Continuing Education Activity

This activity describes the current status of abdominal hysterectomy, which represents the most common gynecologic surgical procedure performed in the United States. It will highlight the most common indications, will review surgical steps, and describe the role of the inter[professional team in the evaluation and management of the patient undergoing abdominal hysterectomy.

Objectives:

• Identify the anatomical structures considered landmarks for abdominal hysterectomy.
• Describe the surgical steps of the abdominal hysterectomy.
• Identify the most common indications of abdominal hysterectomy.

Introduction

Abdominal hysterectomy was first performed in 1843. Prior attempts at removal of the uterus date back to ancient times, when vaginal hysterectomy was performed to treat uterine prolapse or inversion. Laparoscopic assistance was used to facilitate minimally invasive hysterectomy in 1989 and further advanced in 2005 with the approval of the robotic-assisted technique. Today, abdominal, vaginal, laparoscopic, robot-assisted, and a combination of vaginal and laparoscopic techniques are utilized for hysterectomy. The surgical approach to hysterectomy depends on the clinical indication, the technical experience of the surgeon, the resources available, the general health condition of the patient, and patient preference.

An abdominal hysterectomy involves the removal of the uterus through an incision in the abdominal wall. As minimally invasive techniques have become more available, the rates of abdominal hysterectomy have declined since the less invasive approaches offer benefits such as less post-operative pain, expedited recovery times, and better short-term quality of life after surgery, as well as shorter hospitalization stays and reduced costs. Furthermore, the use of hysterectomy, in general, has decreased as alternatives to hysterectomy continue to gain favor, such as endometrial ablation for symptomatic uterine bleeding and uterine artery embolization for uterine leiomyomas.[1][2][3] Still, hysterectomy remains the most appropriate management option for many patients.[4][5]

Large uterine size has been cited as a common reason for choosing the abdominal approach to hysterectomy, as it has been thought that an enlarged uterus may require better visualization and exposure due to higher risks of blood loss, injury to neighboring viscera, and prolonged operating times. However, there are no specific recommendations up to which uterine weight or size should qualify a patient for abdominal hysterectomy, and studies have shown that minimally invasive techniques, such as laparoscopy, can safely remove larger uteri.[6][7] Despite these findings, abdominal hysterectomy remains a common route of surgery being most commonly indicated for uterine fibroids, followed by abnormal uterine bleeding, prolapse, and endometriosis.[8]

Anatomy and Physiology

External genitalia: Also known collectively as the vulva, the external genitalia comprise the accessory structures of the female reproductive and urinary systems that are external to the vagina.

Vagina: A passageway that connects the cervix and the external genitalia. 

Cervix: The most inferior portion of the uterus. The cervical canal, with boundaries at the external cervical os and internal cervical os, connects the uterus to the vagina.

Uterus corpus: The body of the uterus, located deep in the pelvis in females, posterior to the urinary bladder and anterior to the rectum.

Broad ligaments: Sheet of pelvic peritoneum that overlies the uterus, fallopian tubes, and ovaries anteriorly and posteriorly and extends bilaterally to the lateral pelvic sidewalls. 

Round ligaments: Attached to the uterine cornu and travels through the inguinal canal to connect to the labia majora and mons pubis. Contains the artery of Sampson. 

Cardinal ligaments: Forms the inferior border of the broad ligament and attaches to the lateral cervix on either side. Contains the uterine artery and veins. 

Infundibulopelvic ligaments: Peritoneal fold that extends from the ovary to the lateral pelvic walls on either side. It contains the ovarian artery and vein, ovarian nerve plexus, and lymphatic vessels. 

Uterosacral ligaments: Fibrous bands extending dorsally along the rectal sidewalls to reach the sacrum. Suspend the cervix and vaginal tube, ensuring the craniodorsal orientation of their long axis.

