[ Editorials | Letters | Selected Articles | Signature Series | Patient Handouts | Index ]

2002 Selected Articles

Abdominal Hysterectomy: A New Look at an Established Procedure

Richard S. Guido, MD

There are roughly 600,000 hysterectomies performed annually in the United States, with abdominal hysterectomies comprising the vast majority even though increased use of laparoscopy has reduced the percentage of hysterectomies performed abdominally from 73% in 1990 to 63% in 1997.¹ Abdominal hysterectomy thus remains one of the fundamental procedures performed by OB/GYNs.

The classic Richardson technique for performing an abdominal hysterectomy has been the "gold standard" for more than 70 years.² However, gynecologic surgeons still strive to improve patient care and outcomes by reducing operative time, morbidity, and cost, while expediting recovery. This article covers a variety of techniques designed to achieve these goals.

REDUCING BLOOD LOSS

Excessive blood loss (more than 500 mL) and anemia represent the third most common complication of abdominal hysterectomy. Allogeneic blood transfusions are relatively rare in this patient population, occurring in 2.2% to 7% of patients, with the average patient requiring 2.5 U of blood.^3,4 A variety of preoperative and intraoperative techniques can help to limit the need for transfusion.

Preoperative autologous blood donation has been studied for abdominal hysterectomy with unfavorable results. Due to the low rate of any transfusion associated with the procedure, women who donate autologous blood preoperatively are prone to iatrogenic anemia, and are at much higher risk (18% versus 0.8%) for requiring transfusion.⁵ The increased cost associated with the preparation of the blood and the small risk of adverse events associated with an autologous transfusion do not justify its routine use in abdominal hysterectomy for benign conditions.

Gonadotropin-releasing hormone (GnRH) agonists are used preoperatively to reduce or eliminate menstrual bleeding, reduce fibroid size, and decrease the pain associated with endometriosis. Randomized, prospective studies have demonstrated a statistically significant difference in preoperative hemoglobin levels (12.6 g/dL versus 11.5 g/dL) in patients using 3.75 mg of leuprolide acetate depot in conjunction with iron supplementation for 12 weeks compared with iron alone.⁶ Preoperative use of these medications must be balanced against their potential side effects (hot flashes, vaginal dryness) and cost. While there is a statistical improvement in preoperative hemoglobin levels in patients using GnRH agonists, iron alone markedly corrects most patients’ anemia (8.0 g/dL pretreatment versus 11.5 g/dL posttreatment). Physicians should determine whether GnRH agonists are appropriate on a case-by-case basis.⁶

Recombinant human erythropoietins (r-HuEPO, epoetin-alfa) stimulate bone marrow production of red blood cells and hemoglobin. Epoetin-alfa has been used extensively in orthopedic surgery to increase the preoperative hemoglobin levels of patients undergoing elective hip and knee surgery.^7,8 Randomized, prospective studies have established that weekly subcutaneous injections of epoetin-alfa, 600 IU/kg, increases preoperative hemoglobin values, reduces the need for allogeneic blood transfusion, and is more effective than preoperative autologous donation in decreasing postoperative anemia.⁹ Clinical trials in the gynecologic literature have been limited to treating anemia associated with the treatment of gynecologic malignancies. The use of epoetin-alfa shows great potential for preoperative preparation of patients undergoing benign gynecologic surgery, and is presently under study.^10,11

The surgeon’s operative technique plays a major role in reducing the ultimate blood loss from any surgical procedure. Meticulous hemostasis, reduced operative time, and control of the vascular supply to the uterus early in the operative procedure help to minimize intraoperative blood loss. For example, it has been demonstrated that routine use of intraoperative vasopressin can reduce blood loss from abdominal hysterectomy by 40% (P<0.05).¹² This randomized, double-blind, placebo-controlled study compared routine injection of 10 U of vasopressin in 10 mL of normal saline solution given in divided 5-mL doses into the lower uterine segment 1 cm medial to the uterine vessels with a 21-gauge needle at the start of the hysterectomy. Vasopressin produced little to no effect on the cardiovascular parameters of the study patients, and was not associated with any increase in infectious morbidity (Figure).

