This document discusses hysterectomy procedures. It notes that hysterectomy is the most common gynecological surgery, with over 600,000 performed annually in the US mostly for benign conditions. The main types of hysterectomy procedures discussed are abdominal, vaginal, laparoscopic (LAVH, TLH), and robot-assisted laparoscopic hysterectomy. Factors such as uterine size and mobility, prior surgeries, and need for oophorectomy or other procedures help determine whether an abdominal, vaginal, or laparoscopic approach is most appropriate. The risks, techniques, and post-operative care are reviewed for each approach. Alternatives to hysterectomy are also mentioned.

1. Hysterectomy
Robert D. Auerbach, M.D.
Senior Vice President & Chief Medical Officer
CooperSurgical, Inc.
Associate Clinical Professor
Yale University School of Medicine

2. Introduction
• Hysterectomy is the most commonly performed gynecological surgical
procedure
 600,000 hysterectomies are performed yearly (US)
 90% done for benign conditions
• Abdominal hysterectomy was more common than vaginal hysterectomy
(65% vs. 35%)
• Proportion of vaginal hysterectomies performed with laparoscopic
assistance doubled (from 13% to 28%)

3. Indications
• Leiomyomata
• Pelvic pain
• Pelvic relaxation
• Abnormal uterine bleeding
• Malignant and premalignant disease
“In the absence of a life-threatening emergency (eg, uterine hemorrhage), the decision to proceed with
hysterectomy is made mutually by the woman and her physician based upon her functional impairment,
childbearing plans, response to medical therapy, discussion of alternatives, and perception that the risks of the
procedure are outweighed by the expected benefits.” UpToDate, March 17, 2007

4. Alternatives: Depend on Underlying Disorder
• Uterine artery embolization and myomectomy may be used to treat
symptomatic leiomyoma
• Pain control services may be able to return patients with intractable pelvic
pain to a functional status without surgery
• Endometrial ablation may be an effective therapy for menorrhagia
• GnRH analogs can help reduce discomfort associated with endometriosis
• Endometrial hyperplasia can sometimes be treated medically with
progestins
• Conization may be adequate therapy for some women with high grade
CIN/CIS

5. Hysterectomy
Complete removal of fundus/cervix
• TAH
• TVH
• LAVH
• TLH

6. Hysterectomy
Subtotal or supracervical hysterectomy
• Result in cyclic vaginal bleeding in 7-11% of patients
• May require future resection
• No difference in the rates of incontinence, constipation or measures of
sexual function
• Length of surgery and amount of blood lost during surgery were
reduced during subtotal hysterectomy compared to total
hysterectomy
 No difference in transfusion rates

7. Hysterectomy
Subtotal/supracervical hysterectomy
• There was no difference in the rates of other complications, recovery
from surgery, or readmission rates
• Absolute contraindication to subtotal hysterectomy
 presence of a malignant or premalignant condition of the uterine corpus or
cervix
• Extensive endometriosis is a relative contraindication
 persistence of dyspareunia if the cervix is retained

8. Abdominal vs. Vaginal Hysterectomy
• Historically, TAH has been designated as the appropriate route for more
serious conditions
 Abdominopelvic exploration
 Procedures deemed too difficult to perform through the vagina
• These traditional indications for laparotomy have been challenged

9. Uterine mobility
• Prospective study
• All patients without prolapse undergoing hysterectomy for benign
conditions were included
• There were 97 abdominal and 175 vaginal procedures, with no
significant differences in patient characteristics
• The frequency of complications was low and similar in both groups
Abdominal vs. Vaginal Hysterectomy
Varma, R, Tahseen, S, Lokugamage, AU, Kunde, D. Vaginal
route as the norm when planning hysterectomy for
benign conditions: change in practice. Obstet Gynecol
2001; 97:613.

10. Abdominal vs. Vaginal Hysterectomy
Uterine size
• Prospective study evaluated vaginal hysterectomy outcome in 204
consecutive women with a myomatous uterus weighing 280 to 2000 g.
• Vaginal morcellation was performed in all cases
 no patient had uterovaginal prolapse
• Four patients underwent conversion to a laparoscopic procedure for the
completion of the hysterectomy
 two of these ultimately required laparotomy
• Adnexectomy was successfully performed vaginally in 91% of patients in
whom it was indicated
• Traditional uterine weight criteria for exclusion of the vaginal approach
may not be valid
Sizzi, O, Paparella, P, Bonito, C, et al. Laparoscopic assistance after
vaginal hysterectomy and unsuccessful access to the ovaries or
failed uterine mobilization: changing trends. JSLS 2004; 8:339.