Indications

The most common indications for abdominal hysterectomy are the following:[8]

• Abnormal uterine bleeding
• Malignancy and premalignant disease
• Uterine leiomyoma
• Endometriosis
• Pelvic organ prolapse
• Chronic pelvic pain
• Pelvic infection

Whenever feasible, the vaginal route is the preferred surgical approach for hysterectomy.[9][10] There are several factors that challenge the utility of the vaginal route including the size and shape of the uterus, pelvis, and vagina, the accessibility of the uterus, and the extent of extrauterine disease. Abdominal hysterectomy is often performed in patients with enlarged, bulky uteri or past history of abdominal surgery and in the presence of extrauterine disease, severe adhesions or endometriosis, and gynecological malignancies in whom a minimally invasive route is considered technically challenging.[2] 

Uterine size larger than 12 weeks’ gestation considered a reasonable qualification for an abdominal approach to hysterectomy; however, with the advances in surgical technology and the consistently proven superior outcomes of patients undergoing hysterectomy with minimally invasive approaches, less invasive techniques are favored over the abdominal route when feasible.[9][11]

Contraindications

Contraindications to hysterectomy are any factor that precludes a safe surgical approach or offers no benefit to the patient.  For example, traditional abdominal hysterectomy (simple hysterectomy) is curative only for microscopically invasive cervical cancer. A more extensive dissection to assure negative margins may be considered for tumors confined to the cervix with no metastatic disease. However, for advanced malignancy of the uterine cervix beyond Stage IB, there is no role for hysterectomy prior to chemoradiation.

Equipment

The following equipment is required:

• Long angled #3 knife handle and blade 
• curved and straight Zepplin forceps 
• Kelly forceps 
• Tonsil forceps  
• long Allis clamps 
• curved and straight Mayo uterine scissors
• Jorgenson scissors
• sponge forceps
• self-retaining retractor 
• Deaver retractors
• Richardson retractors 
• malleable retractors 
• short and long needle holders
• sutures  
• electrosurgical device 
• suction apparatus

Personnel

The following personnel is needed:

• Gynecologist
• Anesthesiologist
• Scrub nurse 
• Circulating nurse 
• Surgical assistant(s) 

Preparation

The following steps are taken:

• A pregnancy test is recommended in reproductive-age women prior to surgery, as well as preoperative hemoglobin or hematocrit levels and any additional laboratory tests as indicated by the patient’s medical conditions.[12]
• Pubic/vulvar hair removal: Scissors or an electric clipper device should be used only if the hair is covering the operative site. Shaving may increase the risk of wound infection or cellulitis and should, therefore, be avoided.[13]
• DVT prophylaxis: Sequential compression devices should be placed and assessed for proper functioning.[14]
• Proper patient positioning: The patient should be placed in a supine position or dorsal lithotomy position with the help of boot-type stirrups.
• Antibiotic prophylaxis: A single intravenous dose is given 15 to 60 minutes prior to skin incision for surgical site infection prevention. A second dose should be administered for procedures lasting longer than 3 hours or when the intraoperative blood loss is estimated greater than 1,500 mL. Cephalosporins are the most commonly used and studied antimicrobials for prophylaxis in abdominal hysterectomy.[15]
• Time out: All personnel should take a moment to pause prior to commencement of surgery, as per the standard hospital protocol, in order to verify the patient’s identifying information, type of operation, equipment, and the surgeon performing the procedure. Pelvic Examination: The patient should be examined once under anesthesia for uterine size, shape, and mobility and to confirm the best surgical approach. The surgeon can also assess the location of pathology and characterize pelvic structures.
• Skin preparation:
  • Pelvis: Bacteriostatic scrub (betadine or chlorhexidine) is generously introduced inside the vagina and applied to the hair-bearing skin from the pubic symphysis, inferiorly to cover the entire female external genitalia.
  • Abdominal: The umbilicus is first cleaned using Q-tips. Bacteriocidal scrub (chlorhexidine with isopropyl alcohol) is applied using a circular motion, beginning at the umbilicus and extending outwards from the xiphoid to the anterior thighs and bilaterally to the midaxillary line.
• Draping: Sterile surgical drapes are used to cover the patient to ensure a sterile field.
• Bladder decompression: A Foley catheter is inserted and remains postoperatively until the patient is ambulatory. Other preparations to consider in special circumstances include preserved blood preparation in cases where a large amount of bleeding is predicted and urinary stent placement if there is a high risk for ureteral injury.

