Hysterectomy

Hysterectomy and Leiomyomas

Key Points

  • Hysterectomy is a procedure that comprises removal of the entire uterus (total hysterectomy) or the uterine corpus, sparing the cervix when it is called subtotal or supracervical hysterectomy. The procedure can be performed vaginally (vaginal hysterectomy) without any abdominal incisions, or abdominally either via laparotomy (laparotomy hysterectomy, sometimes called "abdominal hysterectomy"), or under laparoscopic direction (laparoscopic hysterectomy), which can also be performed remotely with the assistance of a microprocessor-based device sometimes called a "robot".

  • Hysterectomy, by any route, is an option for patients with fibroid-associated symptoms with no interest in future fertility or who have failed or are unsuitable for medical therapy or minimally invasive uterine sparing procedures. This can be considered regardless of FIGO type for patients desiring definitive therapy. The size of fibroid can impact the preferred route for hysterectomy based on surgeon skillset and expertise as well as patient characteristics.  
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  • Laparoscopic hysterectomy for women with uterine leiomyomas is a minimally invasive approach that is considered to be a preferred alternative to hysterectomy via laparotomy approach as it can decrease hospital length of stay, with reduced recovery time, and, when properly performed, a lower rate risk of intra- and postoperative complications. 
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  • Vaginal hysterectomy remains the preferred approach to total hysterectomy as it avoids any complications associated with either laparoscopic or laparotomic techniques.
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  • Unlike vaginal hysterectomy, laparoscopic techniques can be performed in a fashion that allow for contained morcellation.

Determining the Route of Hysterectomy

More on Route of Hysterectomy

While hysterectomy can be performed via a number of routes, there exist a number of reasons to select one over the others in a given clinical situation. Included are features of the uterus, the patient including a previous history of pelvic-abdominal surgery, and the training and experience of the surgical team.

Supracervical versus Total Hysterectomy

More on Supracervical Hysterectomy

When hysterectomy was first performed  in the 19th century via laparotomy, it was almost always accomplished leaving the cervix in place. By the middle of the 20th century the procedure was rarely performed, but by the end of the century there was an increased interest, especially when performed laparoscopically. There have been various studies.....

Vaginal Hysterectomy

More on Vaginal Hysterectomy

It is generally accepted that if total hysterectomy is to be performed, the vaginal technique is associated with the least risk and morbidity. The only incisions are those in the vagina. Some have facilitated access to the upper pedicles of the uterus using an endoscopic device called  "V-Notes", which allows multiport access via an occlusive device placed in the vagina.

Laparoscopic Hysterectomy

More on Laparoscopic Hysterectomy

Using the laparoscopic to direct hysterectomy was introduced in the late 1980s as a less morbid replacement for laparotomy based surgery, with a clearly defined reduction in the time taken until normal activities are resumed. While not all myomectomies should be done by laparoscopic technique - many can be performed hysteroscopically, while others require laparotomy, laparoscopic myomectomy is a key component of uterine surgery, whether or not performed with the assistance of a remotely operated system such as da Vinci.

Laparotomic ("Abdominal") Hysterectomy

More on Laparotomic Hysterectomy

Performing hysterectomy through a laparotomy was the most common approach until late in the second half of the 20th century. However, the development of laparoscopic techniques has made it possible, with suitable training and equipment, to perform many abdominal myomectomies by a laparoscopic approach, with or without the use of a remote assistive device such as the da Vinci system. Still, many cases are not best treated laparoscopically, or have a phenotype that is not amenable to laparoscopic technique. Consequently, laparotomy remains an option necessary for many women.

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