FIGURE. Administration of Vasopressin
The standard method is to inject the vasopressin (10 U in 10 cc of normal saline): 5 cc each on each side, injected 1-2 cm medial to the uterine vessels in the lower uterine segment.	The alternative injection site is the top of the fundus, when the lower uterine segment is obscured by fibroids.

CLOSING THE VAGINAL CUFF

There is a great deal of surgical variety in the techniques used for closing the vaginal cuff following abdominal hysterectomy. Using the optimal technique would ideally reduce operative time, blood loss, bacterial contamination, postoperative granulation tissue formation, and infection. A survey of 1,147 British gynecologists to identify the method used most frequently for managing the vaginal cuff found that the majority of physicians (87%) closed the cuff, while 13% left the cuff open for granulation.¹³ The most popular suture materials were chromic gut (60%), synthetic polymers (33%), and plain gut (6%). The development of absorbable staples has led to their increased use for closing the vaginal cuff.

Despite the clear preference for closing the vaginal cuff, the gynecologic literature has not clearly shown this technique to be superior to leaving the cuff open. In a randomized, prospective study of 273 patients comparing running-suture closure with the open technique, the rate of vaginal cuff or abdominal infection was similar in both the closure group (6.1%) and the open group (7.1%).¹⁴ The study failed to demonstrate a reduction in granulation tissue formation by closing the vaginal cuff (11% in both groups), nor was there a decrease in abdominal wound infection. This study agrees with other randomized, prospective trials performed in the era of antibiotic prophylaxis.¹⁵

The type of suture and the method of closure have been examined by numerous authors, with recent studies demonstrating a reduction in cuff granulation when polyglactin delayed absorbable suture (Vicryl) was used compared with chromic catgut (odds ratio [OR] 0.32; 95% confidence interval [CI] 0.14 to 0.74).¹³ Both interrupted and continuous closure techniques had similar rates of granulation.

Vaginal stapling devices that use absorbable suture material offer an alternative to suturing that theoretically should reduce operative time, bacterial contamination, and postoperative infection. The randomized, prospective clinical trials comparing stapling with open and closed techniques have differing results. When compared with an open technique, use of Polysorb 55 absorbable staples produced significant reductions in total operative time (116 versus 110 minutes) and postoperative granulation tissue formation.¹⁶ However, when absorbable staples were compared with interrupted closure using delayed absorbable suture, there was no statistical difference in total operative time despite a 3.5-minute decrease in the time needed to close the cuff with staples.¹⁷ Postoperative testing of material from pelvic drains demonstrated similar rates of bacterial contamination in both groups, with the staple group actually having a slightly higher rate of contamination (20% versus 13%). The author concluded that there is no clinical advantage to using the stapling device, especially in light of the increased expense it entails.

The current literature provides no definitive evidence for the best method of cuff closure. Surgeons should use the method with which they are most comfortable, practice meticulous hemostasis, and minimize operative time.

ALTERNATIVE METHODS FOR CONTROL OF VASCULAR PEDICLES

The majority of operative time in an abdominal hysterectomy involves identification, isolation, and control of the various vascular pedicles that supply the uterus. Traditional management includes clamping and suture ligation of these vessels. Recent developments in laparoscopic surgery have led to a variety of new techniques for controlling these pedicles.

One option is the LigaSure, a feedback-controlled, high-current (4 A), low-voltage (less than 200 V) bipolar vessel-sealing device.¹⁸ The high-current, low-voltage combination melts the collagen and elastin in the tissue, forming a plastic-like seal with minimal thermal spread. The device has been approved by the US Food and Drug Administration for vessels up to 7 mm in diameter. When the LigaSure was compared with standard suture techniques in a small, randomized trial of 50 patients undergoing abdominal hysterectomy, the device resulted in a 37% reduction in operative time and a statistically significant decline in blood loss.¹⁹

Another option for controlling vascular pedicles is the bipolar scissors (Power Star). Results of a randomized, prospective comparison of the bipolar scissors with traditional ligation techniques for abdominal hysterectomy showed that the scissors yielded in a 25% reduction in operative time and a statistically significant, but not clinically relevant, improvement in postoperative hemoglobin levels.²⁰ While the initial clinical trials with this device appear promising, large-scale studies with a complete cost analysis are still required.

