Vaginal Hysterectomy

What the Anesthesiologist Should Know before the Operative Procedure

Hysterectomy is the second most commonly performed procedure in the United States. In addition to a vaginal approach, other options include an abdominal hysterectomy, laparoscopic assisted vaginal hysterectomy, and total laparoscopic hysterectomy. Robotically-assisted laparoscopic hysterectomy is also performed.

Factors such as the indication for surgery, the patient’s pelvic anatomy, and the surgeon’s preference are taken in to account when determing the type of hysterectomy. A vaginal hysterectomy is performed primarily on an elective basis, and the likelihood of converting to a laparoscopically-assisted or abdominal approach should be clarified with the surgeon prior to developing an anesthetic plan. Overall, evidence demonstrate that the vaginal hysterectomy is the surgical route of choice for benign disease.

1. What is the urgency of the surgery?

What is the risk of delay in order to obtain additional preoperative information?

A vaginal hysterectomy is almost always an elective procedure. The most common indications for a vaginal hysterectomy include uterine leiomyomata, menstrual disorders, pelvic organ prolapse, pelvic pain or infection, and malignant or premalignant disease. The patients presenting for a vaginal hysterectomy do not have a higher prevalence of any specific comorbidities that may need to be evaluated prior to surgery, and the decision to obtain additional preoperative information should be patient-specific. If further evaluation or testing is needed, the surgery can usually be delayed.

Emergent: A hysterectomy can be an emergency in the peripartum period, due to uncontrolled hemorrhage secondary to uterine atony, uterine rupture, or placenta acreta, but this would be completed via an abdominal, not vaginal, approach.

Urgent: The majority of vaginal hysterectomies are performed for benign conditions; however they are also performed for gynecologic malignancies including cervical, ovarian, and uterine cancer. Significant delay of surgery for a malignancy may affect oncological prognosis and outcome.

Elective: Almost all vaginal hysterectomies are performed on an elective basis.

2. Preoperative evaluation

The average age of the female undergoing a vaginal hysterectomy is late 40s to early 50s. Patients should undergo a routine history and focused physical exam. The indication for the procedure may help guide the preoperative evaluation of the patient. In particular, patients with abnormal uterine bleeding require a closer assessment for anemia, and patients with a malignancy may require an evaluation for metastatic disease.

Patients presenting for a vaginal hysterectomy should also have a detailed respiratory and cardiac assesment with management guided by the American College of Cardiology/American Heart Association (ACC/AHA) Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery.

• Medically unstable conditions warranting further evaluation include unstable or severe angina, recent myocardial infarction, decompensated heart failure, significant arrhythmias, severe valvular disease, recent stroke or TIAs, or COPD exacerbation.

• Delaying surgery may be indicated if the patient has an unstable medical condition and further evaluation or medical optimization would affect the surgical or anesthetic management of the patient.

3. What are the implications of co-existing disease on perioperative care?

Perioperative evaluation

A basic history and physical exam should be perfomed on every patient.

Perioperative risk reduction strategies

A more detailed work-up should be guided by the patient’s baseline medical condition and comorbidities.

b. Cardiovascular system

Perioperative evaluation

Acute/unstable conditions

If history or physical examination suggest the patient has unstable or severe angina, a recent MI, decompensated heart failure, significant or new-onset arrhythmia, or severe valvular disease, these issues should be further evaluated and treated prior to undergoing surgery. Evaluation may include a 12-lead EKG, cardiac biomarkers for patients with active chest pain, cardiac stress tests, resting echocardiogram to evaluate cardiac function and valves, cardiac angiography, and consultation with a cardiologist.

Baseline coronary artery disease or cardiac dysfunction

A thorough cardiac history should be taken, including looking for the presence of, or change in, any cardiac symptoms. The patient’s functional status should be assessed. Prior EKGs, stress tests, and echocardiograms should be reviewed in addition to the most recent notes from the patient’s primary care provider or cardiologist, if she has one. A discussion with the patient’s cardiologist may be necessary. If a patient has a pacemaker or an AICD, information regarding the manufacturer, mode, response to a magnet, and whether the patient is pacemaker-dependent should also be determined.