Technique or Treatment

The surgical route of hysterectomy should be individualized to each patient. Uterine characteristics include size, mobility, and location, as well as the extent of gynecologic pathology. Prior history of abdominal surgery is important to consider since the anticipated extensive adhesive disease can increase the risk of complications. Other factors to consider include vaginal caliber, potential complication risks based on patient comorbid medical conditions, presence of concomitant pathology, patient preference, and surgeon experience. The technique of abdominal hysterectomy is as follows:

1. Laparotomy: Accessing the peritoneal cavity is achieved through either a low transverse or midline vertical incision. The low transverse incision is usually preferred, though the midline incision is generally performed if a malignant disease is present or access to the upper abdomen is required. Other deciding factors include uterine size, prior surgical scars, and patient preference as long as adequate exposure is assured.
2. Retraction: A self-retaining retractor is often placed into the abdomen, and the bowel is packed cephalad. Placement of the retractor should be done carefully in order to avoid bowel entrapment and nerve injury at the pelvic sidewall.
3. Restore normal anatomy: Once the peritoneum is entered, the surgeon will explore the cavity, assessing for pathology, and performing lysis of adhesions in order to free the pelvic organs and afford good exposure of the pelvis.
4. Uterine elevation: The round ligaments and utero-ovarian ligaments are clamped bilaterally at the cornua to elevate the uterus out of the pelvis.
5. Division of the round ligament and accessing the retroperitoneal space: Retracting the uterus laterally facilitates the identification of the round ligament. The right round ligament and artery of Sampson are ligated bilaterally to expose the retroperitoneal space for blunt dissection.
6. Bladder reflection: The peritoneal incision is extended transversely, distal to the bladder reflection, and the bladder is sharply dissected away from the cervix proximally in the vesicovaginal plane.
7. Exposure of the iliac arteries: Gentle dissection through the retroperitoneum will eventually reveal the external iliac arteries on the medial surface of the psoas muscles and should be extended superiorly to the bifurcation of the common iliac arteries, where the ureters can be seen crossing the pelvic brim. The internal iliac arteries run parallel with the ureters into the deep pelvis.
8. Division of the ovarian vessels: This is performed only if the ovaries are being surgically removed with the uterus. An opening is made in the medial peritoneum cephalad to the ovaries bilaterally, between the ureter and ovarian vessels. The vessels are doubly clamped and divided between the two clamps. Both pedicles are suture ligated, and the posterior peritoneum is released to the cornua to allow suspension of the distal pedicle to the cornual clamp.  This is performed bilaterally.
9. Skeletonization of the uterine artery and vein: The uterine artery is usually found immediately adjacent to the uterus at the level of the internal cervical os. Sharp dissection of the areolar tissue away from the uterus allows for exposure of the vessels to facilitate clamping immediately adjacent to the uterus. This is performed bilaterally.
10. Dividing the uterine vessels: The vessels clamped perpendicular to the uterus at the level of the internal cervical os, cut, and the pedicles are doubly ligated, ensuring hemostasis.
11. Dissection of the rectum: If the rectum is adherent to the posterior cervix or vagina, it is sharply dissected free of the posterior uterus. 
12. Dividing the broad ligament: Once the cervix is freed anteriorly and posteriorly, tension is placed superiorly on the uterus to provide deeper exposure. The cardinal ligaments are clamped with a series of straight clamps along with the lateral cervix. The pedicles are cut and suture ligated. This is performed in serial fashion, incorporating the uterosacral ligaments, until reaching the cervical-vaginal junction.
13. Dividing the vagina: A series of clamps are placed across the vagina below the cervix, including both the anterior and posterior vaginal wall. The vagina is then divided above the clamps and below the level of the cervix to free the surgical specimen.
14. Closing the vaginal cuff: Suture ligatures are placed on the angles, incorporating the uterosacral ligament posteriorly for vaginal apex suspension, and a figure-of-eight stitch is placed in the middle of the cuff for complete closure.
15. Final Examination and Closure: Warm saline is used to irrigate the pelvis, and inspection for hemostasis and injury is performed. Correct surgical counts are confirmed, and the surgery is completed with incisional closure. Many surgeons find it unnecessary to close the abdominal peritoneum. The fascia and skin are reapproximated separately to close the incision.

