CPT® Code 59350

1. Indications

The procedure of hysterorrhaphy is indicated in specific circumstances where a rupture of the uterus occurs, particularly during childbirth. The following conditions warrant the performance of this procedure:

• Ruptured Uterus A rupture of the uterus during labor, which can lead to significant maternal and fetal complications, necessitating surgical intervention for repair.
• Broad Ligament Hematoma The presence of a hematoma in the broad ligament due to the rupture, requiring drainage and repair to prevent further complications.
• Cervical and Vaginal Injury Extension of the uterine rupture into the cervix and vagina, which requires careful suturing to restore anatomical integrity.

2. Procedure

The procedure of hysterorrhaphy involves several critical steps to ensure effective repair of the ruptured uterus. Each step is essential for addressing the injury and preventing complications.

• Step 1: Abdominal Exploration The surgeon begins by making an incision to open the abdomen, allowing for exploration of the abdominal cavity. This step is crucial for assessing the extent of the uterine rupture and identifying any associated injuries or complications, such as blood clots that need to be removed.
• Step 2: Uterine Assessment Once the abdomen is opened, the uterus is carefully lifted out to visualize the site and extent of the rupture. This assessment is vital for determining the specific nature of the repair required.
• Step 3: Bladder Separation The bladder is then separated from the lower edge of the uterine segment to prevent injury during the repair process. This step is important for ensuring that the bladder remains intact and functional.
• Step 4: Ligating Uterine Vessels The surgeon locates and ligates any uterine vessels as necessary to control bleeding. This step is critical for maintaining hemostasis during the procedure.
• Step 5: Managing Broad Ligament Hematoma If a broad ligament hematoma is present, the round ligament is clamped, cut, and tied off. The anterior leaf of the broad ligament is then opened to allow for drainage of the hematoma, and any bleeding vessels are ligated to control further bleeding.
• Step 6: Cervical and Vaginal Repair In cases where the rupture extends into the cervix and vagina, the bladder is mobilized to facilitate access. The upper portion of the cervical injury is sutured first, and the repair is carried down distally until the entire cervical and vaginal injury is addressed.
• Step 7: Uterine Tear Repair The uterine tear is repaired in one or two layers, depending on the extent of the injury. Bleeding is controlled through suture ligation of any bleeding vessels encountered during the repair.
• Step 8: Drain Placement and Closure An abdominal drain is placed to facilitate the removal of any fluid accumulation post-operatively. Before closing the abdomen, the bladder is inspected to ensure it is free of injury. Finally, the abdomen is closed in layers around the drain to complete the procedure.

3. Post-Procedure

After the completion of the hysterorrhaphy procedure, the patient will require careful monitoring and post-operative care. Expected recovery includes observation for any signs of complications, such as infection or excessive bleeding. The abdominal drain will help manage fluid accumulation, and it is important to monitor its output. Patients may experience pain and discomfort, which can be managed with appropriate analgesics. Follow-up appointments will be necessary to assess healing and ensure that the uterus is recovering properly. Additionally, the patient will be advised on activity restrictions and signs of potential complications that should prompt immediate medical attention.