Perioperative risk reduction strategies

• ˆ In addition to standard ASA monitors, invasive monitoring, including a pre-induction arterial line, CVP, PA catheter, or TEE, may be required depending on the patient’s condition.

• ˆ If performing a general anesthetic, induction of anesthesia should be performed without large fluctuations in blood pressure and heart rate.

• ˆ The overall goal is to prevent myocardial ischemia by maintaining a favorable balance between myocardial oxygen supply and demand. Strategies to improve this balance include avoidance of tachycardia, arterial hypoxemia, and diastolic hypotension. A general recommendation is to maintain blood pressure and heart rate within 20% of awake values.

• ˆ A spinal anesthetic may be relatively contraindicated in patients with certain cardiac lesions, including aortic stenosis. If choosing a neuraxial technique, a spinal technique will cause a more rapid onset of sympathectomy than an epidural with larger fluctuation in blood pressure and heart rate.

c. Pulmonary

In general, patients with pulmonary disease are at an increased risk of post-operative pulmonary complications, including pneumonia and atelectasis. In patients with gynecologic cancer, a chest x-ray may be indicated to rule out lung pathology. If there is significant pulmonary involvement, an ABG or pulmonary function tests may be indicated. Patients with obstructive sleep apnea (OSA) are at a higher risk for postoperative complications, so and all patients should be evaluated for risk factors for OSA.

COPD

Perioperative evaluation

A history including current respiratory symptoms, recent exacerbations or URIs, pack years, medications, and oxygen usage should be obtained. Any available pulmonary function tests or ABGs should be reviewed. A physical exam and room air oxygen saturation should also be performed. Chronic hypoxemia may lead to pulmonary hypertension.

Perioperative risk reduction strategies

• ▪ Continue current pulmonary medications perioperatively. An inhaled beta-agonist or combination beta-agonist/anticholinergic preoperatively may be beneficial.

• ▪ For patients under general anesthesia, mechanical ventilation should be adjusted to decrease the the risk of barotrauma and rupture of emphysematous bullae and also allow for a maximal exhalation time to decrease gas trapping.

• ▪ Using a neuraxial technique with sedation will avoid airway manipulation and mechanical ventilation and decrease the risk for bronchospasm. However, patients with limited pulmonary reserve may depend on their accessory muscles for respiration, and a high spinal could decrease their respiratory function.

Reactive airway disease (Asthma)

Perioperative evaluation

Conduct a history to assess asthma severity including triggers, frequency of exacerbations, use of controller medications and rescue medications, emergency room visits, and current symptoms. Review available pulmonary function studies and degree of reversibility of the obstructive airway pathology with a bronchodilator.

Perioperative risk reduction strategies

• ▪ Continue current pulmonary therapies throughout the perioperative period including inhaled corticosteroids and beta-agonists

• ▪ Consider a neuraxial technique, which will have a lower incidence of bronchospasm than a general anesthetic

• ▪ If a general anesthetic is chosen, a deep level of anesthesia should be achieved prior to tracheal intubation to minimize bronchospasm associated with airway manipulation.

d. Renal-GI:

i. Assessment of volume status

The majority of vaginal hysterectomies are elective cases and the patient should be appropriately NPO. Assess last oral intake and dehydration status during the history and physical exam, including an assessment of vital signs (hypotension, tachycardia, orthostatic hypotension). If there is a specific concern regarding hypovolemia, one can also examine skin turgor, mucus membranes, urine output and laboratory values including BUN/Cr. This is often not necessary in the elective case in patients with no history of renal disease. If the patient received a bowel prep, they may have an additional fluid deficit.

ii. Chronic renal insufficiency

The etiology of renal insufficiency, baseline Cr, and if the patient is on dialysis should be determined. If they are dialysis-dependent, examine their dialysis access site and review when they were last dialyzed. A recent potassium level should be available and fluids should be managed judiciously during the case.

iii. The patient should be adequately NPO. NPO guidelines still need to be followed even if a regional technique is chosen. If using a general anesthetic, determine if the patient has factors placing them at an increased risk for pulmonary aspiration that necessitates a rapid sequence induction.

