Please see the algorithm below.
Abdominal hysterectomy
In November 1843, Charles Clay performed the first hysterectomy in Manchester, England. The earliest hysterectomies were supracervical, or subtotal, hysterectomies. The body of the uterus was removed while the cervix remained intact. In 1929, Richardson, MD, performed the first TAH, in which the entire uterus was removed. [1]
Prior to an abdominal hysterectomy, the patient undergoes a regional or general anesthetic. A patient remains awake during a regional anesthetic, with only part of the body being numbed to prevent pain. When given a general anesthetic, the patient is unconscious. In the absence of contraindications, neuraxial anesthesia provides a better quality of recovery than general anesthesia. [18]
The abdominal hysterectomy begins via a surgical incision 6-8 inches long, made either vertically, running from the navel to the pubic bone, or horizontally, running along the top of the pubic hairline. The cut exposes the ligaments and blood vessels surrounding the uterus. These ligaments and blood vessels then are separated from the uterus and cervix. In the process, the blood vessels are tied off to prevent bleeding and to help in healing. The uterus and cervix are then cut off at the superior portion of the vagina and removed. The top of the vaginal cuff is closed with sutures, and the surgical wound is closed in layers.
An abdominal hysterectomy may be performed in conjunction with a salpingo-oophorectomy, in which the adnexa are removed, if needed. Possible complications include surgical wound infection; excessive bleeding; injury to the bowel, bladder, or ureter; nerve damage; and urinary tract infection. Candidates for this surgery include those who have fibroids, abnormal or heavy bleeding, chronic pelvic pain, endometriosis, adenomyosis (endometrial tissue that has infiltrated the myometrium), uterine prolapse, cancer of the reproductive organs, or pelvic inflammatory disease.
Vaginal hysterectomy
In a vaginal hysterectomy, the uterus is removed through the vaginal introitus. Prior to surgery, the patient is given a regional or a general anesthetic and the skin surrounding the vagina is prepped with an antibacterial solution. A surgical incision is then made in a circular fashion around the cervix and through the upper vagina to expose the tissue and blood vessels around the cervix and uterus. The tissues and vessels are cut and tied off for the uterus and cervix to be removed from the top of the vagina. The upper part of the vagina, where the surgical incision was made, is then sutured.
Possible complications include surgical wound infection; excessive bleeding; injury to the bowel, bladder, or ureter; nerve damage; and urinary tract infection. Often, colporrhaphy (reconstructive surgery) is performed to repair or prevent cystocele, rectocele, and/or vaginal vault prolapse.
Candidates for this surgery include those who have fibroids, abnormal or heavy bleeding, adenomyosis, uterine prolapse, early-stage cancer of the reproductive organs, or precancerous conditions of reproductive organs.
Laparoscopically assisted vaginal hysterectomy
Laparoscopically assisted vaginal hysterectomy (LAVH) is a procedure that uses laparoscopic surgical techniques and instruments to remove the uterus, cervix, and/or fallopian tubes and ovaries through the vagina. Prior to surgery, the patient is usually given a general anesthetic and the abdomen and vagina are prepared with an antibacterial solution.
LAVH begins with several small abdominal incisions inferior to the belly button, which allow the insertion of the laparoscope and other surgical tools. In order for the surgeon to observe the inside of the body clearly, the peritoneal cavity is inflated with gas (usually carbon dioxide), and a camera, which is attached to the laparoscope, captures and produces a continuous image that is magnified and projected onto a television screen.
Using the laparoscopic surgical tools, the tissues and vessels surrounding the uterus are cut and tied off. The uterus and cervix are then removed through the vagina, and the top of the vaginal cuff is sutured. The fallopian tubes and ovaries also may be removed during this surgical procedure.
Possible complications include surgical wound infection; excessive bleeding; injury to the bowel, bladder, or ureter; nerve damage; and urinary tract infection. Candidates for this surgery include those who have had previous abdominal surgery, large fibroids, chronic pelvic pain, endometriosis, or pelvic inflammatory disease, or those who want an oophorectomy. Today, robotic laparoscopic surgery, such as procedures involving the da Vinci Surgical Robot, is also being refined to evaluate the performance of LAVH.
