Difference between revisions of "Hysterectomy"

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}}
 
}}
 
{{Fixation - standard}}
 
{{Fixation - standard}}
 +
For a freshly received uterus, generally gross it fresh to include either opening it up (small specimen, no suspected malignancy seen) or serial sectioning, followed by putting it in formalin until fixation.
 
{{Fixation - general notes}}
 
{{Fixation - general notes}}
 +
{{Comprehensiveness|otherlegend=yes}}
 
==Gross processing==
 
==Gross processing==
 
===Benign indications===
 
===Benign indications===
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*The round ligament lies anterior to the tubes and ovaries.<ref name=stora/>
 
*The round ligament lies anterior to the tubes and ovaries.<ref name=stora/>
 
*The peritoneum extends further down along the cervix posteriorly than anteriorly.<ref name=umich>{{cite web|url=https://www.pathology.med.umich.edu/cutting/viewPage/40/186|title=General Specimen Orientation Tips|website=The University of Michigan|date=2020-01-29}}</ref> Its ends bluntly posteriorly and sharply anteriorly.<ref name=umich/>  
 
*The peritoneum extends further down along the cervix posteriorly than anteriorly.<ref name=umich>{{cite web|url=https://www.pathology.med.umich.edu/cutting/viewPage/40/186|title=General Specimen Orientation Tips|website=The University of Michigan|date=2020-01-29}}</ref> Its ends bluntly posteriorly and sharply anteriorly.<ref name=umich/>  
 
Optionally, remove the adnexa.<ref name=stora/>
 
  
 
Steps:<ref name=stora/>
 
Steps:<ref name=stora/>
*Perform a general inspection
+
*{{Moderate-begin}}Remove the '''adnexa'''.<ref name=stora/> '''Weigh''' the uterus without the adnexa.{{Moderate-end}}
*Measure length, width, thickness
+
*Perform a general '''inspection'''
*The uterus is usually opened at the front in the midline, optionally with an incision towards each corner.<ref group="notes">The uterus can also be opened laterally, through the parameters.</ref> Open the cavity completely, along the existing incision. The cavity is sometimes be squeezed or rolled around a leiomyoma, and you'll you have to improvise and perhaps go around the leiomyoma to open the cavity properly. Cut through the front wall into both corners.
+
*'''Measure''' the 3 dimensions, including the cervix. {{Moderate-begin}}Also measure the length of the cervix, the maximum diameter of the cervix, and the width of the cervical os.{{Moderate-end}}
*Inspect the mucosa. If any polyps: {{further|Endometrial polyp|linebreak=no}}
+
*'''Open''' the uterus by transmural radial cuts on both sides of the uterine cavity.<ref group=notes>
*Measure the thickness of the mucosa and myometrium
+
*In the '''US''', the cut goes from side to side, through the cervix and uterine cavity, keeping the anterior and posterior halves attached by a relatively thin connection left at the fundus. It is done by cutting with scissors with the blunt end in the cervix and then uterine cavity, or by a blade guided on each side by the shanks of a pair of forceps inserted through the cervix.
 +
*In '''Sweden''', the uterus is usually opened at the front in the midline, optionally with an incision towards each corner.
 +
It can be done by scissors, or by inserting a probe or forceps to guide a long blade.
 +
</ref> The cavity is sometimes be squeezed or rolled around a leiomyoma, and you'll you have to improvise and perhaps go around the leiomyoma to open the cavity properly.
 +
*Inspect the '''mucosa'''. If any polyps: {{further|Endometrial polyp|linebreak=no}}
 +
*'''Serially section''' through almost the entire depth of the myometrium, still keeping the specimen together.
 +
*Measure the '''thickness''' of the mucosa and myometrium
 
[[File:Leiomyoma.jpg|thumb|[[Smooth muscle tumor]] (in this case leiomyoma).]]
 
[[File:Leiomyoma.jpg|thumb|[[Smooth muscle tumor]] (in this case leiomyoma).]]
*Inspect the myometrium. If any tumor: {{further|Smooth muscle tumor|linebreak=no}}
+
*Inspect the '''myometrium'''. If any tumor: {{further|Smooth muscle tumor|linebreak=no}}
  
 
====Gross report====
 
====Gross report====
 
Components:<ref name=stora/>
 
Components:<ref name=stora/>
*Shape of uterus and adnex
+
*{{Moderate-begin}}Shape of uterus and adnex{{Moderate-end}}
 
*Measurements
 
*Measurements
 
*Mucosa, such as smooth or irregular.
 