Perioperative risk reduction strategies

• In patients with preexisting renal disease, or those at high risk, avoid potential nephrotoxic drugs, including NSAIDs and aminoglycosides. Consider avoiding potassium-containing IV fluids.

• In high-risk patients, consider pre-op promotility agents including metoclopramide, H2-blockers, PPIs, or non-particulate acid reducers like Bicitra in addition to a rapid-sequence intubation. This will reduce the risk of pulmonary aspiration.

e. Neurologic:

Acute issues

Perioperative Evaluation

Patients with new onset or unstable neurologic conditions, including recent stroke or TIAs, should undergo additional evaluation prior to surgery.

Chronic disease

Perioperative Evaluation

• ▪ conduct a neurological history evaluating for history of stroke, TIAs, paralysis or weakness, seizure disorders, or dementia.

• ▪ determine of the patient has any condition that may make a neuraxial technique contraindicated or more difficult, such as a history of lumbar spine surgery or disease.

Perioperative Risk Reduction Strategies

• ▪ If a regional technique is chosen for a patient with significant carotid disease, an epidural technique may allow for less hemodynamic changes compared with the more rapid onset of sympatholysis seen with a a spinal or combined spinal-epidural technique.

• ▪ A history of carotid disease may necessitate higher blood pressures to keep the patient within 20% of their baseline. Consider arterial line placement. Have medications readily available to support blood pressure as needed.

• ▪ Older patients may also have coexisting dementia. Minimizing long-acting medications and benzodiazepines may help facilitate recovery.

f. Endocrine:

Perioperative evaluation

During the history, the patient should be evaluated for any baseline endocrine abnormalities, including diabetes mellitus and thyroid disorders.

Perioperative risk reduction strategies

Perioperative glucose control: determine if the patient has type I or type II diabetes, any medications being used to treat, insulin requirements, and range of home blood sugars. Glucose levels should be checked in the perioperative period with insulin treatment if necessary.

Patients on steroids should take their morning dose. For patients who have been treated with chronic steroids, depending on the daily dose and duration of treatment, supplementation with hydrocortisone may be indicated because of suppression of the hypothalamic-pituitary-adrenal axis.

g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)

N/A

4. What are the patient's medications and how should they be managed in the perioperative period?

Women undergoing a hysterectomy may be taking a variety of medications, including presciption and over-the-counter medications, as reviewed below.

h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

Many women in this population may be taking oral contraceptives or hormone replacement therapy. This places them at an increased risk for venous thromboembolism in the post-operative period. Some women may have been placed on a gonadotropin-releasing hormone (GnRh) analog prior to surgery to reduce fibroid size and uterine volume. In patients with iron-deficiency anemia, this results in an increased hemoglobin.

i. What should be recommended with regard to continuation of medications taken chronically?

Cardiac

• ˆ Beta blockers – patients already on a beta blocker should continue the medication perioperatively, including taking their dose the morning of surgery. For patients who are at an intermediate or high cardiac risk, starting beta blockers preoperatively is currently controversial.

• ˆ ACE Inhibitors and angiotensin receptor blockers – for patients already on medications in this class, some providers recommend holding these medications the morning of surgery due to the possibility of refractory hypotension in these patients.

• ˆ Statins – patients already on a statin should continue statin use perioperatively. Statin use should be resumed as soon as possible post-operatively, because statin discontinuation is associated with an increased risk of cardiac events and mortality.