11. Abdominal vs. Vaginal Hysterectomy
Prior cesarean delivery - concerns about scarring
• Retrospective review compared vaginal hysterectomy outcome of 220
women with prior cesarean deliver (one or more) to 200 patients with
no previous pelvic surgery
• Only 3 of the 220 patients had inadvertent urological trauma
intraoperatively
• Factors favoring a successful vaginal approach were only one previous
cesarean, a freely mobile uterus, previous vaginal delivery, uterus not
exceeding 10-12 weeks size, and absence of adnexal pathology
• Infection following the previous cesarean was an unfavorable
prognostic factor due to an increased risk of dense adhesions between
the bladder and cervix
Sheth, SS, Malpani, AN. Vaginal hysterectomy
following previous cesarean section. Int J Gynaecol
Obstet 1995; 50:165.

12. Abdominal vs. Vaginal Hysterectomy
Nulliparity
• Vaginal hysterectomy outcome in 52 nulliparous and 293
primiparous or multiparous women was compared prospectively
• The mean operative time was significantly longer in nulliparous
patients (95 vs. 80 minutes)
• Vaginal hysterectomy was successfully performed in 50/52 of the
nulliparous and 292/293 of the parous patients
• This suggests that nulliparous women can be considered
candidates for vaginal hysterectomy
Agostini, A, Bretelle, F, Cravello, L, et al. Vaginal hysterectomy in
nulliparous women without prolapse: a prospective comparative
study. BJOG 2003; 110:515.

13. Abdominal vs. Vaginal Hysterectomy
Need for oophorectomy
• Multiple clinical trials have shown that as many as 95% of ovaries can
be removed vaginally, with or without laparoscopic assistance*
Obesity
• Exposure of the operative field can be difficult in obese women,
whether an abdominal or vaginal route is taken
• Vaginal approach is suggested for obese women requiring
hysterectomy
 associated with lower postoperative morbidity than abdominal
hysterectomy**
*Davies, A, O'Connor, H, Magos, AL. A prospective study to
evaluate oophorectomy at the time of vaginal hysterectomy.
Br J Obstet Gynaecol 1996; 103:915.
**Isik-Akbay, EF, Harmanli, OH, Panganamamula, UR, et al.
Hysterectomy in obese women: a comparison of abdominal
and vaginal routes. Obstet Gynecol 2004; 104:710.

14. Abdominal Hysterectomy
• Patient Preparation
• For patients at risk, thromboembolism prophylaxis is begun preoperatively, or
pneumatic compression boots are applied in the OR
• Prophylactic antibiotic agent should be given as a single dose 30 minutes prior
to the incision
• Incision choice - transverse or vertical
• Need for exploration of the upper abdomen
• Size of the uterus
• Presence of prior incisions
• Desired cosmetic results

15. Abdominal Hysterectomy - the Procedure
• The peritoneal cavity is entered and the upper abdomen and pelvis
explored
• unexpected pathology
• confirm suspected pathological findings
• cytologic sampling of peritoneal fluid or peritoneal washings if indicated
• Exposure - When positioning retractors, it is important to avoid placing the
lateral blades over the femoral nerves since this can lead to a peripheral
neuropathy
• O'Connor-O'Sullivan
• Balfour
• Bookwalter

16. Abdominal Hysterectomy
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25. Abdominal Hysterectomy - the Procedure
Post-Op care -
• Not necessary to leave a bladder catheter in place postoperatively
• IV fluids for the first 24 hours to ensure that the patient remains well
hydrated
• Early feeding of a regular diet can stimulate the bowel and decrease
the length of hospitalization*
• Deep breathing to prevent atelectasis
• Ambulation is encouraged
• Intermittent compression boots
• Adequate control of postoperative pain
* Fanning, J, Andrews, S. Early postoperative feeding
after major gynecologic surgery: Evidence-based
scientific medicine. Am J Obstet Gynecol 2001; 185:1.

26. Post-op Abdominal Hysterectomy
• Walking and stair climbing are encouraged
• Tub baths or showers are OK
• Avoid heavy lifting (>20 pounds of weight from the floor) for 4-6 weeks to
minimize stress on the healing fascia
• Vaginal intercourse is also discouraged 4-6 weeks to allow the vaginal cuff
to heal completely
• Driving should be avoided until full mobility returns and opioid analgesia is
no longer required
• May return to work as soon as she has regained sufficient stamina and
mobility

27. Vaginal Hysterectomy
• A prophylactic antibiotic agent should be given as a single dose 30 minutes
prior to the first incision for vaginal hysterectomy
• cefazolin, cefoxitin, and cefuroxime
• Metronidazole (500 mg IV) may be used in patients with cephalosporin allergies
• A course of appropriate preoperative antibiotics in women with bacterial
vaginosis can reduce the frequency of cuff infection

