The history of hysterectomy is long and varied. Although significant advances in the technique of hysterectomy did not occur until the 19th century, earlier attempts are known. Some references to hysterectomy even date to the fifth century bc, in the time of Hippocrates. The earliest attempts at removal of the uterus were made vaginally for indications of uterine prolapse or uterine inversion. By the 16th century, a number of hysterectomies already had been done in Europe, including Italy, Germany, and Spain. In 1600, Schenck of Grabenberg cataloged 26 cases of vaginal hysterectomy.

Vaginal hysterectomies were done sporadically through the 17th and 18th centuries. In 1810, Wrisberg presented a paper to the Vienna Royal Academy of Medicine recommending vaginal hysterectomy for uterine cancer. Three years later, the German surgeon Langenbeck successfully performed a vaginal hysterectomy for uterine cancer. The first vaginal hysterectomy performed in the United States was in 1829 by John Collins Warren at Harvard University; however, the patient expired on the fourth postoperative day. Three years following Warren’s attempt, Herman and Werneberg in Pittsburgh successfully performed a vaginal hysterectomy for uterine cancer. By the late 19th century, techniques for vaginal hysterectomy were systematically studied and developed by Czerny, Billroth, Mikulicz, Schroeder, Kocher, Teuffel, and Spencer Wells.

The earliest abdominal hysterectomy attempts usually involved uterine leiomyomata that had been misdiagnosed as ovarian cysts. In the early 19th century, laparotomy for ovarian cysts still was considered dangerous, despite initial successes by McDowell in the United States and Emiliami in Europe in 1815. Abdominal hysterectomy for any reason was considered impossible to accomplish successfully. Many of the earliest myomectomies involved pedunculated tumors. Washington L. Atlee of Lancaster, Pennsylvania, performed the first successful abdominal myomectomy in 1844; although in a series of 125 surgeries, he did not attempt to remove the uterus.

The first reported abdominal hysterectomy was attempted by Langenbeck in 1825. The 7-minute operation for advanced cervical cancer resulted in the patient’s demise several hours later. Abdominal surgery was commonly complicated by postoperative hemorrhage that was often lethal. In the mid-19th century, an English surgeon, A.M. Heath from Manchester, was the first to ligate the uterine arteries, but it would be nearly 50 years before his technique became common practice.

Successful surgery depends on control of bleeding, infection, and pain. Ligatures were known to be used to tie off bleeding vessels as early as 1090, and artery forceps were invented in the mid-16th century by Ambroise Pare. However, information regarding the pathophysiology of hemorrhage, shock, and blood transfusions was not available until the 20th century. The importance of infection control was first recognized by Austrian Ignaz Semmelweiss in his work with childbed fever. His 1840s work was furthered by Joseph Lister in the 1860s and aided by notable discoveries by Louis Pasteur and Robert Koch.

It was not until 1864 that the Frenchman Koeberle introduced his method of securing the large vascular pedicle of the lower uterus with his tool, the serrenoeud. This ligature en masse around the lower uterus with the corpus amputated above was the usual technique of controlling bleeding with hysterectomy in the earliest years. The stump thus formed was such a large mass of tissue that it could not always be safely returned to the peritoneal cavity owing to risk of intraperitoneal bleeding; often, the stump was fixed extraperitoneally in the incision so that it could be clamped later if necessary.

American Crawford W. Long first used ether as anesthesia in 1842, and Scotsman Sir James Y. Simpson initiated the use of chloroform in his obstetric practice. W.A. Freund of Germany further refined hysterectomy techniques in 1878 using anesthesia, antiseptic technique, Trendelenburg position, and ligature around ligaments and major vessels. The bladder was dissected from the uterus, and the cardinal and uterosacral ligaments were detached; the pelvic peritoneum then was closed. Late in the 19th century, further refinements were made to abdominal hysterectomy techniques by the surgeons of the Johns Hopkins Hospital, where they reduced their mortality to 5.9%.

In the early decades of the 20th century, hysterectomy became more commonly used as treatment for gynecologic disease and symptoms. Gynecology as a specialty was developing, and little else but surgery was available to gynecologists to help their patients. Major discoveries and concepts of reproductive organ physiology and pathology were just beginning. Estrogen and progesterone were not discovered until the late 1920s and early 1930s.