• ˆ Aspirin – aspirin is often discontinued seven days prior to elective surgery due to an increased risk of perioperative bleeding. However, patients with coronary artery disease or cerebrovascular disease taking aspirin for the prevention of myocardial infarction or stroke require an individualized evaluation of the relative risk-benefit ratio of aspirin discontinuation.

• ˆ Clopidogrel (Plavix) – patients with a coronary stent may be on clopidogrel to maintain stent patency. In the preoperative evaluation, determine when the stent was placed and what type of stent was placed, bare metal or drug eluting. A discussion with the patient’s cardiologist and surgeon may be necessary to determine the optimal timing of surgery if a stent was placed recently and when anticoagulation should be restarted post-operatively. Patients who have received clopidogrel within the past seven days are not a candidate for a neuraxial technique based on the American Society of Regional Anesthesia and Pain Medicine guidelines from 2010.

• ˆ Coumadin – A thromboembolic risk assessment should be made for patients with atrial fibrillation on chronic coumadin to determine if a low molecular weight heparin (Lovenox®) “bridge” is necessary preoperatively.

Pulmonary

Medications including beta2-agonists, inhaled anticholinergic bronchodilators, inhaled steroids, and leukotriene inhibitors to control daily respiratory symptoms should be continued in the perioperative period, including the morning of surgery. One may consider additional short-acting beta2-agonists prior to induction of anesthesia. If a patient experiences worsening of their baseline symptoms, you may consider a delay of surgery until the patient is medically optimized with a steroid course or antibiotics as needed.

Neurologic

Patients with coexisting neurologic diseases, such as Parkinson’s disease and seizure disorders, should continue their medications perioperatively. Patients with a history of cerebrovascular disease on anticoagulants should have a risk-benefit assessent made regarding perioperative discontinuation of medications.

Anti-platelet

see above for a discussion of aspirin and clopidogrel.

Psychiatric

mood stabilizers, antidepressants, and anxiolytics should be continued in the perioperative period.

j. How To modify care for patients with known allergies –

For patients with known allergies, clarify if the reaction was a true allergy, an intolerance, or known side effect of the drug.

k. Latex allergy- If the patient has a sensitivity to latex (e.g., rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.

N/A

l. Does the patient have any antibiotic allergies- [Tier 2- Common antibiotic allergies and alternative antibiotics]

For patients allergic to cephalosporins, alternative antibiotics include clindamycin, metronidazole, and ciprofloxacin.

m. Does the patient have a history of allergy to anesthesia?

Malignant hyperthermia

Documented

avoid all triggering agents, such as succinylcholine and inhalational agents.

▪ Proposed general anesthetic plan: General anesthesia may be used with a total intravenous anesthetic technique and nondepolarizing muscle relaxants, if necessary.

▪ Insure MH cart is available and anesthesia machine is flushed with high-flow oxygen. Preparations for a general anesthetic still need to be made even if planning a regional technique as the primary anesthetic.

Family history or risk factors for MH

proceed as above for a patient with documented malignant hyperthermia.

Local anesthetics/ muscle relaxants

• ˆ If planning a regional technique, attempt to clarify the specific local anesthetic allergy or class of local anesthetics and the reaction. If there is concern for a true allergy, a general anesthetic may be indicated. Also, inform the surgeon of the allergy, because local anesthetic is often injected to assist with post-operative pain control.

5. What laboratory tests should be obtained and has everything been reviewed?

Preoperative laboratory tests should be guided by the patient’s baseline condition and comorbidities. A vaginal hysterectomy is a low risk procedure with minimal fluid shifts and an average blood loss of 100-200 ml. For patients with abnormal uterine bleeding, a preoperative hemoglobin will assess the degree of anemia.

Common laboratory normal values will be same for all procedures, with difference by age and gender.

