The gold standard diagnostic modality for uterine fibroids appears to be gray-scale ultrasonography,

with magnetic resonance imaging being a close second option in complex clinical circumstances.

The management of uterine fibroids can be approached medically, surgically, and even by minimal
access techniques. The recent introduction of selective progesterone receptor modulators (SPRMs)
and aromatase inhibitors has added more armamentarium to the medical options of treatment.

The vagina isn’t positioned vertically within the pelvis – it is angled towards the lower back.
In most women, the uterus is tipped forward so that it lies over the bladder, with the top
(fundus) towards the abdominal wall. Another normal variation found in some women is the
upright uterus, where the fundus is straight up.

About one quarter of women have a retroverted uterus. This means the uterus is tipped
backwards so that its fundus is aimed toward the rectum. While a retroverted uterus doesn’t
cause problems in most cases, some women experience symptoms including painful sex.

studied risk factors for postoperative infections at the operative site after hysterectomies. Data were
collected prospectively on all women undergoing vaginal hysterectomies (323 patients) or abdominal
hysterectomies (1125 patients) at the Boston Hospital for Women between February 1976 and April
1978. Logistic-regression analysis indicated that factors significantly associated (P<0.05) with a
higher risk of infection at the operative site were increased duration of operation, lack of antibiotic
prophylaxis, younger age, being a clinic patient, and an abdominai approach. After these variables
were accounted for, the variables of obesity, preoperative functional and anatomical diagnoses,
postoperative anatomical and pathological diagnoses, estimated blood loss, menopausal status, and
operation by a specific surgeon did not add predictive power. An increasing duration of operation was
associated with a decreasing effect of antibiotic prophylaxis, the preventive fraction of which
diminished from 80 per cent at one hour to an unmeasurable effect at 3.3 hours. (N Engl J Med. 1982;
307:1661–6.)
rom the Charming Laboratory and the Departments of Medicine and Obstetrics and Gynecology, Brigham and Women's
Hospital and Harvard Medical School, Boston. Address reprint requests to Dr. Polk at the Department of Epidemiology,
Johns Hopkins University School of Hygiene and Public Health, 615 N. Wolfe St., Baltimore, MD 21205.

Committee Opinion: Choosing the Route of Hysterectomy for Benign Disease

“Choosing the Route of Hysterectomy for Benign Disease,” issued by ACOG in November 2009
(reaffirmed 2011), reviews medical evidence to compare different approaches to hysterectomy for
noncancerous reasons—vaginal, abdominal, and laparoscopic—and finds that vaginal hysterectomy is
associated with better outcomes and fewer complications.
https://www.acog.org/Womens-Health/Hysterectomy

aBSTRACT: Hysterectomy is one of the most frequently performed surgical procedures in the United
States. Selection of the route of hysterectomy for benign causes can be influenced by the size and
shape of the vagina and uterus; accessibility to the uterus; extent of extrauterine disease; the need for
 concurrent procedures; surgeon training and experience; average case volume; available hospital
technology, devices, and support; whether the case is emergent or scheduled; and preference of the
informed patient. Vaginal and laparoscopic procedures are considered “minimally invasive” surgical
approaches because they do not require a large abdominal incision and, thus, typically are associated
with shortened hospitalization and postoperative recovery times compared with open abdominal
hysterectomy. Minimally invasive approaches to hysterectomy should be performed, whenever feasible,
based on their well-documented advantages over abdominal hysterectomy. The vaginal approach is
preferred among the minimally invasive approaches. Laparoscopic hysterectomy is a preferable
alternative to open abdominal hysterectomy for those patients in whom a vaginal hysterectomy is not
indicated or feasible. Although minimally invasive approaches to hysterectomy are the preferred route,
open abdominal hysterectomy remains an important surgical option for some patients. The
obstetrician–gynecologist should discuss the options with patients and make clear recommendations
on which route of hysterectomy will maximize benefits and minimize risks given the specific clinical
situation. The relative advantages and disadvantages of the approaches to hysterectomy should be
discussed in the context of the patient’s values and preferences, and the patient and health care
provider should together determine the best course of action after this discussion.

