Hysterectomy is one of the most frequently performed gynecologic procedures, and more than 500,000 women undergo this procedure for benign disease annually in the United States (Jacoby, 2009). Of benign reasons, symptomatic leiomyomas and pelvic organ prolapse are the most frequent, although adenomyosis, endometriosis, chronic pain, and premalignant uterine or cervical disease are also relatively common.
To reach the preoperative diagnosis, testing varies on clinical signs and symptoms and is discussed within the respective chapters covering specific etiologies. Prior to hysterectomy, all patients require cervical cancer screening. With abnormal findings, further evaluation is completed to exclude invasive cancer, which is treated instead with radical hysterectomy or chemoradiation. Similarly, women at risk for endometrial cancer and whose indication includes abnormal bleeding are also usually screened before surgery (Chap. 8). Last, concurrent cervical infection or bacterial vaginosis is sought for preoperative eradication to lower postoperative infection risks.
Decision-making for Approach Selection
Hysterectomy may be completed using an abdominal, vaginal, laparoscopic, or robotic approach, and selection is influenced by many factors. For example, shape and size of the uterus and pelvis, surgical indications, presence or absence of adnexal pathology, extensive pelvic adhesive disease, surgical risks, hospitalization and recovery length, hospital resources, and surgeon expertise are all weighed once hysterectomy is planned. Each approach carries distinct advantages and disadvantages, discussed subsequently.
Surgeons usually choose this approach if the uterus is relatively small, extensive adhesions are not anticipated, no significant adnexal pathology is expected, and some degree of pelvic organ descent is present. When this procedure is compared with abdominal hysterectomy, patients usually benefit from faster recovery and from reduced hospital stays, costs, and postoperative pain (Johnson, 2005; Nieboer, 2009).
Despite the advantages of vaginal hysterectomy, most uteri in the United States are removed through an abdominal incision (Jacoby, 2009). Either a transverse or vertical incision may be selected depending on the clinical setting.
Abdominal hysterectomy allows the greatest ability to manipulate pelvic organs. Thus, it may be preferred if large pelvic masses or extensive adhesions are anticipated. Additionally, an abdominal approach affords access to the ovaries if oophorectomy is desired, to the space of Retzius or presacral space if concurrent urogynecologic procedures are planned, or to the upper abdomen for cancer staging. However, for surgeons with advanced skills in minimally invasive surgery (MIS), most of these limitations are overcome, and their indications for abdominal hysterectomy may be few. That said, abdominal hysterectomy typically requires less operating time than laparoscopic or robotic hysterectomy and requires no advanced MIS expertise or instrumentation. Moreover, the Food and Drug Administration (FDA) (2014) has recently discouraged the use of laparoscopic power morcellators due to the potential dispersion of occult cancer cells. While data are being collected regarding this risk, many surgeons and patients may forego MIS hysterectomy for larger uteri, and thus rates of abdominal hysterectomy may increase.
Disadvantages of abdominal hysterectomy include longer patient recovery and hospital stays, increased incisional pain, and greater risk of postoperative fever and wound infection (Marana, 1999; Nieboer, 2009). Additionally, compared with a vaginal approach, abdominal hysterectomy is associated with greater risk for ureteral injury, but lower rates of bladder injury (Frankman, 2010; Gilmour, 2006).
Selected more and more frequently, this hysterectomy group uses laparoscopic techniques to complete some or all steps of hysterectomy, and specific definitions are provided in Chapter 44 (Turner, 2013). Although criteria vary depending on surgeon skill, this approach is often selected if the uterus is not excessively large, extensive adhesions are not expected, and some limitation deters vaginal hysterectomy alone. Patient recovery, hospital stays, and postoperative pain scores are comparable with those of vaginal hysterectomy, but a laparoscopic approach allows greater visualization and access to the abdomen and pelvis. This may be advantageous if oophorectomy is planned or if adhesive disease or bleeding is encountered. However, laparoscopy typically requires longer operating times, expensive equipment, and MIS expertise. In addition, in most studies, laparoscopic hysterectomy has been associated with greater rates of ureteral injury than either abdominal or vaginal hysterectomy (Frankman, 2010; Gilmour, 2006; Mamik, 2014).