Hemoglobin levels

There is no uniform transfusion trigger, as one must take into account the individual patient and their comorbidities. Also evaluate the possibility for ongoing blood loss, the degree of hemodynamic instability, and evidence for inadequate oxygen carrying capacity to end organs.

Electrolytes

• Potassium – patients on potassium-wasting diuretics may have hypokalemia. Hyperkalemia may be seen in patients with renal insufficiency or those on hemodialysis.

• Sodium – a preoperative sodium is generally not necessary, unless the patient has had a previous sodium disorder

• BUN/Cr – patients with renal insufficiency should have a recent BUN/Cr to determine the degree of insuffiency and to evaluate for recent deterioration in kidney function

• Glucose – patients with diabetes mellitus should have a preoperative glucose. A recent Hgb A1C should be reviewed, if available, to assess long-term glucose control.

Coagulation panel

a coagulation panel should be done for patients with a history of easy bruising or bleeding, and an INR should be obtained for patients on coumadin preoperatively. Coags may also be ordered for patients with hepatic disease or a history of coagulopathy.

Imaging

There generally are no specific imaging tests required for this patient population, unless their individual history and physical indicates further evaluation.

Other tests

• Pregnancy testing should be performed before surgery on all women who could be pregnant.

• Hypothyroidism may be encountered in this patient population, and so a recent TSH should be reviewed. If a patient provides a history consistent with medication non-compliance or significant symptoms of hypothyroidism or hyperthyroidism, further evaluation may be needed prior to elective surgery.

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

A vaginal hysterectomy can be performed under general anesthesia or regional anesthesia, including spinal, epidural, or combined spinal-epidural anesthesia. If a regional technique is used, a T6 sensory level is sufficient for procedures involving the uterus.

Regional anesthesia

– A neuraxial technique can performed as the primary anesthetic with supplemental sedation as needed for patient comfort or in combination with a general anesthetic. When used with a general anesthetic, an epidural is most commonly used for postoperative pain control. A spinal may consist of local anesthetic alone or with opioids, such as fentanayl and Duramorph, for post-operative pain control. A peripheral nerve block is not an option for this procedure.

Neuraxial

• Benefits

  May not need to manipulate a potentially difficult airway.

  May benefit patients with pulmonary disease to avoid airway manipulation and mechanical ventilation.

  May reduce post-operative cognitive dysfunction in the elderly.

  May decrease nausea in the immediate PACU period in most patients. For patients with a history of severe postoperative nausea and vomiting, avoiding inhalational agents may decrease their risk.

  May initially have superior pain control and have reduced need for IV and PO analgesics.

• Drawbacks

  Basic contraindications to regional anesthesia include patient refusal, infection at the site of needle placement, bacteremia, and hypovolemia. Aortic stenosis is a relative contraindication.

  If there is a need to convert to a general anesthetic, a difficult airway that could have been managed electively at the beginning of the case may now be more difficult.

  A neuraxial technique may be contraindicated in patients on anticoagulants or with a coagulopathy.

  Patients with chronic pain issues may have difficulty lying flat or may require higher levels of sedation.

  If the hysterectomy cannot be completed vaginally or further evaluation needs to be accomplished by the surgeon, a general anesthetic may be necessary for an abdominal approach or a laproscopically-assisted vaginal hysterectomy.

  In younger patients, if a spinal anesthetic is chosen, a pencil-point needle should be used to decrease the incidence of post-dural puncture headache.

Issues

If a patient is to get an epidural, postoperative anticoagulation management needs to be planned with the surgical team.

Peripheral Nerve Block

the surgeon may perform a paracervical block prior to starting the procedure for post-operative analgesia or for preemptive local analgesia.

General Anesthesia

• Benefits

  the airway is controlled and secured

  the anesthetic does not have to be altered if the surgeon converts to a different approach or the case takes longer than anticipated

  there is no failure rate, as with a spinal or epidural

• Drawbacks

  may increase post-operative cognitive dysfunction in the elderly

  may have increased risk for postoperative nausea and vomitting

  does not provide any sustained postoperative pain control

• Airway concerns- routine airway management. No specific concerns for this patient population.

