Abdominal Hysterectomy

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Abdominal hysterectomy
Authors: Thomas G Stovall, MD, William J Mann, Jr, MD

Section Editor: Howard T Sharp, MD
Deputy Editor: Kristen Eckler, MD, FACOG
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Apr 2018. | This topic last updated: Nov 16, 2017.
INTRODUCTION — Hysterectomy (surgical removal of the uterus) may be performed using an abdominal, vaginal, or laparoscopic approach. Abdominal hysterectomy refers to removal of the uterus via a laparotomy. Either
total hysterectomy (uterus including cervix) or subtotal (supracervical) hysterectomy may be performed. The ovaries may or may not be removed at the time of hysterectomy. The choice of surgical approach depends upon
clinical circumstances, the surgeon's technical expertise, and patient preference. (See "Choosing a route of hysterectomy for benign uterine disease".)
Issues related to abdominal hysterectomy will be reviewed here. Other approaches to hysterectomy are discussed separately. (See "Choosing a route of hysterectomy for benign uterine disease" and "Vaginal hysterectomy"
and "Laparoscopic hysterectomy" and "Radical hysterectomy".)
INDICATIONS AND ALTERNATIVES — The indications for, and alternatives to, hysterectomy are presented elsewhere. (See "Choosing a route of hysterectomy for benign uterine disease".)
PREOPERATIVE ISSUES — Complete preoperative evaluation and counseling helps to set patient expectations and prepare for, or prevent, perioperative complications. An overview of issues pertaining to preoperative
preparation and assessment, including women with medical comorbidities, can be found separately. (See "Overview of preoperative evaluation and preparation for gynecologic surgery".)
Surgical planning — Discussion of a patient's choices regarding surgical approach (eg, retention of ovaries or cervix) should be documented in the medical record and on the consent form.
Choice of incision — Women should be counseled before surgery about the planned type of abdominal incision, including the possibility that this plan may change depending on an examination under anesthesia or
other clinical factors. If a woman has a previous vertical abdominal surgical scar, most surgeons prefer to use this incision. However, if the planned procedure can be accomplished via a transverse incision, it is also an
option to ask a patient if she would prefer a transverse incision (figure 1 and figure 2). (See "Incisions for open abdominal surgery".)
Elective oophorectomy — Many physicians remove the ovaries in women over the ages of 40 or 45 for prevention of ovarian cancer, however, no data exist to support this approach in women who are not at a high risk
of ovarian cancer. Patients planning hysterectomy should be counseled regarding the risks and benefits of oophorectomy, which are discussed in detail elsewhere. (See "Risk-reducing bilateral salpingo-oophorectomy in
women at high risk of epithelial ovarian and fallopian tubal cancer" and "Elective oophorectomy or ovarian conservation at the time of hysterectomy", section on 'Introduction'.)
Total versus subtotal hysterectomy — Retention or removal of the cervix should be addressed with a patient preoperatively. There are no proven medical or surgical benefits of performing subtotal hysterectomy if the
cervix can be easily removed with the corpus. Retaining the cervix commits the patient to continued cervical cancer screening (ie, Pap smear and appropriate follow-up) and may result in persistent post-hysterectomy
bleeding.
The only absolute contraindication to subtotal hysterectomy is the presence of a malignant or premalignant condition of the uterine corpus or cervix.
A detailed discussion of total versus subtotal hysterectomy can be found separately. (See "Choosing a route of hysterectomy for benign uterine disease", section on 'Supracervical (subtotal) hysterectomy'.)
Prophylactic measures prior to hysterectomy
Thromboprophylaxis — Women undergoing abdominal hysterectomy require venous thromboembolism (VTE) prophylaxis. The type of thromboprophylaxis, pharmacologic or mechanical, depends upon the patient’s risk
factors. The risk categories in the guidelines for perioperative thromboprophylaxis published by both the American College of Obstetricians and Gynecologists (ACOG) and the American College of Chest Physicians (ACCP)
differ somewhat, but the recommendations are consistent with each other for most patients undergoing AH:
● ACOG defines patients undergoing AH as at least moderate risk of VTE and advises either mechanical or pharmacologic prophylaxis [1].
● ACCP defines most patients undergoing AH as at least moderate risk of VTE (Caprini score of 3 to 4) (table 1) and advises either mechanical or pharmacologic prophylaxis; the exception to this is women who are low
risk (Caprini score of 1 to 2; only women ≤40 years-old who have no other risk factors), for whom mechanical prophylaxis is advised [2].
Thromboprophylaxis for surgical patients is discussed in detail separately. (See "Prevention of venous thromboembolic disease in surgical patients" and "Overview of preoperative evaluation and preparation for gynecologic
surgery", section on 'Thromboprophylaxis'.)
Prophylactic antibiotics — A prophylactic antibiotic to prevent surgical site infection is given as a single intravenous (IV) for abdominal hysterectomy; appropriate antibiotic agents are shown in the table (table 2).
Prevention of gynecologic surgical site infection is discussed in detail separately. (See "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Surgical site infection prevention'.)
Women undergoing hysterectomy do not require antibiotic prophylaxis of bacterial endocarditis, in the absence of high risk conditions indications. (See "Antimicrobial prophylaxis for the prevention of bacterial endocarditis",
section on 'Clinical approach'.)
Bacterial vaginosis treatment — For women with bacterial vaginosis, treatment of bacterial vaginosis for eight days, starting four days before surgery can reduce the frequency of vaginal cuff infection in a randomized
trial [3,4]. (See "Bacterial vaginosis: Treatment", section on 'Women undergoing gynecologic procedures'.)
OPERATIVE TECHNIQUE
Patient positioning — The initial steps after a patient enters the operating room include:
● Position in the dorsal supine or lithotomy position (preferred by some surgeons so that a second assistant can stand between the patient's legs)
● Perform an examination under anesthesia (helps to confirm pelvic findings and guide the final choice of incision) (see "Pelvic examination under anesthesia")
● Insert Foley bladder catheter
● Perform sterile preparation of the abdomen and vagina
● Place surgical draping.
It is not necessary to remove hair at the planned incision site. If hair is removed, it should be clipped rather than shaved, as patients who are shaved appear to be more likely to develop surgical site infection. (See "Overview
of control measures for prevention of surgical site infection in adults", section on 'Hair removal'.)
Skin and vaginal preparation — In our practice, we use 4 percent chlorhexidine gluconate solution with 70 percent isopropyl alcohol for the abdominal preparation. For vaginal preparation, either 4 percent chlorhexidine
gluconate with a lower isopropyl alcohol concentration (typically 4 percent) or povidine-iodine solution can be used [5]. (See "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Vaginal
preparation'.)
Incision and exploration — The skin incision may be transverse or midline vertical and is determined by a variety of factors, such as presence of prior surgical scar, need for exploration of the upper abdomen, size and
mobility of the uterus, and desired cosmetic results. If a prior incision exists, most surgeons prefer to use this incision. If the prior scar is cosmetically unacceptable, it may be excised at the beginning or end of the procedure.
This is easily accomplished by elevating the old scar with Allis clamps and making an elliptical incision around the old scar. (See 'Choice of incision' above and "Incisions for open abdominal surgery".)
The peritoneal cavity is entered and the upper abdomen and pelvis explored for unexpected pathology and to confirm preoperative findings. Peritoneal washings may be collected for cytologic analysis if a malignancy is
suspected.
Exposure — Most surgeons prefer to use a self-retaining retractor for an abdominal hysterectomy, although use of hand held retractors is an option. The type of self-retaining retractor used depends on surgeon preference.
With very large masses, it is often impossible to place a retractor until the mass has been mobilized and freed from adhesions.
When positioning retractors, it is important to avoid placing the lateral blades over a femoral nerve as it emerges lateral to the psoas muscle, since this can lead to a peripheral neuropathy. Surgical personnel should not lean
on the retractors for the same reason. Safe placement is assured by lifting the abdominal wall as the retractor is placed, and then checking to be sure no bowel has been trapped beneath a blade and that the blade is not
pressing on the side wall of the pelvis. (See "Nerve injury associated with pelvic surgery".)
Adhesiolysis — If pelvic or intraabdominal adhesions are present, it is important to mobilize the pelvic organs by dividing omental, intestinal, or abdominal wall adhesions. Restoring normal anatomy allows for visualization
of important pelvic structures (eg, ureter, blood vessels).
Round ligament ligation — Traditionally, a large Kelly clamp is placed across each uterine cornu (fallopian tube and round ligament are included in the clamp). This allows uterine elevation and prevents back bleeding
when the round ligaments are divided (figure 3 and figure 4). An alternative technique, which is essentially identical to the technique used at laparoscopic procedures, may be more time efficient. Using this approach, the
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round ligament is clamped and divided using electrosurgery. The electrosurgical device can then be used to open the anterior peritoneum and mobilize the bladder, and to incise the lateral peritoneum without adding extra
time to change instruments.
A common error is to divide the round ligament too close to the uterus, which limits exposure in the broad ligament and makes incision of the peritoneum over the broad ligament more difficult. The round ligament is best
divided at its mid portion, or more laterally, and then the ligament can be easily lifted to facilitate peritoneal dissection and division.
Broad ligament dissection — The incision in the round ligament is then carried inferiorly through the peritoneum of the broad ligament to the level of the uterine artery, and then medially along the vesicouterine fold,
separating the bladder peritoneum from the lower uterine segment (figure 5).
The retroperitoneum is entered by extending the incision on the posterior leaf of the broad ligament superiolaterally, remaining lateral to both the infundibulopelvic ligament and iliac vessels. Blunt or sharp dissection clears
the loose connective tissue overlying the external iliac artery. The perivesical space and perirectal space can be created at this time.
The perivesical space is lateral to the bladder, and medial to the external iliac vessels. It is an avascular space created by sharp or blunt dissection that extends down to the levator ani muscles. The superior vesicle artery is
at medial border.