SUPRACERVICAL HYSTERECTOMY

Supracervical hysterectomy has enjoyed a resurgence in popularity among some gynecologists and patients in the past decade. Today, more women are asking their surgeons to discuss the pros and cons of removing the uterine cervix. Recent data from the Healthcare Cost and Utilization Project show that there has been a 3-fold increase in the number of supracervical hysterectomies performed in the United States between 1990 and 1997. More than 11,000 supracervical procedures were performed in 1997 or 2% of all hysterectomies.¹

The major argument for the removal of the cervix at the time of hysterectomy is elimination of the risk of cervical cancer. With the development of the Papanicolaou test²¹ and its subsequent widespread use as a highly effective method of screening for cervical cancer, there has been a significant reduction in the incidence of cervical cancer over the past 50 years. It has been argued that total hysterectomy removes the possibility of cancer developing in the cervical stump, which historically is estimated to occur at an incidence of 0.11% to 1.9%.²² Currently, the lifetime risk of cervical cancer for monogamous women with at least three normal Papanicolaou tests is 0.05%, and the 5-year risk for development of cervical cancer is lowered by 69% with two to four negative prior Papanicolaou tests.^23-25 The risk of cervical cancer may be further reduced by screening women undergoing hysterectomy for the presence of high-risk subtypes of human papillomavirus infection.

Improvements in the diagnosis and treatment of preinvasive cervical disease, along with the development of new, less invasive surgical techniques have led numerous authors to question whether removing the cervix at the time of hysterectomy has any scientific validity.^26-28 Fundamental issues regarding the effect of removing the cervix on pelvic organ support, bladder function, and sexual function must be addressed before a conclusion can be drawn regarding the preferred surgical technique.

Vaginal vault prolapse following a hysterectomy depends on the same general risk factors that govern the prolapse of other pelvic organs. In the Oxford Family Planning Association Study,²⁹ the incidence of prolapse for which there was an inpatient admission following hysterectomy for any reason was 3.6 per 1,000 person-years. Supracervical hysterectomy leaves the structural support of the upper vagina and cervix (ie, the cardinal-uterosacral complex) intact. By contrast, if the cervix is separated from the vagina at the time of hysterectomy, the cardinal uterosacral complex is disrupted, and the vagina remains aligned with the pelvic sidewall solely via support from the long, vertically oriented connective tissue fibers of the upper paracolpium (ie, the classic Richardson technique).³⁰ Suspension of the vaginal vault can be enhanced by incorporating the uterosacral ligaments in the closure of the vaginal cuff, reducing the risk of postoperative vault proloapse.³¹ The theoretical benefit of supracervical hysterectomy is both retention of the normal supportive attachments to the cervix and upper vagina, as well as a lower risk of denervation injury.

Normal bladder function requires coordinated action of the detrusor muscle and urethra. These are ultimately controlled by a complex neurologic interaction between sympathetic and parasympathetic innervation. These nerve fibers culminate in the uterovaginal plexus of Frankenhauser, which is located below the broad ligament. This plexus surrounds the cervix and upper vagina, comprising a large ganglionic plate on either side of the cervix and above the posterior fornix in front of the rectum. ^32,33 Thus, removal of the cervix at the time of hysterectomy has the potential to alter the function of the nerves controlling the bladder and the urethra.