*Mucosa, such as smooth or irregular.
*Any polyps. {{further|Endometrial polyp|linebreak=no}}
+
*{{Moderate-begin}}Even the absence of{{Moderate-end}} any polyps. {{further|Endometrial polyp|linebreak=no}}
 
*Mucosal and endometrial thickness
 
*Mucosal and endometrial thickness
*Any smooth muscle tumor. {{further|Smooth muscle tumor|linebreak=no}}
+
*{{Moderate-begin}}Even the absence of{{Moderate-end}} any smooth muscle tumor. {{further|Smooth muscle tumor|linebreak=no}}
 +
 
 +
;Example:
 +
{|class=wikitable
 +
| {{Moderate-begin}}A. Labeled - __. The specimen is received in formalin and consists of a resected{{Moderate-end}} uterus with cervix [and bilateral fallopian tubes and ovaries].  The uterus and cervix measure [ ] cm and weighs [ ] grams. The serosa is [tan-pink and smooth]. The cervix measures [ ] cm in diameter and [ ] cm in length. The ectocervical mucosa is [tan-pink and smooth] and the cervical os[ is patent] and measures [ ] cm in diameter. The specimen is bisected in the coronal plane. The endocervical canal is [patent and displays a tan-pink smooth mucosa]. The endometrial cavity is [triangular] and is lined by[ smooth] endometrium measuring [0.1] cm in average thickness. The myometrium measures up to [ ] cm in thickness.[
 +
- It displays __ intramural leiomyomata measuring up to __ cm in greatest diameter.
 +
 
 +
] The right ovary measures [ ] cm and has a [tan-pink and smooth] capsule. Cut sections show [no gross lesions]. The right fallopian tube measures [ ] cm in length and [ ] cm in average diameter. The serosa [is tan-pink and smooth]. Cut sections reveal a small patent lumen and no gross lesions. The left ovary measures [ ] cm and has a [tan-pink and smooth]  capsule. Cut sections show [no gross lesions].The left fallopian tube measures [ ] cm in length and [ ] cm in average diameter. The serosa [is tan-pink and smooth]. Cut sections reveal a small patent lumen and no gross lesions. Representative sections are submitted for microscopic examination in [ ] cassettes.
 +
|}
  
 
====Slices for microscopy====
 
====Slices for microscopy====
 
Submit:<ref name=stora/>
 
Submit:<ref name=stora/>
*Four cross-sectiosn from any accompanying ectocervix. In subtotal extirpation, a cross-section is taken from the lower resection border.
+
*One, {{Moderate-begin}}two - at 6 and 12 o'clock{{Moderate-end}}, {{Comprehensive-begin}}or four{{Comprehensive-end}} cross-sections from any accompanying '''ectocervix'''. In subtotal extirpation, a cross-section is taken from the lower resection border.
*A transverse slice through the endocervix, possibly divided into two.
+
*{{Comprehensive-begin}}A transverse slice through the '''endocervix''', possibly divided into two.{{Comprehensive-end}}
*One slice from the front and one from the back wall of the corpus, and one piece from each corner, including myometrium.
+
*'''Endometrium and myometrium''', by one slice from the front and one from the back wall of the corpus.
*Any mucosal parts with macroscopically abnormal appearance, including polyps.
+
*{{Finding-begin}}Any mucosal parts with macroscopically '''abnormal''' appearance, including polyps.{{Finding-end}}
*In case of endometrial hyperplasia, most of the mucosa of the corpus and fundus.
+
*{{Finding-begin}}In case of '''endometrial hyperplasia''', most of the mucosa of the corpus and fundus.{{Finding-end}}
*Samples form all smooth muscle tumors >5 cm in diameter. {{further|Smooth muscle tumor|linebreak=no}}
+
*{{Finding-begin}}Samples from all '''[[smooth muscle tumor]]s''' >5 cm in diameter.{{Finding-end}} {{further|Smooth muscle tumor|linebreak=no}}
 +
 
 +
See also:
 +
*[[Fallopian tube]]
 +
*[[Ovary]]
  
 
==Microscopic evaluation==
 
==Microscopic evaluation==

Revision as of 16:57, 1 December 2020

Author: Mikael Häggström [note 1]

Fixation

Generally 10% neutral buffered formalin. For a freshly received uterus, generally gross it fresh to include either opening it up (small specimen, no suspected malignancy seen) or serial sectioning, followed by putting it in formalin until fixation.

  See also: General notes on fixation


Comprehensiveness

On this resource, the following formatting is used for comprehensiveness:

  • Minimal depth
  • (Moderate depth)
  • ((Comprehensive))
Other legend

<< Decision needed between alternatives separated by / signs >>
{{Common findings / In case of findings}}
[[Comments]]
Link to another page

Gross processing

Benign indications

Applicable in bleeding disorders, pain, leiomyoma and endometrial hyperplasia.[1]

Gross examination

For orientation:

  • The round ligament lies anterior to the tubes and ovaries.[1]
  • The peritoneum extends further down along the cervix posteriorly than anteriorly.[2] Its ends bluntly posteriorly and sharply anteriorly.[2]

Steps:[1]

  • (Remove the adnexa.[1] Weigh the uterus without the adnexa.)
  • Perform a general inspection
  • Measure the 3 dimensions, including the cervix. (Also measure the length of the cervix, the maximum diameter of the cervix, and the width of the cervical os.)
  • Open the uterus by transmural radial cuts on both sides of the uterine cavity.[notes 1] The cavity is sometimes be squeezed or rolled around a leiomyoma, and you'll you have to improvise and perhaps go around the leiomyoma to open the cavity properly.
  • Inspect the mucosa. If any polyps: Further information: Endometrial polyp
  • Serially section through almost the entire depth of the myometrium, still keeping the specimen together.
  • Measure the thickness of the mucosa and myometrium
Smooth muscle tumor (in this case leiomyoma).