Monitored Anesthesia Care

not an option

6. What is the author's preferred method of anesthesia technique and why?

I strongly take into account patient preference and individual patient characteristics and comorbidities when deciding on the anesthetic technique. The limited studies available suggest that a spinal may provide better immediate postoperative pain control compared to a general anesthetic.

For patients undergoing a vaginal hysterectomy with minimal chance of conversion to another approach or a more extensive procedure, a spinal anesthetic consisting of local anesthetic and Duramorph in combination with IV sedation works well for the intraoperative anesthetic and also provides pain control postoperatively. Data is conflicting on whether a spinal versus general anesthetic is associated with less chronic pain or an improvement in functional status months out from surgery.

It has also been shown that overall patient satisfaction with anesthesia and post-operative pain control is not significantly different between patients receiving a spinal and a general anesthetic. If there is the possibility of intra-op conversion to an abdominal approach or laprascopically-assisted vaginal hysterectomy, I prefer to perfom a general anesthetic without any regional technique.

What prophylactic antibiotics should be administered?

A vaginal hysterectomy is classified as a clean-contaminated wound. For gynecologic procedures, the Surgical Care Improvement Project (SCIP) recommends cefazolin 1g or 2g IV, cefotetan, cefoxitin, cefuroxime, or ampicillin-sulbactam. For patients with a cephalosporin allergy, alternatives include clindamycin with either gentamicin, a fluoroquinolone, or aztreonam; or metronidazole with gentamicin or fluoroquinolone. (SCIP antibiotic recommendations from 10/1/10- 3/31/11.)

What do I need to know about the surgical technique to optimize my anesthetic care?

• The average surgical time for a vaginal hysterectomy is 45-90 minutes.

• When the surgeon grasps the cervix, this may cause vagal stimulation with subsequent bradycardia. Treatment includes requesting the surgeon stop the cervical stimulation and treatment with IV atropine or glycopyrrolate if needed.

• A hemoconstrictive agent such as vasopressin or epinephrine may be used by the surgeon to decrease local bleeding. This may cause subsequent hypertension.

What can I do intraoperatively to assist the surgeon and optimize patient care?

• Patient positioning- the patient is positioned in the high dorsal lithotomy position using candy cane or Allen stirrups with the perineum positioned at the end of the operating table. Postoperative peripheral neuropathies are an uncommon complication. They may be related to surgical factors such as retractors or surgical resection, but also may be secondary to positioning. The femoral nerve is at risk especially in thin women with exaggerated hip flexion or abduction. The sciatic nerve is also at risk of injury because the nerve may be stretched with external rotation of the leg. The common peroneal nerve may be damaged if it is compressed between the frame of the leg support and the fibular head.

What are the most common intraoperative complications and how can they be avoided/treated?

• Although rare, possibility for bleeding.

• Risks associated with any surgery, including cardiac complications, pulmonary embolism, and allergic reactions.

• Conversion to another surgical approach. This may be due to further evaluation of the patient or for technical difficulties, such as with the salpingo-oophorectomy.

• Bladder injuries

Cardiac complications

The risk of cardiac complications is low with a vaginal hysterectomy and is primarily based on the patient’s baseline cardiac status. Whether using a neuraxial or general anesthetic there is a risk of arrhythmias, myocardial ischemia or infarction, and hypotension or hypertension as with any anesthetic. The sympathetic blockade from a spinal or high epidural block may cause hypotension and bradycardia.

Pulmonary

There are no unique complications to this procedure. Patients are at risk for pulmonary aspiration, hypoxemia, and hypercarbia; but no higher risk than other surgical procedures.

a. Neurologic:

Patients are at risk for peripheral nerve damage secondary to nerve compression, most commonly due to exaggerated positioning for a prolonged period of time. Patients receiving neuraxial anesthesia are also at risk of post-dural puncture headaches, direct nerve damage from block placement, spinal or epidural hematomas, and infection.

b. If the patient is intubated, are there any special criteria for extubation?

