B3. Indications and methods of hysterectomy

From greek.doctor

Hysterectomy is the surgical removal of the uterus, sometimes with other surrounding structures as well. It is the most common gynaecological surgery.

The main indications for hysterectomy are gynaecological cancer and precancerous lesions (vaginal, cervical, endometrial, ovarian, gestational), but hysterectomy is also an option in several conditions when they are refractory to medical treatment:

  • Pelvic organ prolapse
  • Adenomyosis
  • Endometriosis
  • Pelvic inflammatory disease
  • Uterine leiomyoma

Vaginal, abdominal, and laparoscopic hysterectomy

The hysterectomy may be performed by the vaginal, abdominal, or laparoscopic route.

In general, vaginal hysterectomy is preferred because of lower cost, lower complication rates, and shorter hospital stay. Vaginal hysterectomy can be problematic in nulliparous and obese women. The uterus is removed through an incision in the vagina.

Laparoscopic hysterectomy is the second choice. It may allow for same-day discharge if the patient has no comorbidities that require inpatient care and there are no perioperative complications.

Sometimes, these routes may be combined, for example as in laparoscopically assisted vaginal hysterectomy (LAVH).

Supracervical, total, and radical hysterectomy

Supracervical or subtotal hysterectomy (or Chrobak operation) means the removal of the uterus only, not including the cervix. This may prevent the vaginal prolapse which may occur with total hysterectomy, but it must obviously be used with care in those who may have cancer spreading to the cervix. It’s mostly relevant in case of non-malignant indications.

Total or simple hysterectomy means the removal of the uterus and cervix, not including the vagina. This is mostly used in case of ovarian or endometrial cancer.

Radical hysterectomy (Wertheim operation) means the en bloc removal of the uterus, fallopian tubes, ovaries, cervix, upper 1/3 of the vagina, and parametrium. The pelvic and sometimes para-aortic lymph nodes are also removed. This is mostly used in case of cervical cancer.

Trachelectomy

Trachelectomy is a fertility-preserving surgical alternative to radical hysterectomy in cervical cancer. In trachelectomy the upper vagina, cervix, parametrium, and pelvic lymph nodes are removed. Trachelectomy is not an option for tumours > 2 cm.

This procedure is usually performed through a vaginal approach rather than an abdominal approach.

Oophorectomy or salpingo-oophorectomy

Bilateral oophorectomy and salpingo-oophorectomy refer to the removal of the ovaries or the tubes and ovaries, respectively. These procedures may be performed simultaneously as the hysterectomy if there are indications for it, like:

  • Presence of or high risk for ovarian cancer
  • Endometriosis

Complications of hysterectomy

  • Major haemorrhage
  • Thromboembolism
  • Urinary tract injury – ureteral or bladder injury
  • Bowel injury
  • Pelvic organ prolapse