Hysterectomy is one of the most frequently performed surgical procedures.
Approximately 600,000 hysterectomies are performed each year.
May be performed vaginally, abdominally, laparoscopically, or with robotic assistance.
Factors to be considered in choosing the route should include safety, cost-effectiveness, and the medical needs of the patient.
Hysterectomy may be performed vaginally, abdominally, laparoscopically, or with robotic assistance, with the route depending primarily on physician choice.
Factors to be considered in choosing route for hysterectomy should include safety, cost-effectiveness, and the medical needs of the patient.
A large body mass index (BMI) may also play a role in the route chosen.
Outcomes of abdominal hysterectomy, laparoscopic hysterectomy, and vaginal hysterectomy in very obese and morbidly obese patients: abdominal hysterectomy is associated with more postoperative complications such as wound dehiscence and wound infections and longer length of hospital stay in this patient population than were seen with the other two procedures.
Vaginal hysterectomy, when feasible, is the safest and most cost-effective procedure for removal of the uterus.
However, the abdominal route is the one most commonly chosen: 66% of hysterectomies are performed abdominally, 22% are performed vaginally, and 12% are performed laparoscopically.
The most common indications for hysterectomy are: symptomatic uterine leiomyomas, endometriosis, and uterine prolapse.
Very few absolute contraindications for vaginal hysterectomy exist and include pregnancy, and cancer.
Factors influencing the choice of hysterectomy include:
Surgeon training and experience
Accessibility of the uterus
Extent of extrauterine disease
Size and shape of the uterus
Need for concurrent procedures
Relative contraindications to vaginal hysterectomy include:
Narrow pubic arch of less than 90º.
Possible factors that may militate against vaginal hysterectomy include: adnexal pathology, severe endometriosis, adhesions, and an indication for salpingo-oophorectomy.
Saplings-oophorectomy is not a contraindication for vaginal hysterectomy.
Many nulliparous women and many women who have undergone cesarean delivery have sufficient vaginal capacity to allow a vaginal hysterectomy, as long as the surgeon can obtain adequate access for division of the uterosacral and cardinal ligaments, to mobilize the uterus sufficiently to allow vaginal extraction.
In the presence of an enlarged uterus, vaginal hysterectomy often can be accomplished safely by means of morcellation, uterine bisection, wedge debulking, or intramyometrial coring.
Vaginal hysterectomy, compared with all other routes for hysterectomy, yields better outcomes and fewer complications.
When vaginal hysterectomy is not possible, laparoscopic vaginal hysterectomy has advantages over abdominal hysterectomy.
Laparoscopic vaginal hysterectomy compared to abdominal hysterectomy has a faster return to normal activity, shorter hospital stay, reduced intraoperative blood loss, and fewer wound infections.
Laparoscopic vaginal hysterectomy disadvantages include longer operating time and higher rate of urinary tract injury.
Culdoplasty is generally recommended to reduce the risk of subsequent enterocele formation and potential vaginal vault prolapse.
There are 2 methods of culdoplasty: Moschcowitz repair, closing the cul-de-sac and bringing the uterosacral-cardinal complex together in the midline, and the McCall culdoplasty that obliterates the cul-de-sac, plicating the uterosacral-cardinal complex, and elevating any redundant posterior vaginal apex.
The McCall procedure may be superior in preventing enterocele by placing
an absorbable suture through the full thickness of the posterior vaginal wall at the apex of what will be the vaginal vault.
The primary intraoperative complications are visceral injury and hemorrhage.
Reported rates of hemorrhage during the procedure range from 1.4% to 2.6%.
The reported rates of ureteral and bladder injury are 0.88% and 1.76%, respectively.
The most common postoperative complication is pelvic infection.
Fever occurs in approximately 15% of women who undergo vaginal hysterectomy and can be reduced by means of prophylactic antibiotics.
Infections after vaginal hysterectomy include vaginal cuff cellulitis, pelvic cellulitis, and pelvic abscess, occuring in approximately 4% of women.
For enlarged uteri, morcellation, intramyometrial coring, uterine bisection, and wedge debulking maybe employed.
Morcellation can be used with uterine enlargement, uterine fixation, or limited vaginal exposure.
Morcellation should not be performed if the uterine arteries cannot be secured or if malignancy is suspected.
A culdoplasty is recommended to reduce the risk of subsequent enterocele formation and potential vaginal vault prolapse.
The primary intraoperative complications of vaginal hysterectomy are visceral injury and hemorrhage, with
rates of hemorrhage ranging from 1.4% to 2.6%, and rates of ureteral and bladder injury are 0.88% and 1.76%, respectively.
The most common postoperative complication of vaginal hysterectomy is pelvic infection.
Fever occurs in approximately 15% of women who undergo vaginal hysterectomy and can is reduced by prophylactic antibiotics.
Infections after vaginal hysterectomy occur in approximately 4% of women, and include: vaginal cuff cellulitis, pelvic cellulitis, and pelvic abscess.