Description
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 infl ammatory 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
C H A P T E R 2
Total Abdominal
Hysterectomy
Robert E. Bristow
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 benefi t over total
hysterectomy in sexual function, bladder function, or
pelvic fl oor 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.