As gynecology matured as a specialty, knowledge of reproductive organ function and disease became more complete. Special and more accurate diagnostic techniques were developed, and effective nonsurgical methods of therapy were discovered. In the modern practice of gynecology, appropriate use of this knowledge and advanced modern diagnostic technologies allow more accurate diagnosis, and conditions such as uterine fibroids or abnormal uterine bleeding, which used to be treated primarily by surgery, can now often be managed with hormones or other medications. In addition, surgical techniques have evolved and minimally invasive or even noninvasive approaches to uterine pathology have been developed. Focused ultrasound destruction of uterine fibroids and vascular embolization of fibroids are two examples of modern techniques (done primarily by radiologists) that have replaced traditional gynecologic surgical procedures.

Advances in anesthetic techniques, blood transfusions and fluid management, and the use of prophylactic antibiotics have made surgery safer and appropriate for more women with medical comorbidities. But the gynecologic surgical procedures themselves have changed significantly in the modern era. Laparoscopy, hysteroscopy, and robotically assisted techniques have added new technology to manage gynecology pathology and new platforms to accomplish a hysterectomy.

Hysterectomy is a very common surgical procedure. In the United States, more than half a million women undergo hysterectomy each year, and it is estimated that by age 65, one third of women in this country will have had their uterus surgically removed. Annual medical costs related to hysterectomy exceed $5 billion in the United States. However, there are significant variations in hysterectomy rates within the United States and throughout the world. In a study from the Kaiser health care plan in California, Jacobson and colleagues reported an overall hysterectomy rate of 3.41 per 1,000 women older than age 20 in 2003. This is similar to but somewhat lower than the rate of 4.7 per 1,000 women reported from Olmsted County, Minnesota, from 1995 to 2002. In a nationwide sample, Farquhar and Steiner reported an overall hysterectomy rate of 5.6 per 1,000 women in the United States in 1997. In Western Australia, Spilsbury and colleagues recently reported an agestandardized rate of 4.8 per 1,000 women. In Italy, Mataria has reported a rate of 3.7, and a very low rate of 1.2 per 1,000 eligible women was reported from Norway.

This variation in rates from one location to another is due to several factors, including patient expectations and availability of medical care. But it is primarily related to the training and practice patterns of the local gynecologic surgeons. In some areas, abnormal uterine bleeding may be managed primarily by hormonal therapy, whereas in other locations, hysterectomy may be quickly recommended. Alternatives to hysterectomy have decreased the rate of hysterectomy in recent years. Systemic hormonal therapies have been effective for managing menorrhagia; recently, a progestational intrauterine system has been shown to be similarly effective. Intrauterine thermal balloons, microwave, and electrical instruments are all effective outpatient techniques for endometrial ablation as an alternative to hysterectomy for symptomatic uterine bleeding. Leiomyomata can now be treated with transcervical hysteroscopic resection and also by transcatheter uterine artery embolization. These new management techniques, together with an overall desire to decrease the use of major surgery, have decreased the use of hysterectomy in recent years.

In addition, today’s gynecologic surgeon has several techniques for hysterectomy from which to choose. Although abdominal hysterectomy is still the most commonly used approach, there has been a definite increase in the use of both vaginal and laparoscopic hysterectomy in recent years. Table 32A.1 shows
the frequency of the various techniques in recent reports from around the world. For the first time, this edition of the hysterectomy chapter is subdivided into sections on abdominal, vaginal, and laparoscopic hysterectomy. In this section, we concentrate on the abdominal approach to hysterectomy.

Table 32A.2 lists commonly accepted indications for hysterectomy. As discussed above, a variety of new surgical and nonsurgical techniques or treatments are now available to manage many of the symptoms or conditions for which hysterectomy has been required in the past. These approaches are often a compromise. Alternative management approaches may be less invasive, less morbid, and possibly less expensive, but symptoms, although improved, may persist. Eventually, hysterectomy may be elected as a secondary management option for some patients, such as those who continue to have more bleeding than they are willing to tolerate after transcervical endometrial ablation.