The perirectal space is between the ureter and iliac vessels, is also avascular, and extends down to levator ani muscles. If you create both spaces, placing an index finger into the perivesical space and the middle finger into
the perirectal space will give you the parametrium between your fingers. These spaces delineate the pelvic vasculature and ureter well.
By following the external iliac artery superiorly to its bifurcation, the ureter can be identified as it crosses the common iliac artery. The ureter is left attached to the medial or posterior leaf of the broad ligament so as not to
disrupt its blood supply (figure 6). The left ureter is always more medial than the right and deeper in the pelvis along the posterior peritoneum.
Avoiding ureteral injury — For most women undergoing gynecologic surgery, we recommend not using prophylactic ureteral stents. We find ureteral identification and dissection, if necessary, is adequate for ureteral
protection. There are those who suggest use of prophylactic stents for women with severe endometriosis or a history pelvic irradiation, but we have not found this helpful in our practice. (See "Urinary tract injury in
gynecologic surgery: Epidemiology and prevention", section on 'Prophylactic ureteral catheters'.)
We prefer to open the retroperitoneum and visualize the ureter on the posterior leaf of the broad ligament peritoneum to prevent ureteral injury. If palpation alone is used, the internal iliac artery, ovarian vessels, and vessels
of the broad ligament are easily confused with the ureter. The visualization of ureteral peristalsis confirms its identity. Additionally, when the vesicouterine space is developed, the bladder is displaced inferiorly to laterally
displace the ureters. In some women, the ureter is as little as 5 mm from the uterine artery, and reflecting the bladder downward prior to dividing the uterine artery will slide the ureter laterally, providing more space for
placement of clamps.
There is no space between the infundibulopelvic ligaments where they cross the ureter, and clamping down to get these vessels can risk damage to the ureter. Elevating the infundibulopelvic ligaments prior to division
creates a space between the ureter and ovarian vessels and ensures that the ureter is not included in the clamp.
Ureteral identification is particularly important if the patient has had prior pelvic surgery. If the patient has extensive pelvic disease, we dissect the ureter down toward the bladder until optimal visualization is achieved.
Adnexal conservation or removal
Conserving ovaries and tubes — If the ovaries are to be conserved, with the ureter under direct vision, an opening is created in the posterior leaf of the broad ligament under the utero-ovarian ligament and fallopian
tube (figure 7). The utero-ovarian ligament is clamped, cut, and ligated with a free tie followed by a suture ligature (placed just medial to the free tie). The medial large Kelly clamp at the uterine cornu will control back
bleeding.
It is our practice to use measures to prevent the ovaries and fallopian tubes from adhering to the vaginal apex (a possible cause of dyspareunia). Some surgeons place a suture through the stump of the utero-ovarian
ligament and then sew the stump to the psoas muscle or to the round ligament stump using an absorbable suture [6]. Alternatively, the bilateral utero-ovarian stumps may be sutured together in the midline. There is no
evidence that this decreases the risks of dyspareunia following hysterectomy.
Salpingo-oophorectomy — If the ovaries are to be removed, the broad ligament opening is extended superiorly to the infundibulopelvic ligament. A curved clamp is placed lateral to the ovary, making certain that the
entire ovary is included in the surgical specimen (figure 8). This is facilitated by elevating the infundibulopelvic ligament and creating a generous space in the posterior pelvic peritoneum between the ureters and vessels.
Each infundibulopelvic ligament is cut and ligated with a free tie followed by a suture ligature (placed just medial to the free tie) (figure 9). Tying the pedicle before suturing it prevents formation of an expanding hematoma
through inadvertent puncture of the ovarian vessels. Sutures on vascular pedicles should not be used to elevate the pedicle, as this may compromise knot strength and hemostasis.
Perivesical and perirectal dissection — It is beneficial to dissect the perivesical and perirectal spaces to separate the bladder and rectum from the uterus, thereby avoiding injury of these organs. Developing these spaces
is particularly important if there is distortion of anatomy by pelvic pathology (eg, endometriosis, pelvic inflammatory disease, prior surgery). Identification and mobilization of the structures which surround the uterus allow
prompt identification and control of any problems encountered intraoperatively. (See "Complications of gynecologic surgery" and "Urinary tract injury in gynecologic surgery: Epidemiology and prevention".)
The bladder is dissected off the lower uterine segment and cervix (figure 10). An avascular plane exists between the lower uterine segment and bladder, which allows for its mobilization. We prefer sharp dissection, as the
use of a blunt dissection with a sponge stick may lead to a cystostomy, particularly if there has been prior surgery (eg, cesarean delivery). In addition, an incision into the bladder is more easily repaired than a tear from blunt
dissection. After this dissection, a lap sponge can be placed beneath the bladder retractor to tamponade any small bleeding vessels.
If the rectum requires mobilization from the posterior cervix, the posterior peritoneum between the uterosacral ligaments just beneath the cervix and rectum is incised. A relatively avascular tissue plane exists in this area,
which allows mobilization of the rectum inferiorly out of the operative field (figure 11).
Uterine vessel ligation — Sharp dissection is used to skeletonize the uterine vessels, removing any loose overlying connective tissue. This allows visualization of the uterine vessels, thereby ensuring that clamps are
placed on these vessels and not on the ureter (as it passes below the uterine vessels). As noted previously, the bladder is reflected inferiorly with sharp dissection prior to dividing the uterine arteries.
A curved clamp is placed perpendicular to the uterine artery at the junction of the cervix and lower uterine segment. Care is taken to place the tip of the clamp adjacent to the uterus at this site of anatomic narrowing (figure
12). The uterine artery is cut and ligated. Some surgeons place two curved clamps and ligate the uterine artery twice. Given the proximity of the ureter to the uterine artery, we prefer single clamping. The same procedure is
then carried out on the opposite side.
To control back bleeding and aid visualization, a large Kelly can be placed immediately adjacent to the uterus on each side, incorporating the attachments of the tube, ovarian ligament and round ligament, extending down to
the level of the uterine artery. Once placed, the clamp is not removed until the uterus is amputated.
The cardinal ligament and any remaining broad ligament are divided by placing a straight clamp medial to the uterine vascular pedicle and parallel to the cervix for a distance of 2 to 3 cm. The pedicle is cut and ligated with a
suture ligature (figure 13). The number of bites needed to reach the vagina can vary depending on the length of the cervix.
Use of electrosurgery — An alternative to suture ligation of vascular pedicles is use of electrocautery coagulation [7]. Use of this approach for hysterectomy requires a device that can achieve hemostasis in large
vessels. As an example, the Ligasure™ bipolar sealing device can be used in vessels up to 7 mm in diameter.
However, there are no data that show that use of this device for abdominal hysterectomy improves surgical outcomes. Two small randomized trials (n = 30 and 57) that compared the use of Ligasure in abdominal
hysterectomy with traditional suture ligature found no benefits regarding operative time, blood loss, or complication rate [8,9]; however, they were underpowered to detect clinically significant differences. Postoperatively, one
study found that pain scores during the first three days after surgery were reduced by more than 20 percent with use of Ligasure™ [8]; postoperative outcomes were not assessed in the other study. (See "Overview of
electrosurgery", section on 'LigaSure device'.)
Cervical amputation or removal — At this point in a hysterectomy for benign indications, if a large uterus is impeding visualization or a supracervical hysterectomy is planned, the cervix can be amputated and the uterus
removed.
Supracervical (subtotal) hysterectomy — If a supracervical hysterectomy is planned, the cardinal and broad ligaments are clamped until a point is reached midway between the level of the internal and external cervical
ostia. The cervix is then amputated with a scalpel or cautery. Care is taken to avoid injury to surrounding structures.
To avoid continued cyclical bleeding from retained lower uterine segment endometrium, some surgeons will cauterize or resect the endocervix [10]. Resection can be done with an electrocautery loop.
The cervical stump is then closed with a size 0 absorbable suture in a running or interrupted fashion. Some surgeons will cover the stump with peritoneum. Comparison of total and supracervical hysterectomy is discussed
separately. (See "Choosing a route of hysterectomy for benign uterine disease", section on 'Supracervical (subtotal) hysterectomy'.)
Total hysterectomy — If a surgeon is proceeding with a total hysterectomy, the cardinal and broad ligaments are clamped, cut and ligated bilaterally until the level of the external cervical os is reached. A series of
pedicles may be required depending upon the size of the uterus.
To remove the cervix, the uterus is pulled cephalad and the tip of the cervix is palpated. Care should be taken to avoid foreshortening the vagina.
● Extrafascial technique – This is the most commonly used approach to total abdominal hysterectomy [11]. The cervicovaginal junction at the level of the external cervical os is palpated, and an incision is made, entering
the vaginal apex. A circumferential vaginal incision is made with the Jorgenson scissors, amputating the cervix and uterus.
● Intrafascial technique – This technique may preserve the neurovascular supply at the cervicovaginal junction by preserving the pubovesicocervical fascia [11]. Transverse incisions are made on the anterior and posterior
surfaces of the cervix, below the level of the uterine vasculature. The pubovesicocervical fascia is then dissected off the lower uterine segment and cervix with the handle of the scalpel or with gauze-covered index
finger. Care is taken to avoid incising too deeply into the cervix, as the loose fascial plane would be missed, causing the dissection to be difficult and bloody. A curved Heaney clamp is placed inside the fascia on each
side of the uterus to incorporate the uterosacral ligaments and upper vagina just below the cervix (figure 14). The vagina is incised and the cervix and uterus are then resected using heavy curved scissors (figure 15).
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Treatment of the vaginal cuff — Numerous techniques have been described for management of the vaginal cuff closure. Randomized trials have found no difference in postoperative infectious morbidity with an open or