Special Considerations:

• Total vs. Subtotal (Supracervical) Abdominal Hysterectomy: Total abdominal hysterectomy involves removing the entire uterus as described above, including the uterine corpus and cervix. This approach differs from the subtotal hysterectomy, or supracervical hysterectomy, whereby the uterine cervix is left in situ after the upper portion of the cervix is transected just below the level of the uterine vessels. While supracervical abdominal hysterectomy has gained favor among the lay public amidst the beliefs that removal of the cervix will affect orgasmic and bladder function, prospective, randomized studies have revealed that when comparing the two approaches, there is no difference in sexual satisfaction, vaginal prolapse, or bowel and urinary tract dysfunction.[16] Importantly, however, women who keep their cervix will require continued surveillance for cervical cancer with pap smear screening and appropriate follow-up. Additionally, there may be post-hysterectomy bleeding associated with the retained cervical tissue. Supracervical hysterectomy is contraindicated in the presence of uterine malignancy or premalignancy and is strongly discouraged when the indication for the hysterectomy is for pelvic pain.
• Elective oophorectomy/salpingectomy: The decision to remove the ovaries and fallopian tubes should be individualized to each patient after a detailed discussion with the physician regarding advantages and disadvantages. In the absence of ovarian pathology or a familial cancer syndrome, most women who undergo hysterectomy for benign indications should conserve their ovaries, and there should be a discussion regarding the removal of the fallopian tubes. Prophylactic salpingectomy is considered a safe procedure for preventing high-grade serous cancer and can be performed during any kind of hysterectomy without affecting ovarian function or surgical outcomes.[17] In premenopausal women, ovarian conservation has been associated with the potential prevention of osteoporosis, urogenital atrophy, skin changes, and possible arteriosclerotic vascular disease reduction.[18] Oophorectomy is considered reasonable for postmenopausal women over the age of 65 who place a higher priority on ovarian cancer prevention than on other long- term health risks. Hormone replacement therapy may be needed to prevent the hypoestrogenic effects after surgical menopause and is a safe therapeutic option when used at as low a dose as possible.[19]
• Prophylactic Vaginal apex suspension: Incorporating the uterosacral ligaments into the vaginal cuff angle at the time of closure can help minimize loss of apical support and pelvic organ prolapse. This technique requires minimal additional time and is performed with low risk during abdominal hysterectomy. The risk of future pelvic organ prolapse is highest in women with preexisting prolapse, regardless of symptoms.[20] It is recommended to perform apical suspension at the time of hysterectomy in women with prolapse and in women with normal pelvic support who have expected risks of prolapse based on individual factors.[21][22]
• Cystoscopy: Postoperative visualization of proper flow within the ureters is recommended during instances where the ureter is not well visualized during the procedure or when there is suspicion for injury. Injury detection rates may be higher with the use of cystoscopy, and some studies urge its routine use after abdominal hysterectomy, given the increased morbidity and costs associated with unrecognized or delayed diagnosis of urinary tract injury, despite the increased procedural time.[23]

Complications

We can categorize the most common complications of hysterectomy into infectious causes, venous thromboembolic disease, injury to the genitourinary and gastrointestinal tracts, bleeding, nerve injury, and vaginal cuff dehiscence.[24] Additional potential complications after an abdominal hysterectomy include pelvic organ prolapse, pelvic organ fistula, urinary incontinence, and intestinal ileus. As with any surgery requiring general anesthesia, there is also the risk of adverse reactions to anesthetics. Abdominal hysterectomy has been determined to have higher odds of postoperative complications within 30 days of surgery and an overall higher risk of complications when compared to other minimally invasive techniques of hysterectomy such as laparoscopy.[25] The most common complications of abdominal hysterectomy are described below:

Infection

The most common infections identified after a hysterectomy include vaginal cuff cellulitis, pelvic abscess or infected hematoma, wound infection, and urinary tract infection. The risk of infection increases with operative times that exceed 3 hours, lack of preoperative antibiotics, and patient factors such as comorbid medical conditions, compromised immune status, obesity, and poor nutrition.[24] Vaginal cuff cellulitis presents late in the hospital course or soon after discharge. Patients can be asymptomatic with spontaneous resolution of the inflammation or can present with fever, purulent vaginal discharge, pelvic pain, and exam findings of tenderness or induration at the vaginal cuff.[26] These findings can be differentiated from those of infected pelvic hematoma or abscess, which tend to present later after discharge from the hospital, with symptoms of pelvic pain, fever, and rectal pressure, and exam findings of a fluctuant, tender mass, or purulent discharge at the vaginal cuff.[24]

Venous Thromboembolism (VTE)

Patients undergoing major gynecological surgery have a significant risk of developing deep venous thrombosis (DVT) and pulmonary embolism (PE) when no thromboprophylaxis is given. The incidence of DVT after gynecologic surgery has been found in some studies to be higher in open procedures and in patients with malignant conditions.[27] The exact incidence of VTE after hysterectomy is difficult to approximate, as many cases go unrecognized. The risks of thromboembolic events must be balanced against the potential risk of major perioperative bleeding. Thromboprophylaxis is only recommended for patients undergoing gynecological surgery who are considered to be at increased risk of VTE.[28]

Genitourinary and Gastrointestinal Tract Injuries

Injury to the genitourinary tract during pelvic surgery, while rare, can lead to a high risk of patient morbidity. Studies have indicated radical hysterectomy as the most common type of pelvic surgery associated with urologic complications.[29] The bladder is injured more frequently than the ureters. A review of urinary tract injuries during benign gynecologic surgery found lower rates of bladder injury after abdominal hysterectomy than after laparoscopic and vaginal approaches, consistent with other studies within the literature.[30] Injury to the bladder occurs most commonly during dissection within the vesicovaginal plane, whereas injury to the ureter is most common to occur during dissection along the pelvic sidewall, particularly when encountering the infundibulopelvic ligaments where the ovarian vessels are ligated, but also during ligation of the uterine vessels and at the bladder base.[24] While injuries to the bladder and ureter may be noted during surgery, injury to the serosal layer of the bladder may go unnoticed during surgery if the defect in the bladder wall is not full-thickness, and delayed presentation of vesicovaginal fistula can occur.[31] GI tract injuries during an abdominal hysterectomy can occur via thermal injury, direct mechanical damage, and indirectly through interruption of vascular supply.

Bleeding

Abdominal hysterectomy is associated with more bleeding than the other routes of hysterectomy, with an average blood loss of 400mL. Studies have shown that estimated blood loss above this caliber is associated with increased risks of major postoperative complications and increased hospital stay.[32]

Nerve Injury

Damage of the femoral nerve is the most common cause of neuropathy described after pelvic surgery, and the most common site of injury is at the anterior surface of the psoas muscle from direct compression by a self-retained retractor and at the inguinal canal from indirect stretch injury while the patient is in the prolonged dorsal lithotomy position.[33] Other nerve injuries include the iliohypogastric and ilioinguinal nerves at the level of the anterior abdominal wall during laparotomy or excessive stretching of the fascia, the obturator nerve from an inadvertent crush injury by clamps or excessive stretching, and rarely, the peroneal nerve due to positioning of the legs in the stirrups.