In some cases, hysterectomy may be done in conjunction with other abdominal procedures, such as removal of a benign or malignant ovarian tumor or treatment of chronic pelvic inflammatory disease or endometriosis. There may be no pathologic changes in such a uterus, and some have contended that these are examples of an “unnecessary hysterectomy.” This is certainly not true, but it is important that the surgeon clearly explain why the uterus is being removed as a part of the surgical procedure. Because abdominal hysterectomy is the most common major gynecologic operation done in the United States, it is under careful scrutiny by a variety of regulatory agencies and public health care policy groups. The surgeon should carefully evaluate each patient and consider the diagnosis and management options before recommending hysterectomy and, specifically, abdominal hysterectomy. Numerous studies have shown that women who have undergone hysterectomy show a significant improvement in their quality-of-life indices. But care must be taken to make the correct diagnosis, be sure that the patient’s condition will benefit from hysterectomy, and recommend the most appropriate type of hysterectomy for that specific patient.

The late Richard W. Te Linde, professor of gynecology at the Johns Hopkins University and the original author of this text, wrote:

Today, there are many different approaches to hysterectomy. The uterus can be removed via the abdominal route, transvaginally, or laparoscopically. Combinations of several techniques can be selected, such as a laparoscopically assisted vaginal hysterectomy. Although abdominal hysterectomy continues to be the most common approach used worldwide, there is good evidence from multiple randomized, prospective trials that vaginal and laparoscopic hysterectomies are associated with fewer complications, a shorter hospital stay, a more rapid recovery, and lower overall costs (Table 32A.3). In addition, Kovac and others have shown that most patients who require hysterectomy can have it performed vaginally. Who, then, is a proper candidate for an abdominal hysterectomy? Most patients with gynecologic malignancy are still operated on with an abdominal incision. Although this will undoubtedly continue to be true for women with ovarian cancer who frequently have extensive pelvic and upper abdominal metastases, laparoscopic techniques and more recently robotic surgical techniques are being used more and more frequently in women with endometrial and cervical cancer.

Another indication for abdominal hysterectomy is a large uterus that prevents safe and reasonable vaginal hysterectomy. This is obviously very dependent on the skills and experience of the surgeon, because there are various techniques that allow a very large benign uterus to be removed from below. Nevertheless, most gynecologists would agree that a uterus larger than 12 weeks’ gestational size is a reasonable size to qualify for an abdominal approach. The shape and size of the pelvic outlet are also key factors. Although the degree of prolapse is not an absolute factor, patients with limited uterine prolapse are more difficult to do transvaginally. Cervical fibroids or cervical enlargement for any reason may compromise vaginal exposure and make it difficult to place clamps laterally.

An unknown adnexal mass, extensive pelvic endometriosis, or adhesions from prior surgery or pelvic infection may also be an indication for an open abdominal approach including a hysterectomy. In some cases, a diagnostic laparoscopy will clarify the situation and may allow the procedure to be converted to a laparoscopically assisted vaginal hysterectomy. A careful preoperative evaluation—starting with a thoughtful history and physical examination and supplemented, where indicated, by imaging studies such as a pelvic ultrasound or computerized tomography scan of the pelvis and abdomen— will usually enable the gynecologist to decide on the most appropriate type of hysterectomy. The diagnosis and reason for the approach selected should be thoroughly explained and discussed with the patient and any appropriate family or friends. In rare cases, the final decision concerning the type of hysterectomy will depend on the findings of the exam under
anesthesia or the findings at laparoscopy. In those cases, all the “what ifs …” should be carefully reviewed with the patient before the surgery and the family kept informed as decisions are made during the operation.

The gynecologist needs to talk with the patient while trying to decide whether a hysterectomy is indicated. Fortunately for the patient and the gynecologist, time for talking is available in almost every instance. A hysterectomy is rarely an emergency. Unfortunately, the time may not be used properly. In a survey of women who underwent hysterectomy, Neefus and Taylor found that there is an urgent need for patient education on the physical, psychological, and sexual aspects of hysterectomy.

Often, the need for hysterectomy is obvious. There is a complete prolapse, or a large and symptomatic leiomyomatous uterus, or a pelvic cancer. However, under all circumstances, the indications for hysterectomy should be carefully explained. It is important that whenever possible, not only the patient but, in addition, her family and/or those who will support her during the perioperative period be involved in these discussions. The “informed consent” should be explained clearly and in language that the patient and her family can understand. Treatment alternatives should be discussed and the reasons for recommending one approach over another should be explained. The risks, benefits, and side effects, specifically including the possibility of transfusion, must be reviewed, but in such a way that the patient is not unduly alarmed. Then, the patient and the physician should spend the time necessary to discuss any questions that the patient or family may have. Additionally, the patient should be encouraged to ask questions about the operation: how long it will take, the recuperation period in the hospital and at home, whether ovarian function should be conserved, and possible hormone replacement therapy. Patient information pamphlets and videos also are useful for preoperative education. The expectations of the patient and her family are very important in her postoperative view of the success (or failure) of the operation.