closed cuff technique [12,13]. Three methods are described below:
● Kocher clamps are placed bilaterally at the cuff angles. A figure-of-eight suture of 0 or 2-0 gauge synthetic absorbable suture is placed in the midline. This suture is used for both traction and hemostasis. Sutures are
then placed at the tip of each clamp and the angle pedicle is transfixed with the suture ligature. This suture incorporates the uterosacral and cardinal ligament at the angle of the vagina (figure 16). Additional figure-of-
eight sutures are placed along the cuff to close gaps and ensure hemostasis.
● An alternative approach minimizes blood loss and avoids spillage of vaginal content into the peritoneal cavity; however, the vaginal length is somewhat shortened [14]. Two Munion or curved Heaney clamps are placed
from lateral to medial at the level of the external cervical os; care is taken to avoid incorporating bladder tissue in the clamps. The cervix is amputated with a scalpel or scissors. (Note that this is a variation from the
procedure for removing the cervix described above) (see 'Total hysterectomy' above). Using a size 0 absorbable suture, a running stitch is placed from medial to lateral on each side, oversewing the clamp (the suture
ends are left untied and long). The clamps are then removed and the sutures pulled tight. Continuing with the same needle, a running, locked stitch is placed from lateral to medial on each side, and then tied in the
midline.
● Some surgeons prefer to leave the cuff open to heal secondarily. If this method is used, a running suture is used for hemostasis along the cuff edge and the peritoneal defect superior to the cuff is sutured closed. There
appears to be no difference in postoperative febrile morbidity whether the vaginal cuff is closed or remains open [15].
Apical prolapse prevention — The association between hysterectomy and subsequent pelvic organ prolapse is controversial. Experts agree that the vaginal apex should be suspended at the time of hysterectomy to
minimize subsequent apical support loss. However, the optimal technique for suspension is not known.
Common techniques for vaginal apex suspension include: intrafascial hysterectomy (to preserve the uterosacral-cardinal ligament complex) and incorporating the uterosacral ligaments into the vaginal cuff angle at the time
of closure [16-18]. However, as there are no high quality data evaluating these approaches in abdominal hysterectomy, clinical decisions are based on individual surgeon experience. (See "Prophylactic vaginal apex
suspension at the time of hysterectomy".)
A full discussion of hysterectomy and pelvic organ prolapse can be found separately. (See "Choosing a route of hysterectomy for benign uterine disease", section on 'Pelvic organ prolapse'.)
Final examination and closure — The pelvis is thoroughly irrigated with warm saline or Ringer's lactate solution. Meticulous hemostasis at all pedicles is confirmed. The bladder and ureters are inspected.
Strategies to prevent postoperative adhesions include meticulous surgical technique (ie, hemostasis and minimal tissue handling) and the application of anti-adhesive barriers. (See "Postoperative peritoneal adhesions in
adults and their prevention".)
It is not necessary or desirable to reapproximate the visceral or parietal peritoneum [19]. The fascia and skin are reapproximated in standard fashion. (See "Complications of abdominal surgical incisions".)
SPECIAL CIRCUMSTANCES — In technically difficult surgeries, all pelvic surgeons, no matter their experience level, occasionally benefit from assistance.
Malignancy — Prior to surgery, patients should have standard screening tests and, if symptoms are present, appropriate evaluation to exclude gynecologic cancer or other malignancies which commonly metastasize to the
pelvis (eg, breast, stomach, colorectal). (See "Screening for breast cancer: Strategies and recommendations" and "Screening for cervical cancer" and "Screening for colorectal cancer: Strategies in patients at average risk"
and "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Clinical features and diagnosis", section on 'Excluding an extraovarian primary cancer'.)
For patients in whom diagnosis or treatment of a malignancy is the indication for surgery, informed consent and preparation are made for staging and initial surgical management. (See "Invasive cervical cancer: Staging and
evaluation of lymph nodes" and "Endometrial carcinoma: Pretreatment evaluation, staging, and surgical treatment" and "Uterine sarcoma: Classification, clinical manifestations, and diagnosis" and "Epithelial carcinoma of
the ovary, fallopian tube, and peritoneum: Clinical features and diagnosis".)
In cases where an unsuspected malignancy is discovered at time of surgery, management depends upon the type of cancer and experience level of the surgeon. Intraoperative consultation from a gynecologic oncologist
should be requested if available. Staging procedures performed by a gynecologic oncologist appear to lead to better patient outcomes [20].
If a gynecologic oncologist is not available and a surgeon is not experienced in operative management of the cancer (eg, lymphadenectomy, radical hysterectomy), it is prudent to close the patient and arrange for prompt
consultation with a specialist for a second procedure. As an example, in a patient with cervical cancer, a standard versus radical hysterectomy will worsen prognosis.
Large uterus — A large leiomyomatous uterus (typically defined as ≥16 weeks' size or 350 gm) may limit the choice of skin incision and may result in increased intraoperative blood loss [21,22]. It is generally possible to
remove a uterus that is ≤16 gestational week-size (fundus midway between the pubic symphysis and the umbilicus) through a transverse incision (Pfannenstiel, Cherney, or Maylard). While some surgeons will remove a
large uterus through a transverse incision [23], many prefer to use a midline vertical incision. In addition, the incision may need to be extended above the umbilicus if a uterus is 20 gestational weeks-size (fundus at the
umbilicus) or larger [24]. Removal of a very large uterus is associated with concealed blood loss (ie, volume of blood contained within the uterus). Awareness of this facilitates fluid and blood replacement, and can help with
resuscitation in the immediate postoperative period.
Preoperative GnRH analogues — Uterine size can be reduced with preoperative treatment for three to four months with gonadotropin-releasing hormone (GnRH) analogues, and may permit a transverse rather than a
midline vertical incision (or a vaginal approach) [25]. Benefits regarding intraoperative hemorrhage and operating time are minimal.
A systematic review of randomized trials of women undergoing hysterectomy, reported the following findings for patients pretreated with GnRH analogues versus either no treatment or placebo [25]:
● Preoperative hematocrit was increased (3.1 percent, 95% CI 1.8-4.5)
● Uterine size was decreased (-2.2 gestational weeks, 95% CI -2.3 to -1.9)
● Proportion of vertical incisions was reduced (OR 0.36, 95% CI 0.2-0.6)
● Intraoperative blood loss was decreased (-58 mL, 95% CI -75.7 to -40.3)
● Duration of surgery was decreased (-5.2 minutes, 95% CI -8.6 to -1.8)
● Duration of hospital stay was shorter (-1.1 days, 95% CI -1.2 to -0.9)
Intraoperative vasopressin — Blood loss from a leiomyomatous uterus can be decreased by using intramyometrial (IMM) vasopressin [21]. A randomized trial assigned women with uterine fibroids who were undergoing
abdominal hysterectomy to vasopressin (5 mL IMM, 10 units in 10 mL normal saline) or normal saline. Injections were made bilaterally, 1 cm medial to the uterine vessels in the most inferior area of the lower uterine segment
that did not reach the bladder. If this site was obstructed, the midline at the fundus was used. Mean total blood loss was significantly lower with use of vasopressin compared to normal saline (445 versus 748 mL).
Emergency or unplanned hysterectomy — An unplanned or emergency hysterectomy may need to be performed in certain clinical circumstances (eg, acute uterine bleeding, conversion from another planned gynecologic
procedure), if all alternative medical and surgical measures have been exhausted. In such cases, it may not be possible to complete a full preoperative evaluation and consent process. Discussion with, and notification of, a
family member or friend may be appropriate, depending upon patient consent for disclosure of medical information to this person. (See "Overview of preoperative evaluation and preparation for gynecologic surgery", section
on 'Informed consent and patient expectations'.)
Emergency situations require meticulous and efficient surgical technique. Communication with members of the surgical team (eg, anesthesiologist, nurses, scrub technicians) regarding anticipated need for blood products,
surgical equipment, and postsurgical care (eg, intensive care) is of critical importance. It is optimal to have an experienced first assistant.
A midline vertical abdominal incision provides the best exposure and can be easily extended superiorly. This may be useful, particularly in cases where preoperative examination and imaging are limited. Hemostasis should
by achieved quickly by ligating the ovarian and uterine vessels as soon as it is safely possible to do so [24].
Obesity — Incision placement in the overlapping fold of a panniculus should be avoided. Panniculectomy makes the surgical procedure much easier to perform, but may require a long period to time postoperative for
complete wound healing. (See "Incisions for open abdominal surgery", section on 'Special considerations for obese patients' and "Complications of abdominal surgical incisions", section on 'Panniculectomy'.)
Exposure may be more challenging in an obese patient. A surgeon who usually uses a smaller self-retaining retractor may choose to use a larger retractor in obese patients (eg, Bookwalter retractor). Oversized laparotomy
pads exist and are ideal in obese patients. They are easier to place and allow the use of fewer pads. The combination of obesity and a deep pelvis is particularly challenging. Long instruments will be required, most ties will
require use of a pass, and exposure of the cardinal ligaments can be challenged.
Exposure can be aided by placing one or more wet lap pads high in the vagina prior to beginning surgery. This elevates the uterus and makes the surgical procedure much easier. The pads are tagged with a long clamp and
removed by an assistant prior to closing the vaginal cuff.
Mass fascial closure (incorporating the fascia along with a small amount of subcutaneous fat, rectus muscle, rectus sheaths, and peritoneum) may reduce the risk of wound dehiscence in obese patients. Also, closure of the
subcutaneous layer in obese patients reduces the risk of superficial wound disruption according to randomized trials. Similarly, the use of a subcutaneous drain may decrease wound disruption risk, however, this has not
been confirmed. If drains are used, they are closed suction systems and not placed through the incision. (See "Principles of abdominal wall closure", section on 'Mass closure' and "Principles of abdominal wall closure",
section on 'Subcutaneous' and "Complications of abdominal surgical incisions".)
COMPLICATIONS — The rate of unintended major surgical procedures after AH, such as intraoperative injury to intraabdominal organs requiring repair or return to the operating room within eight weeks postoperatively, is
