1. AUDIT OF PATHWAY TO HYSTERECTOMY
DR TIMMY KOWLESSAR (SpR)
MS A. ARYA (Consultant)
Obstetrics & Gynaecology Dep’t
QEH King’s Lynn
13th March 2013

2. AIMS
To determine whether there is a documented discussion of conservative options of treatment, instead of major surgery.
To determine proportion of patients opting for surgery and reasons for discontinuing conservative management.
To determine whether patients are given adequate information on surgical risks at consenting.

3. METHOD
Retrospective analysis of 25 case notes of patients who have had a hysterectomy for benign indications between March – December 2012.

4. RESULTS - AGE

5. INDICATION FOR HYSTERECTOMY

6. Type of hysterectomy

7. Indication for hysterectomy

8. Was there a documented discussion of alternatives to surgical treatment?
60-69yo, prolapse
G3 cystocoele, G1 uterine descent
Seen and consented by Middle Grade.

9. Did the patient agree for trial of expectant management?

10. Indication for hysterectomy in patients DECLINING conservative measures (15 / 24)

11. Indication for hysterectomy in patients who initially tried conservative measures (9/ 24)
Prolapse -
60-69 yrs
PFE’s, pessaries x 9 years
Repeated UTIs and vaginal infections.
Vag hyst
70-79 yrs
Pessary x 8 months
Patient requested surgical mx.
Vag hyst

12. Indication for hysterectomy in patients who initially tried conservative measures (9/ 24)
Menorrhagia -
All yrs
All because of failed conservative mx
(not side effects or pt’s request)
Duration : 6 – 53 months
Mean 16.5 months
Median 9 months

13. Consent, Information Leaflet

14. Discussion of surgical risks – TAH
RCOG Consent Advice Guideline – Hysterectomy for Benign Conditions
Serious Risks
Urinary tract injury, +/- bladder dysfunction
Bowel injury
Haemorrhage +/- bld transfusion
Thromboembolism
Return to theatre
Pelvic abscess / infection
Frequent risks
Wound infection, dehiscence
Numbness, burning at scar
UTI, frequency
Ovarian failure

15. Surgical risks – TAH (n=8)

16. Discussion of surgical risks – VH
RCOG Consent Advice Guideline – Vaginal Surgery for Prolapse
Serious Risks
Urinary tract injury
Bladder dysfunction (new or existing)
Bowel injury
Haemorrhage + bld transfusion
Thromboembolism
Return to theatre
Pelvic abscess / infection
Recurrence
Frequent risks
PV bleeding
Wound infection
UTI, frequency, retention
Postop pain, dyspareunia

17. Surgical risks – VH (n=8)

18. Discussion of surgical risks – Operative Laparoscopy
Infection
Haemorrhage
Thromboembolism
Bowel injury
Urinary tract injury, voiding dysfunction
Conversion to open procedure
Return to theatre

19. Surgical risks – Lap (n=9)

20. Surgical risks – Blood transfusion, additional procedures – documented on consent form

21. Summary of results 25 women, 24 offered non-surgical alternatives.
15 / 24 (63%) preferred surgery.
9 / 24 (37%) opting for conservative mx – 2 prolapse, 7 menorrhagia.
Menorrhagia – opted for surgery after failed medical mx, median duration of treatment – 9 months.
Most consent forms filled by consultant.
Consistently poor documentation of possibility of blood transfusion and whether an information leaflet was provided.
Some significant surgical and postoperative risks not documented on consent form.

22. Discussion Small study, n=25.
Significant proportion of laparoscopic procedures.
No women in 20-30’s had hysterectomy for menorrhagia – successful use of conservative measures.
More patients presenting with prolapse opted for surgery.
Patients with menorrhagia requested hysterectomy after failed medical management.
Good documentation of risks at consenting, but significant omissions!!

23. RECOMMENDATIONS
Info leaflets should be readily available in each clinic room.
Following discussion of options, give info leaflets to women requesting surgery, with contact numbers if they change their minds.
Important to follow guidelines – menorrhagia, prolapse.
Prolapse – appointment with nurse specialist to further discuss use of pessaries, before deciding on surgery.

24. RECOMMENDATIONS Methods to improve compliance with consent guidelines
Use of printed info sheets, transcribed onto consent form.
Stickers.
Procedure-specific consent forms…

28. Advantages HYSTERECTOMY
Word doc can be modified, legible, comprehensive
Uniformity
Saves time
HYSTERECTOMY

29. RECOMMENDATIONS
Re-audit planned after agreed changes implemented.