Approximately 600,000 hysterectomies are performed annually in the United States, and more than one-third of women have had a hysterectomy by age 60 years. The most common diagnoses among women undergoing hysterectomy are uterine leiomyomata (41%), endometriosis (18%), uterine prolapse (15%), and cancer or hyperplasia (12%). Other indications for hysterectomy include adenomyosis, pelvic inflammatory disease, chronic pelvic pain, and pregnancy-related conditions.

The uterus can be removed by a variety of different approaches including the abdominal route (laparotomy), transvaginally, or using minimally invasive surgical techniques. Selection of the operative approach is based on many factors including the physical properties and topography of the uterus and pelvis, the indication for surgery, patient body habitus and medical comorbidities, and the presence or absence of adnexal pathology. Abdominal hysterectomy allows the greatest ability to manipulate distorted pelvic anatomy or perform extensive adhesiolysis safely, and over 60% of hysterectomies performed in the United States are still performed via the abdominal approach. Although abdominal hysterectomy is typically associated with shorter operating times than minimally invasive surgical approaches, it is also associated with a higher level of incisional pain, greater risk of postoperative febrile morbidity and wound infection, longer hospital stay, and a more protracted recovery time.

Hysterectomy may include removal of the uterine corpus and cervix, termed total hysterectomy, or may include only the uterine corpus, called supracervical hysterectomy. The term subtotal hysterectomy refers to the supracervical type but is not the preferred terminology. There has been a recent increase in the popularity of supracervical hysterectomy despite multiple randomized trials indicating no benefit over total hysterectomy in sexual function, bladder function, or pelvic floor support. In the absence of adnexal pathology, the decision to perform prophylactic removal of the ovaries and fallopian tubes should be addressed individually and will depend on patient preference, menopausal status, and the risk of subsequent ovarian cancer or other adnexal pathology that might require surgical intervention.

In preparation for abdominal hysterectomy all patients should undergo a comprehensive history and physical examination focusing on those areas that may indicate a reduced capacity to tolerate major surgery or place the patient at elevated risk for postoperative complications. Routine laboratory testing should include a complete blood count, serum electrolytes, a pregnancy test in reproductive-age women, age-appropriate health screening studies, and an electrocardiogram for women aged 50 years and older. Specifically, all patients undergoing abdominal hysterectomy for a benign indication should have current Pap smear screening, and endometrial biopsy should be performed prior to hysterectomy for abnormal uterine bleeding to rule out an
unexpected endometrial hyperplasia or cancer diagnosis. Preoperative imaging is not required; however, a transvaginal pelvic ultrasound is useful to assess uterine topography and anatomy and determine whether concurrent adnexal pathology is present.

Preoperative mechanical bowel preparation (oral polyethylene glycol solution or sodium phosphate solution with or without bisacodyl) can be utilized according to the surgeon’s preference. Prophylactic antibiotics (Cephazolin 1 g, Cefotetan 1 g to 2 g, or Clindamycin 800 mg) should be administered 30 minutes prior to incision, and thromboembolic prophylaxis (e.g., pneumatic compression devices and/or subcutaneous heparin) should be initiated prior to surgery. Surgical equipment for abdominal hysterectomy includes a standard pelvic surgery tray. Additional equipment may include a self-retaining retractor with or without a fixed arm attaching the retractor ring to the operating table, an electrosurgical unit (ESU or “Bovie”), and a vessel-sealing device. Following is a brief description of the surgical procedure used (see also video: Total Abdominal Hysterectomy).

General or regional anesthesia may be used for abdominal hysterectomy. The patient may be positioned in the dorsal low-lithotomy (perineolithotomy) position using Allen® Universal Stirrups (Allen Medical Systems, Cleveland, OH) or supine on the operating table. The low-lithotomy position is preferable, as it permits intraoperative bimanual examination to accurately assess distorted pelvic anatomy and allows access to the perineum for colpotomy and cystoscopy. Abdominal entry and exposure can be achieved through either a transverse or vertical incision, depending on clinical factors or the anticipated scope of the operation. The low transverse Pfannenstiel incision is usually adequate for most cases of abdominal hysterectomy for benign indications; however, if wide exposure is needed, the transverse Cherney or Maylard incisions may be more appropriate. The vertical midline incision offers the greatest flexibility and can be extended above the umbilicus if necessary. A self-retaining retractor will optimize exposure and reduce surgeon fatigue but is not a requirement.

Once the abdomen has been opened, a thorough exploration of abdominal structures is conducted before directing attention to the pelvis. Adhesions are divided and normal anatomy restored prior to packing the bowel out of the pelvis. The uterus is elevated out of the pelvis and manipulated by two large Kelly clamps placed across the broad ligament adjacent to the uterine fundus encompassing the round ligament, fallopian tube, and utero-ovarian ligament on each side. The broad ligament is incised cephalad to the round ligament, and the peritoneal incision extended toward the pelvic brim parallel to the infundibulopelvic ligament. The external iliac artery is an important landmark and is identified on the medial surface of the psoas muscle. The external iliac artery should be traced proximally to the bifurcation of the common iliac artery. The hypogastric (internal iliac) artery can then be located and followed as it courses deep along the lateral pelvic wall. The uterine arteries originate from the hypogastric artery within the cardinal ligament. The round ligament is identified and a ligature of 1-0 delayed absorbable suture placed midway between the uterus and pelvic sidewall, which is held long for traction (Figure 2.1). A large hemo-clip (or suture ligature) is placed medially (uterine side) to control back-bleeding and the round ligament is divided. An incision is created in the anterior leaf of the broad ligament and continued medially across the vesicouterine peritoneal reflection or fold at the junction of the lower uterine segment and cervix (Figure 2.2).

The pararectal space is developed by carefully dissecting, with a finger or large Kelly clamp, between the hypogastric artery (laterally) and the medial leaf of the broad ligament peritoneum. The ureter is attached to the medial leaf of the broad ligament peritoneum and is most easily located at the pelvic brim in the region of the bifurcation of the common iliac artery. The ureter should be clearly visualized as it courses through the pararectal space toward the cardinal ligament. The ureter can also be palpated along its course by placing the surgeon’s thumb and index finger on opposite sides of the medial leaf of the broad ligament peritoneum, straddling the infundibulopelvic ligament, and drawing the fingers upward. As the fingers cross the ureter, a characteristic “snap” is felt. Visual confirmation of the ureter’s position is the preferred technique, however.

If one or both adnexae are to be left in situ, the uterus is placed on traction anteriorly and medially and a window created in the avascular space of Graves (between the ureter and the infundibulopelvic ligament) in the medial leaf of the broad ligament peritoneum. Two large, curved clamps (e.g., Kelly and Heaney) are placed across the utero-ovarian ligament/fallopian tube complex (the round ligament is not included) and the pedicle divided and suture ligated. The adnexae may then be allowed to drop into the posterior pelvis or packed into the paracolic gutters out of the surgical field, with care taken not to injure the infundibulopelvic ligament, for the remainder of the hysterectomy.
At the conclusion of the case, the adnexal pedicle can be sutured to the round ligament stump on each side to avoid adherence to the vaginal cuff and resulting dyspareunia. If the adnexae are re-approximated to the round ligament stumps, the peritoneal defect lateral to the infundibulopelvic ligament should be closed with a running, nonlocking stitch of 3-0 delayed absorbable suture to prevent an internal small bowel herniation and entrapment.