approximately 0.3 to 0.7 percent [26,27]. Incidence and management of complications specific to AH are discussed here (table 3). Complications associated with other approaches to hysterectomy or general complications
of gynecologic surgery are reviewed separately. (See "Vaginal hysterectomy" and "Laparoscopic hysterectomy" and "Radical hysterectomy" and "Complications of gynecologic surgery".)
The following three large studies illustrate the frequency of complications associated with abdominal hysterectomy performed for benign indications:
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● In the United Kingdom, the VALUE study (Vaginal, Abdominal, or Laparoscopic Uterine Excision) included over 37,000 hysterectomies performed from 1994 to 1995 for benign disease; over 24,000 of the procedures
were performed abdominally [26]. The crude rates for severe intraoperative and postoperative complications for AH were 3.6 and 0.9 percent, respectively. The risk of severe complications was significantly lower in
abdominal versus laparoscopic procedures (4 versus 6 percent). Severe complications were defined as death, thromboembolism, myocardial infarction, stroke, renal failure, severe infection, secondary hemorrhage,
fistula, ureteral obstruction, and visceral damage.
● The eVALuate trial was a concurrent pair of large multicenter randomized trials of hysterectomy in women with benign disease [27]. One trial included 292 women assigned to AH and 584 women assigned to
laparoscopic hysterectomy; the other arm compared vaginal with laparoscopic hysterectomy. Women were excluded from participation if they had 2nd or 3rd degree prolapse, required bladder or pelvic support surgery,
a uterine size larger than 12 weeks, or a contraindication to laparoscopic surgery. In the abdominal trial, the number of patients with at least one major complication was significantly less in abdominal than laparoscopic
hysterectomy (6 versus 11 percent). The most common major complications of AH were hemorrhage (2 percent), bladder injury (1 percent), and bowel injury (1 percent). The major findings from this trial are shown in the
table (table 4). (See "Laparoscopic hysterectomy".)
● A retrospective study of gynecologic hospital inpatients in England included over 61,000 elective abdominal hysterectomies [28]. The rate of emergency readmissions within 30 days postoperatively was 5.7 percent.
Hemorrhage — Average intraoperative blood loss is 300 to 400 mL [29,30]. Excessive bleeding complicates approximately 2 percent of abdominal hysterectomies [26,31]. In a systematic review of randomized trials, blood
loss was slightly less (85 mL) in subtotal compared with total hysterectomy; no difference was found in risk of requiring blood transfusion [32].
● Evaluation and management – Careful inspection of all pedicles before abdominal closure is the best method to prevent intraoperative and postoperative hemorrhage. Postoperative hemorrhage may be plainly visible, in
the case of bleeding from the vagina or wound. Intraabdominal bleeding should be suspected if hemodynamic alteration or oliguria develop. (See "Management of hemorrhage in gynecologic surgery".)
Each bleeding site is approached differently in evaluation and treatment, but all involve prompt stabilization of vital signs, laboratory evaluation of hematocrit, platelets, and clotting parameters (prothrombin time, activated
partial thromboplastin time, and fibrinogen), fluid and blood product replacement, and constant surveillance of the patient's condition.
The patient should be taken promptly to an examining room to inspect the operative site, the abdomen, and the vaginal cuff. Bleeding from the vaginal cuff can usually be sutured in the examination room.
Intraabdominal bleeding should be evaluated in the operating room. An intraperitoneal hematoma in a stable patient can be managed either expectantly or with surgical exploration. A patient who does not stabilize rapidly
with fluid and blood product replacement requires surgical exploration.
If diffuse bleeding is encountered and clotting parameters confirm a coagulopathy, appropriate replacement of blood products and medical therapy are initiated. (See "Clinical features, diagnosis, and treatment of
disseminated intravascular coagulation in adults".)
In some patients, radiographic embolization of the hypogastric vessels may be attempted in addition to, or in place of, surgery. (See "Interventional radiology in management of gynecological disorders".)
Infection — Approximately 11 percent of women undergoing AH without antibiotic prophylaxis develop fever or infection [32,33]. However, in a large prospective study, patients undergoing AH selectively received
prophylactic antibiotics (79 percent of patients); the following sites of infection were identified: urinary tract (4 percent), wound (3 percent), unknown fever (3 percent), vaginal infection (0.2 percent), and intraabdominal (0.1
percent) [31]. Prompt catheter removal postoperatively may reduce the risk of urinary tract infection [34].
● Evaluation and management – Evaluation of a postoperative patient with an oral temperature above 100.4ºF (38ºC) includes examination of potential sites of infection (eg, lungs, abdomen, wound, vagina) and
appropriate laboratory evaluation. Evaluation of postoperative fever is discussed separately (see "Postoperative fever" and "Complications of gynecologic surgery", section on 'Infectious morbidity').
Most women will have an increase in cul-de-sac or other peritoneal fluid following hysterectomy. The importance of these fluid collections is uncertain. If a fluid collection is found in a patient who is febrile despite antibiotic
therapy, it may be drained either percutaneously or the vaginal cuff can be opened using a Kelly clamp or uterine dressing forceps. (See "Posthysterectomy pelvic abscess".)
Pelvic or ovarian vein thrombophlebitis may be detected on computed tomography (CT) or suspected clinically, and may require the addition of heparin to antibiotics. In these patients, the heparin may be discontinued when
the patient becomes afebrile for 24 hours; warfarin is not indicated. (See "Septic pelvic thrombophlebitis".)
Thromboembolic disease — Without thromboprophylaxis, the risk of deep vein thrombosis in patients after major general or gynecologic surgery is 15 to 30 percent; the risk of fatal pulmonary embolism is 0.2 to 0.9
percent [35]. In a population of patients who selectively received prophylactic anticoagulants (38 percent of patients), the rate of venous thromboembolism was 0.2 percent [31].
● Evaluation and management – A postoperative patient who develops localized tenderness, asymmetric swelling in an extremity, dyspnea, pleuritic pain, tachypnea or tachycardia should be evaluated for venous
thromboembolism. (See "Clinical presentation and diagnosis of the nonpregnant adult with suspected deep vein thrombosis of the lower extremity" and "Clinical presentation, evaluation, and diagnosis of the
nonpregnant adult with suspected acute pulmonary embolism".)
Urinary tract issues — Suspected intraoperative ureteral injury should be evaluated and, if present, repaired. Postoperatively, ureteral injury may be asymptomatic or may present as flank or groin pain, fever, prolonged
ileus, or abdominal mass. Urinary tract injury in gynecologic surgery is discussed separately. (See "Urinary tract injury in gynecologic surgery: Identification and management".)
Ureteral injury — In a retrospective study including over 62,000 hysterectomies, the total incidence of ureteral injury after all hysterectomies was 1.0 of 1000 procedures: 13.9 of 1000 after laparoscopic, 0.4 of 1000 after
total abdominal, 0.3 of 1000 after supracervical abdominal, and 0.2 of 1000 after vaginal hysterectomy [36]. Injury detection rates may be higher with routine use of cystoscopy [37].
Bladder injury — The incidence of bladder injury in AH is 0.02 to 1 percent [27,31,36]. Bladder injury may occur upon opening the peritoneum or, more frequently, during dissection of the bladder off the lower uterine
segment, cervix, and upper vagina.
Urinary incontinence — The role of hysterectomy in subsequent urinary incontinence is controversial. A full discussion of this topic can be found separately. (See "Choosing a route of hysterectomy for benign uterine
disease", section on 'Urinary incontinence'.)
Gastrointestinal tract issues
Bowel injury — Bowel injuries occur in approximately 0.2 to 1 percent of cases [27,31]. These injuries occur primarily during lysis of adhesions involving bowel or dissection of the posterior cul-de-sac (pouch of Douglas).
● Management – Serosal abrasions do not need repair, but injuries involving the muscularis and/or mucosa should be repaired. In large bowel injury, lack of preoperative bowel prep is not by itself an indication for
colostomy. (See "Complications of gynecologic surgery", section on 'Bowel injury' and "Overview of gastrointestinal tract perforation", section on 'Instrumentation/surgery' and "Traumatic gastrointestinal injury in the adult
patient".)
There are no postoperative dietary restrictions unless the bowel injury and repair involved a large area. We do not use a nasogastric tube postoperatively.
Ileus — Ileus is common following abdominal surgery. This is discussed in detail separately. (See "Postoperative ileus".)
Bowel obstruction — The risk of bowel obstruction after AH was 13.6/1000 in a multihospital series of small bowel obstruction due to intraabdominal adhesions in non-oncologic patients [38]. The median interval
between hysterectomy and small bowel obstruction was four years.
● Evaluation and management – The most common symptoms of small bowel obstruction are abdominal distention, vomiting, crampy abdominal pain, and inability to pass flatus. Patients may or may not complain of
obstipation and inability to pass flatus since the colon requires 12 to 24 hours to empty after the onset of bowel obstruction. As a result, flatus and even passage of feces may continue after onset of symptoms. (See
"Epidemiology, clinical features, and diagnosis of mechanical small bowel obstruction in adults".)
The diagnosis can be made by history and physical examination in the majority of patients. Plain abdominal radiography is used to confirm the diagnosis; in most patients, no further radiologic tests are needed.
Management of small bowel obstruction is discussed in detail separately. (See "Overview of management of mechanical small bowel obstruction in adults".)
Vaginal cuff dehiscence — Evisceration of the small intestine into the vagina is a rare complication; eviscerated bowel can become incarcerated. In a large retrospective study, the risk of vaginal cuff dehiscence after AH
was 0.12 percent [39].
Eviscerations usually occur in the early postoperative period, although in one series of 12 patients after various pelvic surgeries, the mean time of occurrence was 27 months (range 5 to 48 months) [40]. Symptoms include
abdominal or pelvic pain, vaginal bleeding or discharge, vaginal pressure, or protrusion of bowel.
Management of vaginal cuff dehiscence is discussed separately. (See "Vaginal cuff dehiscence after hysterectomy".)
Adhesions — Postoperative adhesion formation is a common cause of small bowel obstruction and may contribute to pelvic or abdominal pain. However, adhesiolysis does not appear to be an effective treatment for
symptomatic patients. (See "Treatment of chronic pelvic pain in women", section on 'When to perform additional surgery'.)