Gross report

Components:[1]

  • (Shape of uterus and adnex)
  • Measurements
  • Mucosa, such as smooth or irregular.
  • (Even the absence of) any polyps. Further information: Endometrial polyp
  • Mucosal and endometrial thickness
  • (Even the absence of) any smooth muscle tumor. Further information: Smooth muscle tumor
Example
(A. Labeled - __. The specimen is received in formalin and consists of a resected) uterus with cervix [and bilateral fallopian tubes and ovaries]. The uterus and cervix measure [ ] cm and weighs [ ] grams. The serosa is [tan-pink and smooth]. The cervix measures [ ] cm in diameter and [ ] cm in length. The ectocervical mucosa is [tan-pink and smooth] and the cervical os[ is patent] and measures [ ] cm in diameter. The specimen is bisected in the coronal plane. The endocervical canal is [patent and displays a tan-pink smooth mucosa]. The endometrial cavity is [triangular] and is lined by[ smooth] endometrium measuring [0.1] cm in average thickness. The myometrium measures up to [ ] cm in thickness.[

- It displays __ intramural leiomyomata measuring up to __ cm in greatest diameter.

] The right ovary measures [ ] cm and has a [tan-pink and smooth] capsule. Cut sections show [no gross lesions]. The right fallopian tube measures [ ] cm in length and [ ] cm in average diameter. The serosa [is tan-pink and smooth]. Cut sections reveal a small patent lumen and no gross lesions. The left ovary measures [ ] cm and has a [tan-pink and smooth] capsule. Cut sections show [no gross lesions].The left fallopian tube measures [ ] cm in length and [ ] cm in average diameter. The serosa [is tan-pink and smooth]. Cut sections reveal a small patent lumen and no gross lesions. Representative sections are submitted for microscopic examination in [ ] cassettes.

Slices for microscopy

Submit:[1]

  • One, (two - at 6 and 12 o'clock), ((or four)) cross-sections from any accompanying ectocervix. In subtotal extirpation, a cross-section is taken from the lower resection border.
  • ((A transverse slice through the endocervix, possibly divided into two.))
  • Endometrium and myometrium, by one slice from the front and one from the back wall of the corpus.
  • {{Any mucosal parts with macroscopically abnormal appearance, including polyps.}}
  • {{In case of endometrial hyperplasia, most of the mucosa of the corpus and fundus.}}
  • {{Samples from all smooth muscle tumors >5 cm in diameter.}} Further information: Smooth muscle tumor

See also:

Microscopic evaluation

Look for signs of malignancy:

Cervix

edit
Look for cervical dysplasia. It is mainly seen as nuclei with hyperchromasia, coarse chromatin and irregular contours.[3]

Further information: Cervical dysplasia


Uterine body

Main findings:

Microscopy report

Example in a normal case:

Microscopy of hysterectomy shows ecto and endocervix without atypia. The glands have columnar epithelium without atypia.

In the uterine cavity, there is endometrial mucosa with ordinary thickness and regularly arranged endometrial glands. (Optionally: Description of likely menstrual phase.) Sharp delimitation between endometrium and myometrium. The myometrium contains no focal changes. No evidence of malignancy.

Notes

    • In the US, the cut goes from side to side, through the cervix and uterine cavity, keeping the anterior and posterior halves attached by a relatively thin connection left at the fundus. It is done by cutting with scissors with the blunt end in the cervix and then uterine cavity, or by a blade guided on each side by the shanks of a pair of forceps inserted through the cervix.
    • In Sweden, the uterus is usually opened at the front in the midline, optionally with an incision towards each corner.
    It can be done by scissors, or by inserting a probe or forceps to guide a long blade.
  1. For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.

Main page

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 Monica Dahlgren, Janne Malina, Anna Måsbäck, Otto Ljungberg. Stora utskärningen. KVAST (Swedish Society of Pathology). Retrieved on 2019-09-26.
  2. 2.0 2.1 . General Specimen Orientation Tips. The University of Michigan (2020-01-29).
  3. Khaled J. Alkhateeb, M.B.B.S., Ziyan T. Salih, M.D.. HSIL / CIN II / CIN III. PathologyOutlines. Topic Completed: 29 March 2021. Minor changes: 9 February 2022
  4. Source image by Ed Uthman from Houston, TX, USA. Creative Commons Attribution 2.0 Generic (CC BY 2.0) license

Image sources