Bailliere's clinical obstetrics and gynaecology最新文献

Hysterectomy is the commonest major operation performed by gynaecologists and is the definitive cure for many of it's indications which include dysfunctional uterine bleeding, fibroids, utero-vaginal prolapse, endometriosis and adenomyosis, pelvic inflammatory disease, pelvic pain, gynaecological cancers and obstetric complications. It is a successful operation in terms of relieving women of their presenting symptoms and high levels of satisfaction are reported by patients. However, it has a high risk of complications, involves a prolonged convalescence, is expensive and to some women represents a loss of femininity. It should only be employed after trying conservative treatments first if appropriate. If this fails, currently only endometrial ablation and myomectomy are valid alternatives to hysterectomy. If ultimately hysterectomy is required, there is considerable evidence that patient care can be improved by increasing the proportion of operations that are done vaginally and laparoscopically and decreasing the number of laparotomies.

In the relatively long history of man, surgery has been a comparatively recent development; the abdomen was first deliberately opened to remove an ovarian cyst by Ephraim McDowell in Kentucky in 1809. The first abdominal hysterectomy was performed by Charles Clay in Manchester, England in 1843; unfortunately the diagnosis was wrong and the patient died in the immediate post-operative period. The following year, Charles Clay was almost the first to claim a surviving patient, however she died post-operatively and it was not until 1853 that Ellis Burnham from Lowell, Massachusetts achieved the first successful abdominal hysterectomy although again the diagnosis was wrong.

Vaginal hysterectomy dates back to ancient times. The procedure was performed by Soranus of Ephesus 120 years after the birth of Christ, and the many reports of its use in the middle ages were nearly always for the extirpation of an inverted uterus and the patients rarely survived.

The early hysterectomies were fraught with hazard and the patients usually died of haemorrhage, peritonitis, and exhaustion. Early procedures were performed without anaesthesia with a mortality of about 70%, mainly due to sepsis from leaving a long ligature to encourage the drainage of pus. Thomas Keith from Scotland realized the danger of this practice and merely cauterized the cervical stump and allowed it to fall internally, thereby bringing the mortality down to about 8%.

Hysterectomy became safer with the introduction of anaesthesia, antibiotics and antisepsis, blood transfusions and intravenous therapy. During the 1930s, Richardson introduced the total abdominal hysterectomy to avoid serosanguineous discharge from the cervical remnant and the risk of cervical carcinoma developing in the stump. Apart from this innovation, and the transverse incision introduced by Johanns Pfannenstiel in the 1920s, there was little advance in hysterectomy techniques until the advent of endoscopic surgery and the performance of the first laparoscopic hysterectomy by Harry Reich in Kingston, Pennsylvania in 1988.

The refinement and increasing safety of laparoscopic hysterectomy suggests that it will be used increasingly in the future, although developments in pharmacology and photodynamic therapy and interventional radiology may reduce the traditional indications for the operation.

Total abdominal hysterectomy will be performed on one of every three women in the USA. While few changes have occurred in modern times, operative laparoscopy is being used for hysterectomy, though its true role remains unclear. This chapter reviews the indications, preparation and common complications related to total abdominal hysterectomy. A detailed description of abdominal hysterectomy as it is performed at the Mayo Clinic is presented. Key features are pointed out, and the need for proper surgical technique is stressed; specifically, the proper dissection of ureter, bladder and rectum are reviewed and emphasis placed on the need for every pelvic surgeon to possess the skills required for performing these.

Studies of the psychological and sexual outcome of hysterectomy have often arrived at conflicting conclusions and this has resulted in some confusion among health professionals as well as among women themselves. This situation should cause concern, since the incidence of this surgery is high in most countries of the western world.

The confusion about outcome arises out of the methodological problems that plagued earlier research. Some of the more recent studies using prospective design, standardized measures and appropriate statistical analysis have not implicated hysterectomy with increased psychological or sexual disorders. However, both before and after hysterectomy in samples studied, the rate of psychological disorder was higher than would have been expected in a normal population, although a clearer picture has emerged from the most recent study.

In this paper, risk factors are identified, and the need to include women's own evaluation of the procedure is emphasized.

Changing the culture means creating organizations in which using research evidence to support the development and evaluation of services becomes second nature. Experience to date has indicated the need to integrate the promotion of clinical effectiveness into the mainstream activities of hospitals, health authorities and primary care organizations. It is important to use all available mechanisms for encouraging involvement and promoting change, including professional education, clinical audit, organizational and financial systems and information for patients. Successful implementation depends on developing a shared vision of the task to be accomplished, strong clinical leadership and a committed management team, time and resources to sustain the project, clarity about the scale of change required, a suitable plan and timetable, use of routine information systems to monitor progress and good communications between all those involved.

The task of translating research findings into practice is not nearly as straightforward as has been commonly assumed, but it should be a priority for all those concerned about the quality of health care. The effectiveness and efficiency of health services could be substantially improved if evidence-based practice became the norm rather than the exception.

As with other public health interventions, the decision to adopt a screening programme will need to take account of both the benefits and the burdens, including both human and financial costs. A balanced view is called for, and this is best achieved by making explicit the scientific information underpinning the proposed screening programme. In normal medical practice, there is frequently also a conflict between the therapeutic and the iatrogenic, but the detailed justification for preferring a particular medical intervention is often not always made clear. However, in normal medical practice doctors act in response to the patient who seeks alleviation of symptoms, whereas screening is proactive. Consequently, there is a greater obligation to ensure that a proper justification can be made. It is fruitless to try to justify screening in general; each screening programme needs to be considered separately. Some will be found wanting and can be readily discarded. Others will show a clear-cut benefit and, provided sufficient funding were available, could become routine practice. In many cases, however, the balance may be more finely poised, and there is likely to be an element of value judgement.

We have been presented with a clinical treatment problem and have examined how to use the medical literature to look for evidence to guide our clinical decision-making. To summarize, after defining the problems to be resolved, an appropriate search strategy will identify relevant articles. These will need to be assessed for their validity. Consider good or adequate studies further by looking at the results and precision of the treatment effects. Apply the results in your clinical practice if the results can be generalized and provided that all relevant clinical outcomes have been presented. If these criteria are not met, support for use of the therapy is weakened. Finally, an assessment needs to be made of whether the likely benefits of treatment outweight the potential harm and costs.

It is an economic fact of life in all health-care systems that decisions will have to be taken about which programmes and interventions should and should not be provided. The splitting of the roles of purchasing and providing within the UK's NHS has made these decisions more explicit and, together with devolved budgets, required more health service professionals to understand the analytical methods of economic evaluation. Certainly, increasing numbers of economic studies will be undertaken in obstetrics and gynaecology. Checklists exist to assist decision-makers in judging the quality of published studies (Drummond et al, 1987), but it should be emphasized that different studies seek to answer different questions. In particular, it is important to be aware of the level of efficiency being addressed in an analysis.

In this paper I have described a number of examples of the use of clinical decision analysis for guiding both individual patient decisions, and decisions for populations. The former is the only systematic way in which patients' preferences can be formally included in the decision. This is not always appropriate and it would be foolish to use decision analysis for many everyday clinical decisions. However, for difficult decisions, there are good reasons to believe that it will result in decisions that accord better with patient preferences than intuitive methods. Practitioners of evidence-based medicine will be looking for evidence from randomized controlled trials.