● Prevention – Meticulous surgical technique is the first defense against adhesion formation. Physical barriers may also prevent adhesion formation associated with laparotomy. (See "Postoperative peritoneal adhesions
in adults and their prevention".)
Reproductive system
Earlier menopause — Hysterectomy appears to impair ovarian function over the long-term, at least in some women, so that menopause occurs earlier. (See "Choosing a route of hysterectomy for benign uterine
disease", section on 'Earlier menopause or decreased ovarian reserve'.)
Fallopian tube prolapse — Posthysterectomy prolapse of the fallopian tube is an uncommon complication often confused with granulation tissue at the vaginal apex. Development of a hematoma or abscess at the
vaginal apex is a predisposing factor. A patient with tubal prolapse generally presents with one or more of the following: vaginal bloody discharge and/or leukorrhea, dyspareunia, and persistent pelvic pain [6]. These
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symptoms usually arise in two weeks to six months postoperatively, but can appear several years after surgery.
If the tissue at the top of the vaginal cuff does not respond to conservative treatment, such as silver nitrate application or cryotherapy, a biopsy of the area can be done to confirm tubal epithelium. Treatment is surgical; the
surrounding vaginal epithelium is opened and widely undermined, and the tube is resected. Concurrent laparoscopy may be helpful [6].
Cardiovascular disease — A large nested cohort study found that hysterectomy was not associated with a significantly altered risk of mortality from cardiovascular disease, cancer, or all causes [41]. There was no
adjustment for oophorectomy. (See "Overview of cardiovascular risk factors in women", section on 'Hysterectomy'.)
Mortality — A retrospective study of hospital admissions in England included over 61,000 elective abdominal hysterectomies, the mortality rate was 0.5 per 1000 [28]. Similarly, in the VALUE study of over 24,000 abdominal
hysterectomies performed for benign conditions described above, eight deaths were reported within six weeks of AH (mortality rate 0.32 per 1000 procedures); four deaths were due to either cardiac events or pulmonary
embolism [26]. No deaths occurred intraoperatively and six deaths occurred before hospital discharge. In addition, data for abdominal hysterectomy from the 1998 to 2010 United States Nationwide showed a mortality rate of
0.17 percent [42].
The mortality rate, standardized for age and race, is higher for hysterectomies associated with pregnancy or cancer than for procedures not associated with these conditions (2.9, 3.8, and 0.6 per 1000 procedures,
respectively); 61 percent of deaths occurred among women with these conditions [43]. Since almost all hysterectomies performed during pregnancy or for cancer are done abdominally, this contributes to the higher mortality
rate of AH compared to the vaginal procedure (15 versus 4 per 10,000 procedures) [43]. The types of pelvic pathology (eg, severe endometriosis, tubo-ovarian abscess, large tumors) for which the abdominal route is
undertaken also contribute to the higher mortality of this procedure.
INPATIENT POSTOPERATIVE CARE — The average length of hospital stay after AH in the United States is three days [44]. Routine postoperative care includes monitoring of a patient's hemodynamic and fluid status, pain
control, and reintroducing normal diet and activity. Evidence-based specifics of postoperative care are discussed below.
Postoperative pain is managed initially with parenteral administration of analgesics. Patient-controlled anesthesia is an option. This is transitioned to the oral route when a patient can tolerate oral intake, usually on the first
postoperative day. (See "Management of acute perioperative pain".)
The bladder catheter can be removed during the first 24 hours postoperatively. A systematic review of randomized trials was conducted regarding use of urinary catheterization after urogenital surgery in adults [45]. Fewer
urinary tract infections resulted when a catheter was removed after one versus three days (RR 0.50, 95% CI 0.29-0.87). Also, decreased risk of recatheterization was associated with use of a postoperative catheter versus
no catheter, as well as with a suprapubic catheter versus a urethral catheter. However, placement of a suprapubic catheter involves an additional incision. (See "Placement and management of urinary bladder catheters in
adults".)
Postoperative colonic stasis after major abdominal surgery lasts approximately three days, but does not typically require nasogastric decompression or preclude early feeding [46]. Early feeding of a regular diet can stimulate
the bowel and decrease the length of hospitalization, although emesis is common. (See "Measures to prevent prolonged postoperative ileus".)
Preventive measures are appropriate for patients at high risk of postoperative pulmonary complications. All patients are also encouraged to ambulate as soon as is feasible. (See "Strategies to reduce postoperative
pulmonary complications in adults".)
Management of specific postoperative complications is discussed in this and in separate topic reviews. (See 'Complications' above and "Postoperative fever" and "Complications of abdominal surgical incisions".)
FOLLOW-UP
Discharge instructions — A woman is encouraged to resume her normal daily activities as quickly as is comfortable. She may return to work as soon as she has regained sufficient stamina and mobility.
We ask that patients avoid heavy lifting (>13 pounds of weight from the floor) for four to six weeks to minimize stress on the healing fascia. We advise that if the patient cannot easily lift an object with one hand, she should
ask for help. (See "Complications of abdominal surgical incisions", section on 'Fascial dehiscence'.)
Vaginal intercourse is also discouraged for six weeks to prevent cuff infection and allow the vaginal cuff to heal completely. There is not high quality evidence to specify the period of abstinence from vaginal intercourse,
however, intercourse appears to be the most common initiating event in vaginal cuff dehiscence in premenopausal women [39,47]. (See "Vaginal cuff dehiscence after hysterectomy".)
Routine discharge instructions for patients can be found separately. (See "Patient education: Care after gynecologic surgery (Beyond the Basics)".)
Postoperative visit — We see patients for a follow-up visit at one to two weeks postoperatively. The follow-up visit includes an evaluation for potential complications and an examination of the abdomen, wound, and vaginal
cuff, as well as removal of skin staples, if necessary. We review the details of the surgery and pathology results with the patient.
OUTCOME — After hysterectomy, most women report relief of symptoms, no change in sexual function, and satisfaction with the procedure. (See "Choosing a route of hysterectomy for benign uterine disease", section on
'Non-surgical outcomes'.)
A comparison of outcome after hysterectomy versus medical therapy for abnormal uterine bleeding can be found separately. (See "Managing an episode of severe or prolonged uterine bleeding".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on
“patient info” and the keyword(s) of interest.)
● Basics topics (see "Patient education: Hysterectomy (The Basics)")
● Beyond the Basics topics (see "Patient education: Abdominal hysterectomy (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
Preoperative preparation
Surgical planning
● Surgical planning for (abdominal hysterectomy) AH includes patient and surgeon decision-making regarding choice of incision, salpingo-oophorectomy, and subtotal versus total hysterectomy. (See 'Surgical planning'
above.)
● In women undergoing AH in whom a decrease in uterine size would enable a transverse rather than a midline vertical abdominal incision, we suggest GnRH analogue therapy for three to four months preoperatively
(Grade 2B). (See 'Preoperative GnRH analogues' above.)
Thromboprophylaxis
● Thromboprophylaxis is required for women undergoing abdominal hysterectomy. (See 'Thromboprophylaxis' above and "Prevention of venous thromboembolic disease in surgical patients" and "Overview of preoperative
evaluation and preparation for gynecologic surgery", section on 'Thromboprophylaxis'.)
Prevention of surgical site infection
● In women undergoing AH, we recommend antibiotics for surgical site infection prevention rather than no antibiotics (Grade 1A). (See 'Prophylactic antibiotics' above and "Antimicrobial prophylaxis for prevention of
surgical site infection in adults" and "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Surgical site infection prevention'.)
● In women planning AH who have bacterial vaginosis, we recommend treatment for eight days, starting four days preoperatively with metronidazole rather than no treatment (Grade 1A). Clindamycin may be used as an
alternative if there is a contraindication or resistance to metronidazole. (See 'Bacterial vaginosis treatment' above and "Bacterial vaginosis: Treatment", section on 'Women undergoing gynecologic procedures'.)
● Vaginal preparation can be performed with chlorhexidine-alcohol solution that contains a lower (ie, 4 percent) concentration of alcohol or with povidone-iodine solution. (See 'Skin and vaginal preparation' above.)
Operative technique
● The following are the basic steps of AH:
• Patient positioning, examination under anesthesia, and sterile preparation
• Incision, exploration, and adhesiolysis
• Round ligament ligation
• Broad ligament dissection
• Adnexal removal (if indicated or elected by patient)
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• Perivesical and perirectal dissection
• Cervical amputation or removal (subtotal versus total AH)
• Treatment of the vaginal cuff
• Final examination and closure
● Hemostasis is achieved during AH by visualization and ligation of the ovarian and uterine vessels. (See 'Adnexal conservation or removal' above and 'Uterine vessel ligation' above.)
● To prevent ureteral injury, we prefer to open the retroperitoneum and visualize the ureter. If palpation alone is used, the internal iliac artery, ovarian vessels, and vessels of the broad ligament are easily confused with the
ureter. Additionally, when the vesicouterine space is developed, the bladder is displaced inferiorly to laterally displace the ureters. If the patient has extensive pelvic disease, we dissect the ureter down toward the
bladder until optimal visualization is achieved. (See 'Avoiding ureteral injury' above.)
● Dissecting the perivesical and perirectal spaces helps to avoid injury of these organs. We prefer sharp perivesical dissection, as the use of a blunt dissection with a sponge stick may lead to a cystostomy, particularly if a
patient has had prior pelvic surgery. In addition, an incision into the bladder is more easily repaired than a tear from blunt dissection. (See 'Perivesical and perirectal dissection' above.)
● Numerous techniques have been described for management of the vaginal cuff closure. High quality studies have found no difference in postoperative infectious morbidity with an open or closed cuff technique. (See
'Treatment of the vaginal cuff' above.)
● In patients undergoing laparotomy who have a 2 cm or greater subcutaneous fat layer, we recommend closure of the subcutaneous layer (Grade 1A). (See 'Obesity' above and "Cesarean delivery: Surgical technique",
section on 'Subcutaneous tissue layer'.)
● In obese patients undergoing a midline laparotomy, we suggest a mass fascial closure (incorporating the fascia along with a small amount of subcutaneous fat, rectus muscle, rectus sheath, and, possibly, peritoneum)