If all factors are equal, vaginal hysterectomy should be considered. However, with large pelvic masses or large uteri, with risk of gynecologic cancer, with extensive adhesions, or with poor uterine descent, either abdominal or laparoscopic hysterectomy may be required. Of note, surgical expertise is factored into the decision and strongly dictates the approach selected.
Total versus Supracervical Hysterectomy
Prior to hysterectomy, the decision to concurrently remove the cervix is discussed with the patient. Hysterectomy may include removal of the uterus and cervix, termed total hysterectomy, or may involve only the uterine corpus, called supracervical hysterectomy (SCH) (Fig. 43-12.1). The term subtotal hysterectomy is ambiguous and is not a preferred term.
Most hysterectomies performed are total, but SCH may be selected preoperatively. For example, SCH is purported to reduce the risk of mesh erosion at the cuff if concurrent hysterectomy and sacrocolpopexy are planned (Osmundsen, 2012; Tan-Kim, 2011). At one point, SCH was also suggested to improve urinary, bowel, or sexual function compared with total abdominal hysterectomy. But, several studies have shown no short- or long-term differences in these functions between total abdominal or supracervical hysterectomy (Learman, 2003; Lethaby, 2012; Thakar, 2002). Frequently, SCH may be an intraoperative decision during cases in which excision of the cervix risks increased bleeding, surrounding organ damage, or increased operating time.
As a disadvantage, 10 to 20 percent of women following SCH will still note cyclic vaginal bleeding, presumably from retained isthmic endometrium in the cervical stump. Procedures that ablate or core out the endocervical canal can help prevent this complication (Schmidt, 2011). Also, pelvic organ prolapse may develop (Hilger, 2005). For either complication, cervical stump excision, termed trachelectomy, may be required. Last, critics noted the persistent risk for cancer in the conserved stump. However, the risk for cervical cancer in these women is comparable to that in women without hysterectomy. Moreover, the prognosis for cervical stump cancer mirrors that in women with a complete uterus (Hannoun-Levi, 1997; Hellstrom, 2001).
In sum, SCH alone offers no distinct long-term advantages compared with total abdominal hysterectomy (American College of Obstetricians and Gynecologists, 2013b). The risk of persistent bleeding following surgery may deter many women and clinicians from its use. Moreover, although data are limited, trachelectomy following SCH may be surgically challenging due to scarring of bowel or bladder to the stump. Despite these disadvantages, if concurrent sacrocolpopexy is planned, SCH may lower mesh erosion rates. However, current data for this are limited and retrospective, and future research is needed.
For most women with indications, hysterectomy is a safe and effective treatment that typically leads to an improved postoperative quality of life and psychological outcome (Hartmann, 2004; Kuppermann, 2013). However, pelvic organs may be injured during surgery, and vascular, bladder, ureteral, and bowel injury are most commonly cited. Accordingly, these and the risks of wound infection, blood loss, and transfusion are discussed with the patient before surgery. Infrequently, unintended adnexectomy may be required, and if bilateral, will create iatrogenic menopause. Importantly, patients should understand the sterilizing effects of hysterectomy.
Concurrent Adnexal Surgery
Hysterectomy is frequently performed with other operations. Pelvic reconstructive surgeries and bilateral salpingo-oophorectomy (BSO) or salpingectomy are among the most frequent.
Bilateral fallopian tubes and ovaries are prophylactically removed in approximately 40 percent of hysterectomy cases performed for benign indications in the United States (Asante, 2010). In a woman younger than 40 years, ovaries are typically conserved because continued estrogen production is expected until her late 40s. In those older than 50 years, BSO is common. However, for women in their 40s, the decision to prophylactically remove ovaries is controversial.
Proponents of prophylactic BSO between 40 and 50 argue that the procedure lowers future ovarian cancer risk and is estimated to prevent 1000 new cases of ovarian cancer each year (American College of Obstetricians and Gynecologists, 2014b). In addition, patients with retained ovaries may require future surgery for subsequent benign ovarian disease. This risk approximates 3 percent at 10 years posthysterectomy (Casiano, 2013). Specifically, women with endometriosis, pelvic inflammatory disease, and chronic pelvic pain are at greater risk for reoperation. And, if later oophorectomy is required, the risk of ureteral or bowel injury due to adhesions encasing the retained ovary is increased from that with primary BSO. Last, the duration of significant ovarian estrogen production for many will be shortened following hysterectomy. For example, Siddle and coworkers (1987) noted that the mean age of ovarian failure in a group undergoing hysterectomy was 45 years. This was significantly lower than the mean age of 49 years in a control group not receiving surgery.