Recommendations and Conclusions

The American College of Obstetricians and Gynecologists makes the following conclusions and
recommendations:

 Vaginal hysterectomy is the approach of choice whenever feasible. Evidence demonstrates that it is
associated with better outcomes when compared with other approaches to hysterectomy.
 Laparoscopic hysterectomy is a preferable alternative to open abdominal hysterectomy for those
patients in whom a vaginal hysterectomy is not indicated or feasible.
 For an individual patient, the surgeon should account for clinical factors and determine which route of
hysterectomy will most safely facilitate removal of the uterus and optimize patient outcomes, given the
clinical situation and surgeon training and experience.
 Selection of the route of hysterectomy for benign causes can be influenced by the size and shape of
the vagina and uterus; accessibility to the uterus (eg, descensus, pelvic adhesions); extent of
extrauterine disease; the need for concurrent procedures; surgeon training and experience; average
case volume; available hospital technology, devices, and support; whether the case is emergent or
scheduled; and preference of the informed patient.
 The obstetrician–gynecologist should discuss the options with the patient and make clear
recommendations on which route of hysterectomy will maximize benefits and minimize risks given the
specific clinical situation.
 The relative advantages and disadvantages of the approaches to hysterectomy should be discussed in
the context of the patient’s values and preferences and the patient and health care provider should
together determine the best course of action after this discussion.
 Opportunistic salpingectomy usually can be safely accomplished at the time of vaginal hysterectomy.
 The role of robotic assistance for execution of laparoscopic hysterectomy has not been clearly
determined and more data are necessary to determine the most appropriate evidence-based
applications for this technology.
Hysterectomy usually can be safely performed using the vaginal approach in nulliparous women and
women with a history of one or more prior cesarean deliveries. A study showed that 92% of vaginal
hysterectomies planned for a cohort of women with no prior vaginal deliveries could be successfully
completed with that approach (8). If the vagina will allow access to divide the uterosacral and cardinal
ligaments, uterine mobility usually is improved enough to allow vaginal hysterectomy, even in cases
where there is minimal uterine descent (9). Guidelines developed by the Society of Pelvic
Reconstructive Surgeons that incorporate uterine size, mobility, accessibility, and pathology confined
to the uterus (no adnexal pathology or known or suspected adhesions) have been proposed as
selection criteria to determine the most appropriate route of hysterectomy (10–12). In a randomized
trial during which residents applied these guidelines to the selection and performance of
hysterectomy, the percentage of vaginal hysterectomies for benign conditions was greater than 90%.
Techniques to reduce the uterine size intraoperatively were necessary in 11% of cases and laparoscopic
assistance was incorporated in one quarter of patients with extrauterine pathology (10).