28. Vaginal Hysterectomy
• Patient positioning - dorsal lithotomy
• Bimanual pelvic examination is performed
• assess uterine mobility and descent
• confirm that no unsuspected adnexal pathology is found
• A bladder catheter may be inserted
• some surgeons believe that a distended bladder helps with recognition of a
bladder injury and thus do not use a catheter

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45. Vaginal Hysterectomy
Uterine Morcellation
• Piecemeal removal of a large, often myomatous uterus
• Contraindicated in women w/uterine cancer
• Methods
• hemisection (bivalving)
• wedge/V-type incision
• intramyometrial coring
• The uterine vasculature must be ligated before beginning any type of
morcellation

46. Morellation is Safe
• Morbidity is less than that encountered from an abdominal hysterectomy*
• A rare problem in excision of a myoma is loss of the specimen into the
peritoneal cavity due to clamp slippage
• After completing removal of the uterus, the patient's head can be elevated and
lavage of the peritoneal cavity will bring the errant fibroid into the pelvis
• Uterine volume may be reduced preoperatively by administration of a
GnRH
*Taylor, SM, Romero, AA, Kammerer-Doak, DN, et al. Abdominal
hysterectomy for the enlarged myomatous uterus compared with vaginal
hysterectomy with morcellation. Am J Obstet Gynecol 2003; 189:1579.

47. Uterine Morcellation
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48. Uterine Morcellation
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49. Poor Uterine Descensus
• Decide whether to proceed with a vaginal approach or convert the
procedure to an abdominal approach
• If the problem relates to introital narrowing
• midline or mediolateral episiotomy can be performed
• If the problem stems from an enlarged uterus
• morcellation can be begun after the uterine arteries have been ligated
• Lack of descent resulting from extensive adhesive disease usually requires
an abdominal incision or packing the vagina and accessing the pelvis by
means of laparoscopy

50. LAVH
• Laparoscopic hysterectomy was first performed in 1989
• The impetus was to reduce the morbidity and mortality of abdominal
hysterectomy to the level observed with vaginal hysterectomy
• The patient must be counseled about the risks and potential benefits of
surgery, including those risks that are inherent to the laparoscopic
approach. Consent is given for both laparoscopic surgery and laparotomy
in case conversion to an open abdominal procedure becomes necessary

51. LAVH
• ACOG has listed the following as potential indications for laparoscopic
assistance to facilitate hysterectomy via the vaginal approach:
• Need for adhesiolysis
• Need for treatment of endometriosis
• Need for management of large leiomyoma(s) to facilitate uterine extraction
• Need for ligation of the infundibulopelvic ligaments to facilitate oophorectomy
ACOG Committee Opinion #311: Laparoscopically Assisted
Vaginal Hysterectomy. Obstet Gynecol 2005; 105:929.

52. LAVH
• Laparoscopically performed portion of LAVH is limited to adhesiolysis,
excision of endometriosis and division of the upper vascular pedicles and
parametria
• the remainder of the procedure is performed vaginally
• At the completion of the vaginal procedure the abdomen is reinsufflated
• helps the surgeon assess hemostasis

53. TLH
• The entire procedure is performed laparoscopically
• uterus is extracted vaginally, or removed abdominally using morcellation
techniques
• After the uterus is removed, the vaginal cuff is closed using laparoscopic
suturing techniques
MORCELLATION IS NOT PERFORMED IF UTERINE CANCER IS SUSPECTED

54. LSH
LSH is performed in an identical fashion to TLH
• after occluding the ascending uterine vascular pedicles
• cervix is amputated in a coring fashion
 beginning at the level of the internal os, down into the endocervical canal

55. Robot-assisted Lap Hyst
• Superior laparoscopic magnification of an image is achieved with robotic
systems - surgical precision
• Rotational movement of the robotic hands facilitates manipulation of
tissues and suturing
• “Tasks like adhesiolysis, suturing, and knot tying were enhanced with the
robotic suturing system”*
• “Robot-assisted laparoscopic hysterectomy appeared to provide a tool for
overcoming surgical limitations seen with conventional laparoscopy”**
* Beste, TM, Nelson, KH, Daucher, JA. Total laparoscopic hysterectomy
utilizing a robotic surgical system. JSLS 2005; 9:13.
** Advincula, AP, Reynolds, RK. The use of robot-assisted laparoscopic
hysterectomy in the patient with a scarred or obliterated anterior cul-
de-sac. JSLS 2005; 9:287.