Laparoscopic hysterectomy
Laparoscopic hysterectomy (LH) is a procedure in which the uterus and cervix are dissected and ligated from ligaments, tissues, vagina, and blood vessels and removed entirely from small abdominal incisions with the help of instruments like the morcellator. This procedure requires good surgical technique, intra and extracorporal sutures, and different hemostatic devices.
A meta-analysis showed no difference between total LH and vaginal hysterectomy for benign disease in perioperative complications. [19] Total LH was associated with lower pain scores and reduced hospital stay but took longer to perform.
The risk of intraperitoneal dissemination of malignant tissue led to a 2014 FDA black box warning against the use of laparoscopic power morcellation to remove uterine fibroid tumors. [20]
A retrospective cohort study by Multinu et al that included 75,487 women who underwent hysterectomy for benign gynecologic indications reported that major complication rates increased in the subset of 25,571 women who underwent hysterectomy for uterine fibroids after the FDA black box warning from 1.9% to 2.4%. [21]
Supracervical hysterectomy
Supracervical hysterectomy is defined as removal of the uterine corpus with preservation of the cervix and can be performed through abdominal, laparoscopic, or robotic approaches.
During supracervical hysterectomy, removal of the corpus is at or below the internal os along with ablation of the endocervical canal. During laparoscopic and robotically assisted hysterectomy, morcellation of the uterine fundus is performed to facilitate its removal through the port site incisions.
Women with known or suspected gynecological cancer, current or recent cervical dysplasia, or endometrial hyperplasia are not candidates for a supracervical procedure.
Evidence regarding the potential benefits of this procedure like less blood loss, shorter operating time, and fewer complications are limited to retrospective series. Patients should be counseled about the need for long-term follow up, the possibility of future trachelectomy, and the lack of data demonstrating clear benefits over total hysterectomy; hence, it should not be recommended by the surgeon as a superior technique for hysterectomy for benign diseases. [22]
Robot-assisted hysterectomy
Da Vinci surgical system was approved for use in gynecological surgery by FDA in 2005. Da Vinci hysterectomy involves a robotic system in which the surgeon's hands are naturally positioned while his or her fingers grasp the controls below the display, and movements are transferred in real time to surgical instruments inside the patient. This system is useful when the surgery involves dissection in a difficult situation, such as near the ureters, bladder, or blood vessels.
The current system consists of 4 components: (1) console where the surgeon sits and views the screen and controls the robotic instruments, (2) robotic cart with interactive arms, (3) camera and vision system, (4) wristed instruments with computer interfaces.
Advantages are 3-dimensional visualization with improved depth of perception, improved dexterity, less blood loss, shorter hospital stay, less pain, and less risk of wound infection.
Disadvantages include high cost, increased operating time associated with set up and docking, lack of tactile feedback, inability to reposition the patient once the robotic arms are attached, and the bulkiness of the system. [23]
Comparisons of hysterectomy procedures
With the various hysterectomy procedures available, physicians must limit healthcare dollars associated with these surgical procedures while maintaining quality health care for patients. Various studies have been performed to decide which surgical procedure is most suitable in terms of economics and patient health.
The severity of the pathological disorder must be the key standard in selecting the type of hysterectomy, in order to maintain optimum surgical practice. In studies performed in the United States, France, and the United Kingdom in which strict guidelines based on the severity of the pathological disorder have been implemented, most patients underwent successful vaginal hysterectomy without abdominal or laparoscopic assistance. [24]
In a study by Gimbel et al subtotal hysterectomy is faster to perform, has less perioperative bleeding, and seems to have less intra- and postoperative complications. [25] However it does have a slightly high rate of urinary incontinence and cervical stump problems.
Significantly improved outcomes suggest vaginal hysterectomy (VH) should be performed in preference to abdominal hysterectomy (AH) where possible. Where VH is not possible, LH may avoid the need for AH; however, the length of the surgery increases as the extent of the surgery performed laparoscopically increases, particularly when the uterine arteries are divided laparoscopically. Also, laparoscopic approaches require greater surgical expertise. [26]
Four-year follow-up data indicate that patients who underwent laparoscopic hysterectomy reported a better quality of life compared to those who underwent AH. Laparoscopic hysterectomy should be considered for patients in whom VH is not possible. [27]