However, arguments for ovarian conservation are convincing as well. If ovaries are retained during hysterectomy, ovarian cancer risk is still decreased 40 to 50 percent by the hysterectomy itself (Chiaffarino, 2005; Rice, 2013). Additionally, conservation delays the long-term effects of hypoestrogenism (Chap. 21). Parker and colleagues (2013) noted higher ovarian and slightly elevated breast cancer rates but a lower all-cause mortality rate in women after hysterectomy with ovarian conservation compared with those electing BSO without estrogen replacement therapy (ERT). Although these rates became nearly equal in those electing BSO and then receiving postoperative ERT, concerns regarding ERT compliance have been noted. Castelo-Branco and coworkers (1999) found that after 5 years following hysterectomy and BSO, only one third of patients still continued their ERT. Most stopped due to cancer concerns. In addition to loss of estrogen, ovarian androgen production is removed, and its importance in later life has not been entirely delineated (Olive, 2005). The American College of Obstetricians and Gynecologists (2014b) recommends strong consideration of ovarian retention in premenopausal women who are not at increased genetic risk for ovarian cancer. Trends in the United States show a significant decline in BSO rates for those younger than 55 (Novetsky, 2011; Perera, 2013).
Even if ovaries are conserved, the Society of Gynecologic Oncology (2013) encourages consideration of concurrent bilateral salpingectomy during hysterectomy. This practice is hoped to lower peritoneal serous carcinomas (Chap. 35). That said, the degree of compromise of ovarian blood supply and long-term function by this resection is not fully known, and discussion of this point should be part of preoperative consenting.
Because of the risk of postoperative wound and urinary tract infection following hysterectomy, patients typically receive antibiotic prophylaxis with either a first- or second-generation cephalosporin (American College of Obstetricians and Gynecologists, 2014a). These and suitable alternatives are found in Table 39-6. As noted in Chapter 39, preoperative mechanical bowel preparation may be implemented depending on anticipated surgical circumstances. Fortunately, the risk of bowel injury with hysterectomy in general is low, and thus many forego evacuation measures for their patients. Laparotomy dictates venous thromboembolism prophylaxis, and options are found in Table 39-8.
Anesthesia and Patient Positioning
Abdominal hysterectomy is typically performed under general or regional anesthesia. The patient is often supine. But if concomitant vaginal procedures are planned, the patient is placed in low lithotomy position in adjustable booted stirrups. After anesthesia induction, hair in the planned incision path is clipped if needed; a Foley catheter is inserted; and abdominal preparation is completed.
Either a transverse or a vertical incision may be used for hysterectomy, and clinical factors influence selection.
Following entry into the abdomen, a self-retaining retractor such as an O’Connor-O’Sullivan or a Balfour retractor is placed. The pelvis and abdomen are visually and manually explored, and the bowel is packed from the operating field. The uterus is grasped and elevated from the pelvis. If extensive adhesions are present, normal anatomic relationships are restored. Hysterectomy may be performed by one surgeon, but commonly two surgeons are present, with each typically operating on his or her side of the uterus.
Round Ligament Transection
Curved Kelly (pean) clamps are placed immediately lateral to each uterine cornu to permit uterine manipulation. Hysterectomy begins with division of one round ligament at its midpoint (Fig. 43-12.2). This provides entry into the retroperitoneal space for ureter identification and access to the uterine artery and cardinal ligament for later transection. The round ligament is grasped with tissue forceps and elevated. A transfixing stitch using 0-gauge delayed-absorbable suture is placed approximately 1 cm lateral to the planned division site. The first bite of this stitch passes through an avascular site of the mesoteres beneath the round ligament, whereas the transfixing bite pierces the round ligament medial to first bite. This prevents hematoma formation between the transfixing stitch and pelvic sidewall. A second simple stitch of similar suture is placed 1 to 2 cm medial to the first and through an avascular site in the mesoteres and beneath the round ligament. These sutures prevent bleeding from Sampson artery and aid tissue manipulation. Once secured, sutures are held by hemostats and directed outward to create tension along the interposed ligament. The round ligament is then divided, and the incision line is directed deeply into the first 1 to 2 cm of the broad ligament.