56. Tools of the Trade for Scope & Hyst
• Sutures
• Electrosurgery
• Bipolar cautery
• Laser
• Harmonic scalpel
• Argon Beam Coagulator
• Stapling device
• Vessel Sealing device
• Uterine manipulator
• Vaginal fornix delineation tool
• Pneumo-occluder

57. RUMI device
Pneumo-occluder
KOH Cup
Articulation Point
RUMI Tip
RUMI locking
articulation handle

58. Delineation - Anterior Fornix

59. Posterior Fornix and Vaginal Cuff

60. Video clip of TLH using Rumi/KOH

61. Traditional versus Laparoscopic Hysterectomy -
Cochrane Review
• 27 randomized controlled trials with a total of 3,643 participants
• No differences were found between vaginal and laparoscopic
hysterectomy
• intraoperative visceral injury
 intraoperative bleeding
 conversion to laparotomy rates
 return to normal activities
 duration of the hospital stay

62. Traditional versus Laparoscopic Hysterectomy -
Cochrane Review
No significant differences were found in:
• occurrences of pelvic hematoma
• vaginal cuff infection
• urinary tract infection
• chest infection
• thromboembolic events
• fistula formation
• urinary dysfunction
• sexual dysfunction
• patient satisfaction

63. • Return to normal activities was slower after the abdominal hysterectomy
compared to laparoscopic and vaginal hysterectomy
• Total laparoscopic hysterectomy was associated with the longest
operation time, LAVH was comparable with abdominal hysterectomy, and
vaginal hysterectomy was the fastest
• The laparoscopic approach was associated with less risk of wound or other
infections and less blood loss then abdominal hysterectomy
Traditional versus Laparoscopic Hysterectomy -
Cochrane Review

64. • Urinary tract injuries (bladder plus ureteral injuries) appeared to be more
likely in patients undergoing laparoscopic hysterectomy
• No differences were found between TLH and LAVH, with the exception of
surgical time
Traditional versus Laparoscopic Hysterectomy -
Cochrane Review

65. eVALuate Study
Multicenter randomized controlled trials that evaluated the relative roles of
vaginal, abdominal and laparoscopic hysterectomy in routine gynecological
practice
• 2 parallel multicenter randomized trials all with benign disease
• Arm 1: 292 women assigned to abdominal hysterectomy and 584 women
assigned to laparoscopic hysterectomy
 Arm 2: 168 women assigned to vaginal hysterectomy and 336 assigned to
laparoscopic hysterectomy

66. eVALuate study
Multicenter randomized controlled trials that evaluated the relative roles of
vaginal, abdominal and laparoscopic hysterectomy in routine gynecological
practice
Women were excluded if they had:
• 2nd or 3rd degree prolapse
• uterus greater than 12 week size
• medical disorder precluding laparoscopic surgery
• required bladder or pelvic support surgery

67. eVALuate Study
Multicenter randomized controlled trials that evaluated the relative roles of
vaginal, abdominal and laparoscopic hysterectomy in routine gynecological
practice
• Major composite surgical complications occurred more frequently in
laparoscopic than abdominal hysterectomy (11% vs. 6%)
• Rate of minor complications was similar (25% - 27%)
• Laparoscopic hysterectomy took longer than abdominal or vaginal
hysterectomy (median time of 84 vs. 50 minutes, and 72 vs. 39 minutes)

68. Cost Analysis
• Cost analysis found that laparoscopic hysterectomy was not cost effective
relative to vaginal hysterectomy*
• Observational studies have documented cost effectiveness of laparoscopic
hysterectomy as compared to abdominal hysterectomy**’***
* Sculpher, M, Manca, A, Abbott, J, et al. Cost effectiveness analysis of laparoscopic
hysterectomy compared with standard hysterectomy: results from a randomised
trial. BMJ 2004; 328:134.
** Demco, L, Garry, R, Johns, DA, et al. Hysterectomy. Panel discussion at the 22nd
annual meeting of the American Association of Gynecologic Laparoscopists (AAGL),
San Francisco, November 12, 1993. J Am Assoc Gynecol Laparosc 1994; 1:287
***Lenihan, JP Jr, Kovanda, C, Cammarano, C. Comparison of laparoscopic-assisted
vaginal hysterectomy with traditional hysterectomy for cost-effectiveness to
employers. Am J Obstet Gynecol 2004; 190:1714.

69. Summary
• Based upon review of all available data, both laparoscopic assisted vaginal
hysterectomy and vaginal hysterectomy are more cost-effective than
abdominal hysterectomy
• When vaginal hysterectomy is contraindicated or predicted to be difficult,
the laparoscopic approach should be considered

70. Summary
• Laparoscopic hysterectomy was associated with
• less postoperative pain than abdominal hysterectomy
• shorter length of hospitalization (3 vs. 4 days)
• quicker recovery
• better quality of life at 6 weeks postoperatively
• Laparoscopic techniques are applicable to a larger number of pathologies
and situations than vaginal hysterectomy
• Gynecologic surgeons need to learn and apply laparoscopic techniques
when considering hysterectomy