Because the uterus is the main organ associated with reproduction, it is an important part of a woman’s self-image; in some cultures, a woman’s sexuality and reproductive potential are viewed as important parts of her value or status in her family or society as a whole. For these reasons, it is absolutely necessary for the gynecologic surgeon to understand and help patients cope with the emotional turmoil that may accompany hysterectomy. For some women who have had their children and need a hysterectomy for prolonged heavy bleeding and cramping associated with uterine fibroids or those with a diagnosis of endometrial cancer, the indications are clear, the benefits are obvious, and the loss of reproductive capacity often is not of great concern. The emotional stress of hysterectomy on these women is usually minimal, and psychological adjustment often is rapid and complete. However, the young woman needing a hysterectomy for cervical cancer or a complication of pregnancy may have considerable difficulty adjusting to the loss of her uterus. Even the 32-year-old woman with three children and severe uterovaginal prolapse may not be comfortable with the idea of hysterectomy. The gynecologist must be sensitive to these possible concerns and anxiety. Even when the patient does not express any emotional distress, the gynecologist can provide an opening for the patient to discuss her feelings by statements such as “Most studies have shown no change in sexuality and sexual function after hysterectomy, but I know many patients have concerns about this. Do you have any questions?” The support of the patient’s husband or partner and her family and friends are very useful elements to prevent and manage depression and the emotional stress of hysterectomy. The wise surgeon includes members of this support group in preoperative discussions and encourages them to
ask questions or express opinions that actually may be questions or opinions of the patient that she may be hesitant to express.

Despite improvements in preoperative counseling in recent years, some women are depressed after hysterectomy. In most instances, this depression is short-lived and self-limiting, but the gynecologist should be alert for severe or prolonged symptoms of continued lack of energy, inability to return to normal activities of daily living, sleep difficulties, or other indicators of depression following surgery. Occasionally, antidepressants and/or psychiatric consultation may be necessary. The psychological aspects of pelvic surgery are extensively reviewed in Chapter 3.

A complete history and physical examination is indicated before any operative procedure. This evaluation is detailed in Chapter 8, but a few points deserve emphasis. Although it is appropriate to ensure that all gynecologic symptoms have been evaluated carefully and a pelvic examination performed, a complete physical evaluation is necessary to be sure the patient can safely tolerate anesthesia and major surgery. Appropriate consultation should be sought where indicated to assure safe anesthesia administration and anticipation of any perioperative medical problems. In addition to a preoperative hematocrit or hemoglobin and other laboratory tests as indicated by the patient’s medical condition, it is important to have a recent Pap or HPV test to rule out cervical neoplasia. A pregnancy test in reproductive-age women is recommended before surgery.

Preoperative chest x-rays are no longer routinely recommended but may be indicated in women with a history of cardiorespiratory disease or malignancy. An intravenous pyelogram, ultrasound, or computed tomography scan of the abdomen and pelvis may be useful in women with uterine or extrauterine pelvic masses, but these are not indicated routinely.

Mechanical bowel preparation before simple hysterectomy has been largely abandoned in recent years. However, when the uterus is large or extensive adhesiolysis is anticipated, we prefer to have the colon evacuated before pelvic surgery to facilitate exposure and reduce trauma to the bowel caused by retraction and packing. In these patients, we recommend a clear liquid diet on the day before surgery, and 250 mL of oral magnesium citrate is an effective laxative on the afternoon before surgery. A bisacodyl suppository immediately on arising on the morning of surgery will evacuate any residual feces or fluid in the sigmoid and prevent contamination of the field during surgery. A complete mechanical or antibiotic bowel preparation is indicated only when intestinal surgery is a possibility (see Chapter 47).

Surgical site infection risk is decreased by routine use of prophylactic intravenous antibiotics given approximately 30 minutes before the skin incision. First- or second-generation cephalosporins, such as cefazolin or cefoxitin, are commonly used. Recommended antibiotic regimens are shown in Table 32A.4.

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