Vaginal Cuff Dehiscence

Cuff separation can occur within days of surgery or years later. The separation may be along the entire length or localized to a portion of the vaginal incision and can be of partial- or full-thickness. The most feared complication associated with vaginal cuff dehiscence is the evisceration of intraperitoneal contents through tissue separation. Total abdominal hysterectomy has been associated with a lower risk of vaginal cuff dehiscence compared to laparoscopic procedures.[34]

Clinical Significance

Studies reveal that hysterectomy, when clinically indicated, is associated with significant improvement in many quality of life indices.[35] Abdominal hysterectomy remains a commonly practiced route of hysterectomy despite its longer recovery times and hospital stays, higher rates of morbidity and mortality, and overall increased complication rates.[1] There is a paucity of data for long-term outcomes in randomized controlled trials comparing the surgical approach to hysterectomy. Furthermore, no consensus exists regarding indications for the route of hysterectomy. The ultimate decision should be shared by the surgeon, based on his or her expertise, and the patient.

While endoscopic procedures continue to replace more conventional abdominal surgeries, it remains imperative for the upcoming generation of surgeons to master the technical knowledge of the conventional abdominal hysterectomy. An abdominal hysterectomy will always be fundamental to the gynecologic oncologist, as well as the gynecologist during the management of benign gynecologic disease, which more commonly than not requires open surgery, or even during less invasive procedures where conversion to laparotomy is needed. The American College of Obstetricians and Gynecologists published an opinion summary in 2017 recommending vaginal hysterectomy as the first option technique. In cases where the vaginal route does not seem a viable option, laparoscopic hysterectomy should be investigated, and in the event that both of these options are not viable, then abdominal hysterectomy should be performed.[10][9]

It should be understood that abdominal hysterectomy is a major operation that can significantly impact a woman’s physical and mental wellbeing. It is necessary for the surgeon to help patients cope with the emotional turmoil that may accompany hysterectomy. Simple statements and open-ended questions by the physician regarding the patient’s feelings are encouraged during preoperative counseling to address anxiety and emotional distress and to provide support to the patient.

Enhancing Healthcare Team Outcomes

Abdominal hysterectomy remains a common surgical route for hysterectomy for benign disease for a wide range of clinical indications. Optimal healthcare outcomes are achieved when there is a collaboration among the healthcare team involved in the care of the patient, from the time the patient checks into the facility at pre-op until the patient is discharged from the hospital, whether from the post-op recovery unit or after an inpatient stay. An interprofessional team may be made up of nurses, technicians, physicians, surgical assistants, residents, medical students, among other personnel.

The initial care begins prior to the day of operation at the office visit, where it is the responsibility of the physician to discuss the procedure at length, including an assessment of risks vs. benefits and alternative options, while addressing any concerns, expectations, and questions that the patient may have. On the day of the operation, nurses have an important role in assessing the patient’s vital signs and clinical conditions to ensure clinical stability. Physicians obtain all necessary informed consent for the procedure. Prior to obtaining consent, the physician should ensure that the patient is fully informed, understands the nature of the disease for which the procedure is being proposed, the anticipated results and prognosis, risks of not receiving treatment, and recognized possible alternative forms of treatment. All possible complications should be discussed as well as that additional treatment for complications may be required. It is important that the patient is assessed by both the surgeons and anesthesiologists prior to the operation. Calm reassurance and the professional nature of the entire operative team is helpful to the patient and their loved ones prior to surgery.

Once in the operating room, scrub technicians and nurses prepare and confirm the proper functioning of all necessary instruments and equipment. Nurses should assist the physician with all preoperative procedures. The surgeon performs a final assessment of the anatomy prior to surgery with a pelvic examination. During the surgery, the surgical assistants and scrub technician should assist the surgeon in handling the instruments and ensuring proper lighting for maximum visualization of the surgical field. The nurse remains alert to any needs of the surgical team, such as equipment adjustments, patient positioning, or communications with outside personnel. At the conclusion of the procedure, the nurse documents the intraoperative blood loss and urine output. The anesthesiologist should continue to monitor vitals and hemodynamic stability, while all members of the team are responsible for ensuring the general status and comfort of the patient.

The best surgical outcomes for abdominal hysterectomy occur when the interprofessional team taking care of the patient is coordinated and agreeable in their efforts. Effective communication and cooperation among nurses, physicians, technicians, and learners are key.