1. Whiteman MK, Hillis SD, Jamieson DJ, Morrow B, Podgornik MN, Brett KM, et al. Inpatient
hysterectomy surveillance in the United States, 2000–2004. Am J Obstet Gynecol
2008;198:34.e1–7. [PubMed] ⇦
2. Wright JD, Herzog TJ, Tsui J, Ananth CV, Lewin SN, Lu YS, et al. Nationwide trends in the
performance of inpatient hysterectomy in the United States. Obstet Gynecol 2013;122:233–41.
[PubMed] [Obstetrics & Gynecology] ⇦
3. Aarts JW, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BW, et al. Surgical approach to
hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015,
Issue 8. Art. No.: CD003677. ⇦
4. Dorsey JH, Holtz PM, Griffiths RI, McGrath MM, Steinberg EP. Costs and charges associated with
three alternative techniques of hysterectomy [published erratum appears in N Engl J Med
1997;336:147]. N Engl J Med 1996;335:476–82. [PubMed] [Full Text] ⇦
5. Sculpher M, Manca A, Abbott J, Fountain J, Mason S, Garry R. Cost effectiveness analysis of
laparoscopic hysterectomy compared with standard hysterectomy: results from a randomised
trial. BMJ 2004;328:134. [PubMed] [Full Text] ⇦
6. Lonnerfors C, Reynisson P, Persson J. A randomized trial comparing vaginal and laparoscopic
hysterectomy vs robot-assisted hysterectomy. J Minim Invasive Gynecol 2015;22:78–86.
[PubMed] ⇦
7. Einarsson JI, Matteson KA, Schulkin J, Chavan NR, Sangi-Haghpeykar H. Minimally invasive
hysterectomies—a survey on attitudes and barriers among practicing gynecologists. J Minim
Invasive Gynecol 2010;17:167–75. [PubMed] [Full Text] ⇦
8. Tohic AL, Dhainaut C, Yazbeck C, Hallais C, Levin I, Madelenat P. Hysterectomy for benign uterine
pathology among women without previous vaginal delivery. Obstet Gynecol 2008;111:829–37.
[PubMed] ⇦
9. Doucette RC, Sharp HT, Alder SC. Challenging generally accepted contraindications to vaginal
hysterectomy. Am J Obstet Gynecol 2001;184:1386–9; discussion 1390–1. [PubMed] ⇦
10. Kovac SR, Barhan S, Lister M, Tucker L, Bishop M, Das A. Guidelines for the selection of the route
of hysterectomy: application in a resident clinic population. Am J Obstet Gynecol 2002;187:1521–
7. [PubMed] ⇦
11. Kovac SR. Hysterectomy outcomes in patients with similar indications. Obstet Gynecol
2000;95:787–93. [PubMed] ⇦
12. Kovac SR. Decision-directed hysterectomy: a possible approach to improve medical and economic
outcomes. Int J Gynaecol Obstet 2000;71:159–69. [PubMed] ⇦
13. Ballard LA, Walters MD. Transvaginal mobilization and removal of ovaries and fallopian tubes
after vaginal hysterectomy. Obstet Gynecol 1996;87:35–9. [PubMed] ⇦
14. Davies A, O’Connor H, Magos AL. A prospective study to evaluate oophorectomy at the time of
vaginal hysterectomy. Br J Obstet Gynaecol 1996;103:915–20. [PubMed] ⇦
15. Sheth SS. The place of oophorectomy at vaginal hysterectomy. Br J Obstet Gynaecol 1991;98:662–
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16. Agostini A, Vejux N, Bretelle F, Collette E, De Lapparent T, Cravello L, et al. Value of laparoscopic
assistance for vaginal hysterectomy with prophylactic bilateral oophorectomy. Am J Obstet
Gynecol 2006;194:351–4. [PubMed] ⇦
17. Robert M, Cenaiko D, Sepandj J, Iwanicki S. Success and complications of salpingectomy at the
time of vaginal hysterectomy. J Minim Invasive Gynecol 2015;22:864–9. [PubMed] ⇦
18. Salpingectomy for ovarian cancer prevention. Committee Opinion No. 620. American College of
Obstetricians and Gynecologists [published erratum appears in Obstet Gynecol 2016;127:405].
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resource manual. 4th ed. Washington, DC: American College of Obstetricians and Gynecologists;
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gynaecological conditions. Cochrane Database of Systematic Reviews 2012, Issue 4. Art. No.:
CD004993. [PubMed] [Full Text] ⇦
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at: https://www.aagl.org/aaglnews/aagl-statement-to-the-fda-on-power-morcellation.
Retrieved February 7, 2017. ⇦
22. Siedhoff MT, Wheeler SB, Rutstein SE, Geller EJ, Doll KM, Wu JM, et al. Laparoscopic hysterectomy
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Intra-Abdominal Abscess
<< Back to Diseases and Conditions

What is an intra-abdominal abscess?

An intra-abdominal abscess is a collection of pus or infected fluid that is surrounded by inflamed tissue inside the
belly. It can involve any abdominal organ, or it can settle in the folds of the bowel.

What causes an intra-abdominal abscess?

Intra-abdominal abscesses sometimes happen because of another condition. An example might be appendicitis or
diverticulitis. Many cases, however, happen after surgery.

Abdominal abscesses can be caused by a bacterial infection. The most common bacteria to cause them are found in
the stomach and intestines. One of these is Escherichia coli or E. coli. If left untreated, the bacteria will multiply and
cause inflammation and kill healthy tissue.

Who is at risk for an intra-abdominal abscess?

Abdominal surgery or trauma and conditions, such as diabetes or inflammatory bowel disease, can put you at risk for
an intra-abdominal abscess.

What are the symptoms of an intra-abdominal abscess?

If you've recently had surgery or trauma to an abdominal organ and have other risk factors, such as diabetes or
inflammatory bowel disease, be on the lookout for signs of an intra-abdominal abscess.

Common symptoms include:

 Fever

 Belly pain

 Chest pain or shoulder pain

 Lack of appetite

 Nausea and vomiting

 Change in bowel movements

 Rectal tenderness or fullness

 Mass in the belly

 Malnourishment

How is an intra-abdominal abscess diagnosed?

If you have symptoms of an intra-abdominal abscess, your healthcare provider may order tests to look for the
presence of infection:

 Blood tests. Blood may be drawn to look for signs of infection or an intra-abdominal abscess. Particularly useful

are tests that look at the number of white blood cells and other indicators of inflammation.

 Imaging tests. The best imaging test to check for an abscess is typically a computerized tomography or CT scan

to see inside the belly. Other techniques, such as ultrasound or magnetic resonance imaging or MRI, may be used
as well.
 Physical exam. As part of your exam, your healthcare provider will take your temperature and check for

tenderness in the belly. Sometimes, the abscess can be felt as a mass in the midsection.

How is an intra-abdominal abscess treated?