Anterior Broad Ligament Leaf
With this action, the broad ligament separates to create anterior and posterior leaves. Between them, loose areolar connective tissue is seen. To incise the anterior leaf, the round ligament sutures are placed on tension. Metzenbaum scissors are introduced between the anterior leaf and underlying loose connective tissue. Both scissor tips are directed upward to be seen through the peritoneum as they advance. Gentle opening and closing of scissor blade tips during advancement separates the peritoneum from the underlying connective tissue. The tented anterior leaf is then incised sharply. The line of incision curves inferiorly and medially to the level of the vesicouterine fold, which generally lies just below the uterine isthmus (Fig. 43-12.3).
Opening of broad ligament anterior leaf.
Next, to further open the retroperitoneal space, the drape of peritoneum lying between the round ligament and infundibulopelvic (IP) ligament is grasped with smooth forceps and placed on tension. This peritoneum is incised with Metzenbaum scissors and with the same undermining technique used for the anterior leaf (Fig. 43-12.4). Lateral and parallel to the IP, the incision is extended cephalad toward the pelvic sidewall.
Peritoneal incision extension.
This is accomplished by localized blunt dissection that is advanced downward with gentle cephalad and caudad strokes into gauzy retroperitoneal tissue above the presumed ureter path (Fig. 43-12.5). Dissection is directed downward, medially, and slightly cephalad toward the medial aspect of the posterior peritoneal leaf, along which the ureter courses. Small vessels are coagulated as they are found.
Posterior Broad Ligament Leaf
With the ureter directly visualized, the posterior peritoneal leaf is incised to create a window. If ovarian preservation is planned, this window is made beneath the uteroovarian ligament alone. If oophorectomy is planned, the posterior leaf of the broad ligament is incised parallel to the IP ligament. The incision is extended toward the pelvic brim and medially toward the uterus just below the uteroovarian ligament. This delineates the IP for ligation (Fig. 43-12.6).
Posterior peritoneal window.
If the adnexa are to be removed, the fallopian tube and ovary are grasped with a Babcock clamp and elevated medially to place the IP ligament on mild tension for improved delineation (Fig. 43-12.7). With the ureter visualized, a curved Heaney clamp can be placed around this ligament with its arc curving upward. The tips of the clamps are placed through the previously created peritoneal window. A Kelly clamp is placed medial to this and closer to the adnexa.
Infundibulopelvic ligament transection during oophorectomy.
With clamps secured, the IP ligament is sharply transected above the Heaney clamp. A free tie of 0-gauge delayed-absorbable suture is placed around the Heaney clamp. As the knot of this suture is secured, the Heaney clamp is quickly opened and closed, that is, “flashed.” A transfixing stitch is then sutured below the clamp but above and distal to the first free tie. As the knot is cinched, the Heaney clamp is removed.
The adnexa is now freed from the pelvic sidewall, and its increased mobility may obstruct the surgeon’s view. Accordingly, the adnexa can be tied to the Kelly clamp still located on the cornu. Alternatively, adnexa can be simply excised and removed.
With the leaves of the broad ligament now open, if the ovary is to be preserved, then salpingectomy alone is now completed. This is fully described in Section 43-8. In summary, the mesosalpinx is serially clamped, cut, and ligated. Each clamp incorporates approximately 2 cm of mesosalpinx, and resection progresses from the fimbria to its union with the uterus.
To preserve the ovary, one Kelly clamp is already positioned at the cornu and across the uteroovarian ligament. A Heaney clamp is positioned lateral to this, and its arc faces the uterus (Fig. 43-12.8).
Uteroovarian ligament transection for ovarian conservation.