rather than a fascia-only closure (Grade 2B). (See "Principles of abdominal wall closure", section on 'Mass closure' and "Principles of abdominal wall closure", section on 'Subcutaneous'.)
● In women with a large leiomyomatous uterus (≥16 weeks' size), we suggest prevention of excessive blood loss with intramyometrial (IMM) vasopressin (Grade 2B). (See 'Large uterus' above.)
Postoperative care
● In women undergoing AH, the bladder catheter is typically removed 24 hours or less postoperatively. (See 'Inpatient postoperative care' above.)
● Increase in intraabdominal pressure is dependent on the amount of weight lifted, as well as the position of the person relative to the object. We ask that patients avoid heavy lifting (>13 pounds of weight from the floor)
for four to six weeks to minimize stress on the healing fascia. (See 'Follow-up' above.)
Complications
● The most common major complications of AH are hemorrhage, urinary tract injury, and bowel injury. (See 'Complications' above.)
● Careful inspection of all pedicles before abdominal closure is the best method to prevent intraoperative and postoperative hemorrhage. Depending on the site of hemorrhage, hemostasis may be reestablished by local
treatment (eg, vaginal cuff bleeding, wound hematoma) or by surgical exploration. (See 'Hemorrhage' above.)
● If a ureteral injury is suspected intraoperatively, the bladder is evaluated for evidence of ureteral efflux. Confirmation of ureteral patency can be performed with cystourethroscopy or by opening the bladder dome. (See
"Urinary tract injury in gynecologic surgery: Identification and management", section on 'Screening for injury with routine cystoscopy'.)
Postoperatively, ureteral injury may be asymptomatic or may present as flank or groin pain, fever, prolonged ileus, and abdominal mass. Postoperative serum creatinine concentration rises ≥0.3 mg/dL above
preoperative values support this diagnosis. (See 'Ureteral injury' above.)
● Small bladder injuries in the bladder dome can be repaired with a running closure with a small caliber absorbable suture (eg, 3-0). When dealing with an injury which is extensive, in the trigone, or occurs in a patient with
previous bladder injury (eg, trauma, surgery, irradiation), intraoperative consultation with an experienced surgeon is warranted. (See 'Bladder injury' above.)
● Bowel injuries occur primarily during lysis of adhesions involving bowel and dissection of the posterior cul-de-sac. Serosal abrasions do not need repair, but injuries involving the muscularis and/or mucosa are to be
repaired. (See 'Bowel injury' above.)
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REFERENCES
1. Committee on Practice Bulletins--Gynecology, American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 84: Prevention of deep vein thrombosis and pulmonary embolism. Obstet Gynecol
2007; 110:429. Reaffirmed 2018.
2. Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based
Clinical Practice Guidelines. Chest 2012; 141:e227S.
3. Larsson PG, Carlsson B. Does pre- and postoperative metronidazole treatment lower vaginal cuff infection rate after abdominal hysterectomy among women with bacterial vaginosis? Infect Dis Obstet Gynecol 2002;
10:133.
4. ACOG Committee on Practice Bulletins--Gynecology. ACOG practice bulletin No. 104: Antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol 2009; 113:1180. Reaffirmed 2016.
5. American College of Obstetricians and Gynecologists Women's Health Care Physicians, Committee on Gynecologic Practice. Committee Opinion No. 571: Solutions for surgical preparation of the vagina. Obstet
Gynecol 2013; 122:718. Reaffirmed 2018.
6. Hernandez CR, Howard FM. Management of tubal prolapse after hysterectomy. J Am Assoc Gynecol Laparosc 1998; 5:59.
7. Petrakis IE, Lasithiotakis KG, Chalkiadakis GE. Use of the LigaSure vessel sealer in total abdominal hysterectomy. Int J Gynaecol Obstet 2005; 89:303.
8. Lakeman M, Kruitwagen RF, Vos MC, Roovers JP. Electrosurgical bipolar vessel sealing versus conventional clamping and suturing for total abdominal hysterectomy: a randomized trial. J Minim Invasive Gynecol 2008;
15:547.
9. Hagen B, Eriksson N, Sundset M. Randomised controlled trial of LigaSure versus conventional suture ligature for abdominal hysterectomy. BJOG 2005; 112:968.
10. Kilkku P, Grönroos M, Rauramo L. Supravaginal uterine amputation with peroperative electrocoagulation of endocervical mucosa. Description of the method. Acta Obstet Gynecol Scand 1985; 64:175.
11. Kaya H, Sezik M, Ozbasar D, et al. Intrafascial versus extrafascial abdominal hysterectomy: effects on urinary urge incontinence. Int Urogynecol J Pelvic Floor Dysfunct 2004; 15:171.
12. Colombo M, Maggioni A, Zanini A, et al. A randomized trial of open versus closed vaginal vault in the prevention of postoperative morbidity after abdominal hysterectomy. Am J Obstet Gynecol 1995; 173:1807.
13. Aharoni A, Kaner E, Levitan Z, et al. Prospective randomized comparison between an open and closed vaginal cuff in abdominal hysterectomy. Int J Gynaecol Obstet 1998; 63:29.
14. Berman ML, Grosen EA. A new method of continuous vaginal cuff closure at abdominal hysterectomy. Obstet Gynecol 1994; 84:478.
15. Neuman M, Beller U, Ben Chetrit A, et al. Prophylactic effect of the open vaginal vault method in reducing febrile morbidity in abdominal hysterectomy. Surg Gynecol Obstet 1993; 176:591.
16. Jaszczak SE, Evans TN. Intrafascial abdominal and vaginal hysterectomy: a reappraisal. Obstet Gynecol 1982; 59:435.
17. Wall LL. A technique for modified McCall culdeplasty at the time of abdominal hysterectomy. J Am Coll Surg 1994; 178:507.
18. Thakar R, Sultan AH. Hysterectomy and pelvic organ dysfunction. Best Pract Res Clin Obstet Gynaecol 2005; 19:403.
19. Jenkins TR. It's time to challenge surgical dogma with evidence-based data. Am J Obstet Gynecol 2003; 189:423.
20. Vernooij F, Heintz P, Witteveen E, van der Graaf Y. The outcomes of ovarian cancer treatment are better when provided by gynecologic oncologists and in specialized hospitals: a systematic review. Gynecol Oncol
2007; 105:801.
21. Okin CR, Guido RS, Meyn LA, Ramanathan S. Vasopressin during abdominal hysterectomy: a randomized controlled trial. Obstet Gynecol 2001; 97:867.
22. Unger JB, Paul R, Caldito G. Hysterectomy for the massive leiomyomatous uterus. Obstet Gynecol 2002; 100:1271.
23. De Lia JE, Michelin DP, Johnson SC, Kajdacsy-Balla A. Cherney versus midline vertical incision for myomectomy or hysterectomy of a significantly enlarged uterus. Am J Obstet Gynecol 1995; 173:1714.
24. Falcone T, Walters MD. Hysterectomy for benign disease. Obstet Gynecol 2008; 111:753.
25. Lethaby A, Vollenhoven B, Sowter M. Pre-operative GnRH analogue therapy before hysterectomy or myomectomy for uterine fibroids. Cochrane Database Syst Rev 2001; :CD000547.
26. Maresh MJ, Metcalfe MA, McPherson K, et al. The VALUE national hysterectomy study: description of the patients and their surgery. BJOG 2002; 109:302.
27. Garry R, Fountain J, Mason S, et al. The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ
2004; 328:129.
28. Cole P, Berlin J. Elective hysterectomy. Am J Obstet Gynecol 1977; 129:117.
6 of 28 5/11/2018, 1:09 PM
29. Meeks GR, Harris RL. Surgical approach to hysterectomy: abdominal, laparoscopy-assisted, or vaginal. Clin Obstet Gynecol 1997; 40:886.
30. Thakar R, Ayers S, Clarkson P, et al. Outcomes after total versus subtotal abdominal hysterectomy. N Engl J Med 2002; 347:1318.
31. Mäkinen J, Johansson J, Tomás C, et al. Morbidity of 10 110 hysterectomies by type of approach. Hum Reprod 2001; 16:1473.
32. Lethaby A, Ivanova V, Johnson NP. Total versus subtotal hysterectomy for benign gynaecological conditions. Cochrane Database Syst Rev 2006; :CD004993.
33. Hemsell DL. Infections after gynecologic surgery. Obstet Gynecol Clin North Am 1989; 16:381.
34. Bartzen PJ, Hafferty FW. Pelvic laparotomy without an indwelling catheter. A retrospective review of 949 cases. Am J Obstet Gynecol 1987; 156:1426.
35. Greer IA. Epidemiology, risk factors and prophylaxis of venous thrombo-embolism in obstetrics and gynaecology. Baillieres Clin Obstet Gynaecol 1997; 11:403.
36. Härkki-Sirén P, Sjöberg J, Tiitinen A. Urinary tract injuries after hysterectomy. Obstet Gynecol 1998; 92:113.
37. Ibeanu OA, Chesson RR, Echols KT, et al. Urinary tract injury during hysterectomy based on universal cystoscopy. Obstet Gynecol 2009; 113:6.
38. Al-Sunaidi M, Tulandi T. Adhesion-related bowel obstruction after hysterectomy for benign conditions. Obstet Gynecol 2006; 108:1162.
39. Hur HC, Guido RS, Mansuria SM, et al. Incidence and patient characteristics of vaginal cuff dehiscence after different modes of hysterectomies. J Minim Invasive Gynecol 2007; 14:311.
40. Croak AJ, Gebhart JB, Klingele CJ, et al. Characteristics of patients with vaginal rupture and evisceration. Obstet Gynecol 2004; 103:572.
41. Iversen L, Hannaford PC, Elliott AM, Lee AJ. Long term effects of hysterectomy on mortality: nested cohort study. BMJ 2005; 330:1482.
42. Wright JD, Ananth CV, Ojalvo L, et al. Failure to rescue after major gynecologic surgery. Am J Obstet Gynecol 2013; 209:420.e1.
43. Wingo PA, Huezo CM, Rubin GL, et al. The mortality risk associated with hysterectomy. Am J Obstet Gynecol 1985; 152:803.
44. Wu JM, Wechter ME, Geller EJ, et al. Hysterectomy rates in the United States, 2003. Obstet Gynecol 2007; 110:1091.
45. Phipps S, Lim YN, McClinton S, et al. Short term urinary catheter policies following urogenital surgery in adults. Cochrane Database Syst Rev 2006; :CD004374.
46. Charoenkwan K, Phillipson G, Vutyavanich T. Early versus delayed (traditional) oral fluids and food for reducing complications after major abdominal gynaecologic surgery. Cochrane Database Syst Rev 2007;
:CD004508.
47. Iaco PD, Ceccaroni M, Alboni C, et al. Transvaginal evisceration after hysterectomy: is vaginal cuff closure associated with a reduced risk? Eur J Obstet Gynecol Reprod Biol 2006; 125:134.
Topic 3311 Version 33.0
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GRAPHICS
Vertical skin incisions of the abdominal wall
Courtesy of William J Mann, Jr, MD.
Graphic 63560 Version 4.0
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Transverse incisions of the abdominal wall
Courtesy of William J Mann, Jr, MD.
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Modified Caprini risk assessment model for VTE in general surgical patients
Risk score
1 point 2 points 3 points 5 points
Age 41 to 60 years Age 61 to 74 years Age ≥75 years Stroke (<1 month)
Minor surgery Arthroscopic surgery History of VTE Elective arthroplasty
BMI >25 kg/m 2 Major open surgery (>45 minutes) Family history of VTE Hip, pelvis, or leg fracture
Swollen legs Laparoscopic surgery (>45 minutes) Factor V Leiden Acute spinal cord injury (<1 month)
Varicose veins Malignancy Prothrombin 20210A
Pregnancy or postpartum Confined to bed (>72 hours) Lupus anticoagulant
History of unexplained or recurrent spontaneous abortion Immobilizing plaster cast Anticardiolipin antibodies
Oral contraceptives or hormone replacement Central venous access Elevated serum homocysteine
Sepsis (<1 month) Heparin-induced thrombocytopenia
Serious lung disease, including pneumonia (<1 month) Other congenital or acquired thrombophilia
Abnormal pulmonary function
Acute myocardial infarction
Congestive heart failure (<1 month)
History of inflammatory bowel disease
Medical patient at bed rest
Interpretation
Estimated VTE risk in the absence of pharmacologic