Antibiotics may help treat an infection that could lead to an intra-abdominal abscess. But once the abscess has
developed, antibiotics don't work as well for treatment. An intra-abdominal abscess often will need to be drained of
fluid in order to heal. Typically, however, antibiotics are given along with draining the abscess. The type of antibiotic
will depend on how severe your abscess is, your age, and any other conditions you may have.

One way to remove fluid is through percutaneous drainage. This is a process in which your healthcare provider
guides a needle through the skin to the place where the infection is. This is a short procedure. Your healthcare
provider will give you a sedative and a local anesthetic to help you relax and eliminate any discomfort or pain while it
is being done.

Another way to drain the abscess is with surgery. Surgical procedures may also involve repairing the condition that
caused the abscess in the first place, such as a bowel perforation. Sometimes, more than one operation is needed.

Many times, a drainage catheter is left in the abscess cavity after it is drained. This will be checked by the healthcare
team and removed when appropriate.

Your outcome will depend on the cause of your infection and how quickly you sought treatment. The right early
treatment can significantly improve the outcome for people who develop intra-abdominal abscesses.

While you are being treated for an intra-abdominal abscess, you may need nutritional support. This can be done by
placing a feeding tube.

When should I call my healthcare provider?

If you've recently had surgery or trauma to an abdominal organ and have other risk factors, such as diabetes or
inflammatory bowel disease, and you develop a fever, belly pain, nausea or vomiting, or other symptoms, you should
immediately call your healthcare provider.

Key points about an intra-abdominal abscess

 An intra-abdominal abscess is a collection of pus or infected fluid that is surrounded by inflamed tissue inside

the belly.

 An intra-abdominal abscess may be caused by bacteria. If left untreated, the bacteria will multiply and cause

inflammation and kill healthy tissue

 If you've recently had surgery or trauma to an abdominal organ and have other risk factors, such as diabetes or

inflammatory bowel disease, be on the lookout for signs of an intra-abdominal abscess.

 Early treatment can significantly improve the outcome for people who develop intra-abdominal abscesses

Next steps
Tips to help you get the most from a visit to your healthcare provider:

 Know the reason for your visit and what you want to happen.

 Before your visit, write down questions you want answered.

 Bring someone with you to help you ask questions and remember what your provider tells you.
 At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write

down any new instructions your provider gives you.

 Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects

are.

 Ask if your condition can be treated in other ways.

 Know why a test or procedure is recommended and what the results could mean.

 Know what to expect if you do not take the medicine or have the test or procedure.

 If you have a follow-up appointment, write down the date, time, and purpose for that visit.
 Know how you can contact your provider if you have questions.

https://www.hopkinsmedicine.org/healthlibrary/conditions/surgical_care/intra-
abdominal_abscess_134,145

Deep incisiona/ surgical site infections must occur within 30 days after hysterectomy. The diagnosis
is confirmed by at least one of the following: 1) purulent drainage from a deep incision, but not the
organ or space component of the surgical site; or 2) a deep incision that is deliberately opened by a
surgeon when the patient has at least one of the following signs or symptoms: 1) temperature >38C;
2) an abscess or other evidence of infection found at reoperation, by radiologic examination, or at
rcoperation by histopathologic diagnosis; or 3) if the diagnosis is made by the surgeon or attending
physician. This diagnosis can also be made if a deep incision dehisces spontaneously.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2364531/pdf/IDOG-05-052.pdf

Organ or space infections are defined as those that develop in surgical sites other than the
abdominal incision that was opened during the operative procedure. An example would be pelvic
infection after hysterectomy. Table 2 lists the specific organ/space surgical infection sites included in
their definitions. These infections must occur within 30 days of the hysterectomy and must be
accompanied by at least one of the following: 1) purulent drainage from a drain placed through a
stab wound into the organ/ space; 2) organisms isolated from an aseptically obtained culture of fluid
or tissue in the organ/space; 3) an abscess or other evidence of infection involving the organ/space
identified during reoperation or by radiologic or histopathologic examination; or 4) diagnosis of a SSI
by a surgeon or, attending physician. Because of the difficulty in the ability to aseptically obtain a
culture from a pelvic infection site, most infections are diagnosed clinically based on patient
symptoms, vital signs, and physical findings at examination. Radiologic examination may be useful in
diagnosing an infected hematoma or an abscess, however. Urine culture, complete blood count
(CBC) with differential count, blood cultures, and chest X-ray are seldom necessary, but hemoglobin
should be monitored and an unexplained decrease should be investigated.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2364531/pdf/IDOG-05-052.pdf