), hysterectomy with BSO may be considered starting at age 40 years; for PMS2 mutations, starting at age 50 years 1.
Preoperative Preparation Instructions
Bowel Preparation
- Appropriate bowel preparation should be prescribed if bowel resection might be necessary based on imaging findings or suspected disease extent 4.
Positioning and Surgical Access
- Patient positioning for vertical midline abdominal approach will be used for optimal exposure if open surgery is planned 4.
Common Pitfalls to Avoid
Inadequate Risk Assessment
- Failure to obtain family history may miss hereditary cancer syndromes that significantly impact surgical decision-making and extent 1.
- Not discussing hormone replacement therapy preoperatively leaves premenopausal women unprepared for managing premature menopause symptoms 1.