Surgical risk category* Score
or mechanical prophylaxis (percent)
Very low (see text for definition) 0 <0.5
Low 1 to 2 1.5
Moderate 3 to 4 3.0
High ≥5 6.0
VTE: venous thromboembolism; BMI: body mass index.

* This table is applicable only to general, abdominal-pelvic, bariatric, vascular, and plastic and reconstructive surgery. See text for other types of surgery (eg, cancer surgery).
From: Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practical guidelines. Chest
2012; 141:e227S. Copyright © 2012. Reproduced with permission from the American College of Chest Physicians.
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Antimicrobial prophylaxis for genitourinary surgery in adults
Nature of operation Common pathogens Recommended antimicrobials Usual adult dose* Redose interval ¶
Cystoscopy alone Enteric gram-negative bacilli, enterococci High-risk Δ only: ciprofloxacin ◊ 500 mg orally or 400 mg IV N/A
OR trimethoprim-sulfamethoxazole One 160/800 mg (double strength, DS) tablet N/A

orally
◊
Cystoscopy with manipulation or upper tract Enteric gram-negative bacilli, enterococci Ciprofloxacin 500 mg orally or 400 mg IV N/A
instrumentation §
OR trimethoprim-sulfamethoxazole One 160/800 mg (double strength, DS) tablet N/A
orally
Open or laparoscopic surgery ¥ Enteric gram-negative bacilli, enterococci Cefazolin ‡ <120 kg: 2 g IV 4 hours
≥120 kg: 3 g IV
IV: intravenous.
* Parenteral prophylactic antimicrobials can be given as a single IV dose begun within 60 minutes before the procedure. If a fluoroquinolone is used, the infusion should be started within 60 to 120 minutes before the initial incision to have adequate tissue
levels at the time of incision and to minimize the possibility of an infusion reaction close to the time of induction of anesthesia.
¶ For prolonged procedures (>3 hours) or those with major blood loss, or in patients with extensive burns, additional intraoperative doses should be given at intervals one to two times the half-life of the drug for the duration of the procedure in patients
with normal renal function.
Δ Urine culture positive or unavailable, preoperative catheter, transrectal prostatic biopsy, or placement of prosthetic material.
◊ Due to increasing resistance of Escherichia coli to fluoroquinolones and ampicillin-sulbactam, local sensitivity profiles should be reviewed prior to use.
§ Shock wave lithotripsy, ureteroscopy.
¥ Including percutaneous renal surgery, procedures with entry into the urinary tract, and those involving implantation of a prosthesis. If manipulation of bowel is involved, prophylaxis is given according to colorectal guidelines.
‡ For patients allergic to penicillins and cephalosporins, clindamycin (900 mg IV) or vancomycin (15 mg/kg IV not to exceed 2 g) with either gentamicin (5 mg/kg IV), ciprofloxacin (400 mg IV), levofloxacin (500 mg IV), or aztreonam (2 g IV) is a
reasonable alternative.
Adapted from:
1. Antimicrobial prophylaxis for surgery. Med Lett Drugs Ther 2016; 58:63.
2. Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect (Larchmt) 2013; 14:73.
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Elevating the uterus prior to dividing from the adnexa