There are no special criteria for extubation. Follow standard criteria to determine when a patient is ready for extubation.

c. Postoperative management

What analgesic modalities can I implement?

• Epidural (with local anesthetics, opioids, or a combination), spinal Duramorph, IV opioids or PCA, IV NSAIDS (ketorolac). If opioid is used in an epidural or spinal, appropriate monitoring and possibly limiting other opioids is necessary to prevent respiratory depression.

• The surgeon may inject a local anesthetic, such as 0.5% bupivacaine with 1:200,000 epinephrine in a paracervical fashion preemptively at the start of the procedure. This has been associated with lower postoperative pain scores and a reduction in opioid use.

What level bed acuity is appropriate?

The majority of patients are able to be transferred to a ward bed. However, if a patient has significant preoperative comorbidities or has an intraoperative complication a higher level of monitoring may be necessary.

What are common postoperative complications, and ways to prevent and treat them?

The most common postoperative complication is unexplained fever. Other complications that the anesthesiologist may help prevent include positioning injuries, poor pain control, and postoperative nausea and vomiting.

What's the Evidence?

Brandsborg, B, Nikolajsen, L, Hansen, CT, Kehlet, H, Jensen, TS. “"Risk factors for chronic pain after hysterectomy. A nationwide questionnaire and database study."”. Anesthesiology.. vol. 106. 2007. pp. 1003-12. (A nationwide questionnaire and database study including women having hysterectomy for benign indications showed that at a follow-up interval of one year, spinal versus general anesthesia was associated with a lower frequency of chronic pain. This study is limited by its observational nature; however, spinal anesthesia may benefit patients at high risk for chronic pain.)

Tessler, MJ, Kardash, K, Kleiman, S, Rossignol, M. “"A retrospective comparison of spinal and general anesthesia for vaginal hysterectomy: a time analysis."”. Anesth Analg.. vol. 81. 1995. pp. 694-6. (A retrospective chart review comparing time efficinecy of spinal versus general anesthesia concluded that there was no difference in operating room efficiency with a spinal anesthetic. Patients in the spinal group had a slightly longer stay in the PACU.)

Falcone, T, Walters, MD. “"Hysterectomy for benign disease."”. Obstetrics and Gynecology. vol. 111. 2008. pp. 753-67.. (A comprehensive review of the indications, preoperative evaluation, perioperative considerations, and possible complications for hysterectomy.)

Long, JB, Eiland, RJ, Hentz, JG, Mergens, PA, Magtibay, PM, Kho, R, Magrina, JF, Cornella, JL. “"Randomized trial of preemptive local analgesia in vaginal surgery."”. Int Urogynecol J.. vol. 20. 2009. pp. 5-10. (A prospective, randomized, double-blinded trial of preemptive local analgesia consisting of 20 ml of 0.5% bupivacaine with 1:200:000 epinephrine injectected in a paracervical fashion was associated with decreased postoperative pain scores and opioid use.)

Sprung, J, Sanders, MS, Warner, ME, Gebhart, JB, Stanhope, CR, Jankowski, CJ, Liedl, L, Schroeder, DR, Brown, DR, Warner, DO. “"Pain relief and functional status after vaginal hysterectomy: intrathecal versus general anesthesia."”. Can J Anesth.. vol. 53. 2006. pp. 690-700. (A randomized, controlled trial in which patients received either general anesthesia or a spinal anesthetic with bupivacaine, clonidine, and morphine. Patients who received a spinal had better immediate postoperative pain control consistent with the expected duration of the intrathecal medications and less nausea in the PACU. However, overall, patients in both groups were equally satisfied with their anesthetic and pain management.)

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