The intervening segment of uteroovarian ligament is incised between the Heaney and Kelly clamps. Ligation of the ligament is carried out as in Step 8. That is, a free tie of 0-gauge delayed-absorbable suture is placed around the Heaney clamp. As the knot is secured, the clamp is flashed. A transfixing stitch is then placed around the same clamp but distal to the first free tie. As the knot is cinched, the Heaney clamp is removed. The ovary is now freed from the uterus and can be placed laterally near the pelvic sidewall. The Kelly clamp is left in place at the cornu to prevent bleeding and allow uterine manipulation.
Steps 4 through 9 are completed bilaterally, and attention is next turned to the bladder. To avoid urinary tract injury, the bladder is moved caudad and away from the cervix. This is accomplished by first opening the vesicouterine space, the potential space between the bladder and cervix. Several techniques may be used, and at our institution, sharp dissection is preferred (Fig. 43-12.9). This method is particularly beneficial for patients with prior cesarean deliveries who may have scarring between the bladder and cervix. Alternatively, gentle blunt pressure from fingers or sponge stick can be used. Such pressure is directed beneath the bladder, against the cervix, and caudad. With either dissection method, taut uterine elevation creates helpful tension across the tissue planes to be separated. Tension is created by pulling upward on the Kelly clamps, previously placed at the cornua.
Dissection within vesicouterine space.
The peritoneum at the vesicouterine fold was previously incised bilaterally in Step 5. During dissection in the vesicouterine space, this peritoneum is grasped with atraumatic tissue forceps and elevated to create tension between it and the underlying cervix. Only loose connective tissue strands lie in this space, and they are easily cut with Metzenbaum scissors. Incision of these bands is kept close to the cervix to avoid cystotomy. Dissection in the midline minimizes laceration of vessels that course within the vesicocervical ligaments, colloquially termed bladder pillars. Once the correct plane is entered, the pearly white cervix and anterior vaginal wall are clearly differentiated from reddish bladder fibers.
The bladder is ideally dissected off the anterior vaginal wall at least 1 cm below the lower margin of the cervix. This averts incorporating bladder fibers within sutures or clamps placed during cuff closure. Thereby, bladder and distal ureteral injury, and later genitourinary fistulas, are prevented.
The uterine artery and vein(s) are identified laterally along the uterus. At the level of the isthmus, some posterior peritoneum and loose areolar tissue still surrounds these vessels. Incising and removing such tissue from around any vessel is termed skeletonizing. This ultimately creates a smaller vascular pedicle and minimizes risks for vessel retraction during ligation.
To skeletonize, a surgeon individually grasps excess strips of perivascular connective tissue with fine smooth forceps and gently retracts them laterally and away from the uterine artery or vein. Metzenbaum scissors incise this tissue close to and parallel to the vessel, beginning superiorly and proceeding inferiorly. During this process, the remaining posterior broad ligament peritoneum is similarly incised parallel and close to the uterus (Fig. 43-12.10). Importantly, this step further “drops” the ureter away from the path of subsequent clamps.
Once skeletonized, the uterine vessels are clamped by a curved Heaney clamp at the uterine isthmus level. The clamp tips are placed horizontally across the vertical uterine vessels (Fig. 43-12.11). A Kelly clamp is placed medial and more vertical to the first clamp and hugs the lateral uterus to prevent bleeding from severed vessels. Tissue between the clamps is then cut.
Uterine artery skeletonization.
A simple stitch of 0-gauge delayed-absorbable suture is placed below the Heaney clamp’s tip, and the suture ends are wrapped to the clamp’s heel. As the knot is cinched, the Heaney clamp is slowly opened and removed. The Kelly clamp remains.
After bilateral uterine artery ligation, if the uterus is large and bulky, the uterine fundus may be sharply severed from the cervix. After removal of the corpus, Kocher clamps are placed on the anterior and posterior walls of cervix for manipulation.
If supracervical hysterectomy is planned, no further transection is required. In premenopausal women, the upper endocervical canal is coagulated or removed by wedge resection to help avoid postoperative cyclic bleeding. The cervical stump is closed and rendered hemostatic with figure-of-eight stitches using 0-gauge delayed-absorbable suture. Each stitch passes through the posterior peritoneum, the posterior wall of the cervix, and then the anterior wall of the cervix before ligation. Conversely, if the cervical stroma is hemostatic, no suturing may be required.