during abdominal hysterectomy
The uterus is elevated using broad ligament clamps which incorporate the utero-
ovarian and round ligaments.
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Suture ligation of the round ligament during hysterectomy
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Developing the vesicouterine fold during hysterectomy
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Identification of the ureter during hysterectomy
The ureter is located on the medial leaf of the broad ligament and courses under the
uterine artery. Prior to any surgical manipulation, it usually lies 2 cm lateral to the
uterus, but may be nearer. The ureter must be identified before clamping and cutting
the uterine artery to avoid injury.
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Hysterectomy without oophorectomy
Clamp placement when the ovaries are to be retained.
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Creation of a window in the posterior peritoneum during

gynecologic surgery
A window is made in the posterior peritoneum allowing the infundibulopelvic

ligament to be isolated and clamped.
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Suture ligation and placement of a suture tie on the

infundibulopelvic ligament during gynecologic surgery
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Sharp dissection of the bladder from the lower uterine

segment during hysterectomy
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Mobilization of the rectum and detachment from the

posterior uterus during hysterectomy
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Ligation of uterine artery during hysterectomy
Clamp placement is perpendicular to the uterine vasculature.
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Clamp placement across cardinal ligament during

hysterectomy
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Opening the rectovaginal space during hysterectomy
Opening the rectovaginal space allows clamping and division of uterosacral ligaments.
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Resection of uterus
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Closure of vaginal cuff during abdominal hysterectomy
0 or 2-0 gauge synthetic absorbable figure of eight stitches are used to close the vaginal
cuff. The suture incorporates the uterosacral and cardinal ligaments at the angle of the
vagina.
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Complications of abdominal hysterectomy for benign disease
Rate of complications, percent
Overall severe complications 4* to 6 ¶
Major hemorrhage (requiring transfusion or surgical intervention) 2* Δ
Thromboembolism 0.2 (with mechanical or pharmacologic thromboprophylaxis) Δ ; 15 to 30 (without thromboprophylaxis) ◊
Bladder injury 0.02 § to 1 ¶
Ureteral injury 0.04 §
Urinary tract infection 4Δ
Bowel injury 0.2 Δ to 1 ¶
Bowel obstruction 1¥
Surgical site infection 3Δ
Reoperation 0.5* ¶
Mortality 0.03*
* Maresh MJ, Metcalfe MA, McPherson K, et al. BJOG 2002; 109:302.

¶ Garry R, Fountain J, Mason S, et al. BMJ 2004; 328:129.
Δ Makinen J, Johansson J, Tomas C, et al. Hum Reprod 2001; 16:1473.
◊ Greer IA. Baillieres Clin Obstet Gynaecol 1997; 11:403.
§ Harkki-Siren P, Sjoberg J, Tiitinen A. Obstet Gynecol 1998; 92:113.
¥ Al-Sunaidi M, Tulandi T. Obstet Gynecol 2006; 108:1162.
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EVAluate trial of complications of hysterectomy
Abdominal trial Vaginal Trial
Abdominal hysterectomy (n = 292) Laparoscopic hysterectomy (n = 584) Vaginal hysterectomy (n = 168) Laparoscopic hysterectomy (n = 336)
Major hemorrhage 7* (2.4) 27* (4.6) 5 (2.9) 17 (5.1)
Bowel injury 3 (1) 1 (0.2) 0 0
Ureteric injury 0 5 (0.9) 0 1 (0.3)
Bladder injury 3 (1) 12* (2.1) 2 (1.2) 3 (0.9)
Intraoperative conversion 1 ¶ (0.3) 23 (3.9) 7 (4.2) 9 (2.7)
Wound dehiscence 1 (0.3) 1(0.2) 0 1 (0.3)
Hematoma 2 (0.7) 4 (0.7) 2 (1.2) 7 (2.1)
At least one major complication 18 (6.2) 65 (11.1) 16 (9.5) 33 (9.8)
A patient may have more than one complication.
* These patients converted procedure before the operation: one patient undergoing abdominal hysterectomy converted to laparoscopic hysterectomy before the operation in the abdominal trial and had a major hemorrhage. Two patients in the abdominal
trial who were undergoing laparoscopic hysterectomy converted to abdominal hysterectomy before the operation and had a major hemorrhage. One patient undergoing laparoscopic hysterectomy in the abdominal trial converted to abdominal
hysterectomy before the operation and had a major anesthetic problem. One patient undergoing laparoscopic hysterectomy in the abdominal trial converted to abdominal hysterectomy before the operation and had a bladder injury.
¶ This patient in the abdominal trial was randomized to abdominal hysterectomy, converted to laparoscopic hysterectomy before the operation and then converted back to abdominal hysterectomy during the operation.
Adapted from Garry R, Fountain J, Mason S, et al. The eVALuate study: Two parallel randomized trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ 2004; 328:129.
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Contributor Disclosures
Thomas G Stovall, MD Nothing to disclose William J Mann, Jr, MD Nothing to disclose Howard T Sharp, MD Nothing to disclose Kristen Eckler, MD, FACOG Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to
support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.
Conflict of interest policy
28 of 28 5/11/2018, 1:09 PM

Abdominal Hysterectomy

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Abdominal hysterectomy - UpToDate https://www.uptodate.com/contents/abdominal-hysterectomy/print?searc...

Official reprint from UpToDate®

Authors: Thomas G Stovall, MD, William J Mann, Jr, MD

Prophylactic measures prior to hysterectomy

● Insert Foley bladder catheter

● Perform sterile preparation of the abdomen and vagina

● Place surgical draping.

Adnexal conservation or removal

● Preoperative hematocrit was increased (3.1 percent, 95% CI 1.8-4.5)

● Proportion of vertical incisions was reduced (OR 0.36, 95% CI 0.2-0.6)

● Duration of surgery was decreased (-5.2 minutes, 95% CI -8.6 to -1.8)

Gastrointestinal tract issues

● Basics topics (see "Patient education: Hysterectomy (The Basics)")

SUMMARY AND RECOMMENDATIONS

Prevention of surgical site infection

● The following are the basic steps of AH:

• Patient positioning, examination under anesthesia, and sterile preparation

• Incision, exploration, and adhesiolysis

• Round ligament ligation

• Broad ligament dissection

• Adnexal removal (if indicated or elected by patient)

• Perivesical and perirectal dissection

• Cervical amputation or removal (subtotal versus total AH)

• Treatment of the vaginal cuff

• Final examination and closure

Use of UpToDate is subject to the Subscription and License Agreement.

Topic 3311 Version 33.0

Vertical skin incisions of the abdominal wall

Courtesy of William J Mann, Jr, MD.

Graphic 63560 Version 4.0

Transverse incisions of the abdominal wall

Courtesy of William J Mann, Jr, MD.

Graphic 68150 Version 6.0

1 point 2 points 3 points 5 points

Minor surgery Arthroscopic surgery History of VTE Elective arthroplasty

Varicose veins Malignancy Prothrombin 20210A

Pregnancy or postpartum Confined to bed (>72 hours) Lupus anticoagulant

Sepsis (<1 month) Heparin-induced thrombocytopenia

Abnormal pulmonary function

Acute myocardial infarction

Congestive heart failure (<1 month)

History of inflammatory bowel disease

Medical patient at bed rest

Estimated VTE risk in the absence of pharmacologic

Very low (see text for definition) 0 <0.5

VTE: venous thromboembolism; BMI: body mass index.

Graphic 83739 Version 14.0

Antimicrobial prophylaxis for genitourinary surgery in adults

OR trimethoprim-sulfamethoxazole One 160/800 mg (double strength, DS) tablet N/A

Graphic 87199 Version 12.0

Elevating the uterus prior to dividing from the adnexa

Graphic 80308 Version 2.0

Suture ligation of the round ligament during hysterectomy

Graphic 52575 Version 2.0

Developing the vesicouterine fold during hysterectomy

Graphic 77443 Version 2.0

Identification of the ureter during hysterectomy

Graphic 76515 Version 4.0

Hysterectomy without oophorectomy

Clamp placement when the ovaries are to be retained.

Graphic 57421 Version 1.0

Creation of a window in the posterior peritoneum during

A window is made in the posterior peritoneum allowing the infundibulopelvic

Graphic 65769 Version 2.0