Cardinal and Uterosacral Ligament Transection
These ligaments lie lateral to the uterus and inferior to the uterine vessels. A straight Heaney clamp is positioned across the cardinal ligament adjacent to the cervix and medial to the uterine artery pedicle (Fig. 43-12.12). As the Heaney clamp initially grasps the ligament, it is oriented parallel to the lateral side of the uterus. As the clamp is slowly closed, it is angled slightly away from the vertical axis of the cervix. A scalpel is used to transect the portion of the cardinal ligament medial to the clamp. A transfixing stitch of 0-gauge delayed-absorbable suture is placed below the clamp, and the clamp is removed as the knot is cinched. For smaller bites through the cardinal ligament, a simple stitch without transfixion may suffice.
Clamps across uterine artery.
Depending on the ligament length, the above step may be repeated several times. In this manner, the cardinal ligament is transected and ligated from its superior to inferior extent down the lateral aspect of the cervix to the level of the upper vagina. When this is near completion, the uterosacral ligaments remain as final support structures attached to the cervix. These ligaments are more easily felt and seen by placing upward traction on the uterus. In most benign cases, these ligaments are incorporated within instruments used to clamp across the lower cardinal ligament and proximal vagina.
Clamp across cardinal ligament.
For this step, the surgeon’s hand palpates through the anterior and posterior vaginal walls to identify the most inferior level of the cervix. Here, a curved Heaney clamp incorporates the uterosacral ligament and is placed across the anterior and posterior vaginal walls just below the cervix on one side. This is repeated on the other side, and the tips often meet in the midline (Fig. 43-12.13). Importantly, the bladder must be sufficiently mobilized away from this point to prevent injury.
Clamp incorporating uterosacral ligament and proximal vagina.
The vaginal tissue above the level of these clamps is then transected. This procedure frees the uterus from the pelvis. Transfixing sutures are placed below the Heaney clamps, and the clamps are removed (Fig. 43-12.14).
Clamps across proximal vagina. Two transfixing stitches for cuff closure.
During some cases, the cervix may be poorly appreciated between the vaginal walls. To avoid shortening the vagina or leaving cervix behind, the vagina can be entered to identify the cervix. For this, a small longitudinal incision is made in the midline of the upper anterior vaginal wall. A finger is inserted to palpate the cervical margin. Once this level is known, one blade of Jorgensen scissors is inserted into the vagina and positioned just below the cervix (Fig. 43-12.15). At this level, the vagina is then circumferentially cut. Kocher or Allis clamps are placed along the free cut vaginal edge as it forms.
Circumferential vaginal incision.
For support, a 0-gauge delayed-absorbable suture may be placed to suspend the vaginal apex to the uterosacral ligament pedicle on either side (Fig. 43-12.16). This stitch incorporates the anterior and posterior vaginal walls with the distal portion of the uterosacral ligament and helps prevent vaginal cuff prolapse following surgery.
Vaginal cuff closure incorporating uterosacral ligament.
These sutures are kept long and held by hemostats. Upward and lateral traction elevates the vaginal cuff. The full thicknesses of the incised anterior and posterior vaginal walls are then reapproximated with a running suture line using 0-gauge delayed-absorbable suture or with several figure-of-eight sutures. The peritoneum overlying the posterior vaginal margin should be included in this closure to lessen the risk of postoperative oozing. Anteriorly, the bladder should be kept clear of the suture line. Once the vaginal cuff is hemostatic, the lateral suspending cuff sutures are cut.
The abdominal incision is closed as described in Section 43-1 or 43-2.
Postoperative care follows that for laparotomy, although sexual intercourse is usually delayed until 6 weeks after surgery to permit satisfactory vaginal cuff healing.
Febrile morbidity is common following abdominal hysterectomy and exceeds that seen with vaginal or laparoscopic approaches (Peipert, 2004). Frequently, fever is unexplained. But, pelvic infections are common, and other sources of postoperative fever should be evaluated (Chap. 42). Because of the high rate of unexplained fever, which resolves spontaneously, observation for 24 to 48 hours for mild temperature elevations is reasonable. Alternatively, antibiotic treatment may be initiated, and appropriate choices are found in Table 3-20. Additional testing, including transvaginal sonography or computed tomography (CT), may be indicated if a pelvic hematoma or abscess is suspected.