Clinical studies comparing total abdominal hysterectomy with supracervical hysterectomy show mixed results with regard to their effects on bladder function. Prospective evaluation of the bladder function of 105 women undergoing total abdominal hysterectomy and 107 women undergoing supracervical hysterectomy showed that the supracervical hysterectomy patients had a greater reduction in "the sensation of residual urine" at enrollment and 1-year follow-up (from 35.5% to 10.3%) than those undergoing total abdominal hysterectomy (from 28.6% to 22.1%).^34,35 The patients undergoing supracervical hysterectomy had a statistically significant reduction in incontinence (from 47.7% to 22.6%) compared with the total-hysterectomy group (from 36.2% to 28.8%). The only randomized, prospective analysis of supracervical hysterectomy versus total abdominal hysterectomy that thoroughly evaluated bladder function showed no significant difference in micturition frequency, incontinence episodes, and multichannel cystometric data between the two groups at enrollment and postoperatively.³⁶

There is even less scientific evidence to address the complex question as to which technique has the least impact on the sexual function of women undergoing hysterectomy. Clearly, well designed, large, prospective clinical trials are required to assess the role of supracervical hysterectomy in the modern era.

CONCLUSION

Advancements in surgical techniques have reduced the morbidity associated with abdominal hysterectomy. Nonetheless, many questions about this very common procedure remain unanswered.

Richard S. Guido, MD, is an associate professor in the division of gynecologic specialties of the Department of Obstetrics, Gynecology and Reproductive Sciences at the University of Pittsburgh’s Magee-Women’s Hospital in Pittsburgh.

REFERENCES

1. Farquhar CM, Steiner CA. Hysterectomy rates in the United States 1990-1997. Obstet Gynecol. 2002;99:229-234.
2. Richardson EH. Simplified technique for abdominal panhysterectomy. Surg Gynecol Obstet. 1929;48:248-256.
3. Stanley PH. Blood transfusion requirements for abdominal hysterectomy: 3-year experience in a district hospital (1993-1995). Aust NZ J Obstet Gynaecol. 1997;37(4):452.
4. Rock WA, Meeks GR. Managing anemia and blood loss in elective gynecologic surgery patients. J Reprod Med. 2001; 46:507-514.
5. Kanter MH, van Maanen D, Anders KH, Castro F, et al. Preoperative autologous blood donations before elective hysterectomy. JAMA. 1996;276:798-801.
6. Stovall TG, Muneyyirci-Delale O, Summitt RL, Scialli AR. GnRH agonist and iron versus placebo and iron in the anemic patient before surgery for leiomyomas: a randomized controlled trial. Leuprolide Acetate Study Group. Obstet Gynecol. 1995;86:65-71.
7. Faris PM, Ritter MA, Abels RI. The effects of recombinant human erythropoietin on perioperative transfusion requirements in patients having a major orthopedic operation: the American Erythropoietin Study Group. J Bone Joint Surg Am. 1996;78:62-72.
8. de Andrade JR, Jove M, Landon G, et al. Baseline hemoglobin as a predictor of risk of transfusion and response to epoetin alfa in orthopedic surgery patients. Am J Orthop. 1996;25:533-542.
9. Stowell CP, Shandler H, Jove M, et al. An open-label, randomized study to compare the safety and efficacy of perioperative epoetin alfa with preoperative autologous blood donation in total joint arthroplasty. Orthopedics. 1999;22:S105-S112.
10. Stovall TG. Clinical experience with epoetin alfa in the management of hemoglobin levels in orthopedic surgery and cancer. Implications for use in gynecologic surgery. J Reprod Med. 2001;46:531-538.
11. Gachmann GA. Epoetin alfa use in gynecology: past, present and future. J Reprod Med. 2001;46:539-544.
12. Okin CR, Guido R, Meyn LA, Ramanathan S. Vasopressin during abdominal hysterectomy: a randomized controlled trial. Obstet Gynecol. 2001;97(6):867-872.
13. Manyonda IT, Welch RC, McWhinney NA, Ross LD. The influence of suture material on vaginal vault granulation following abdominal hysterectomy. Br J Obstet Gynaecol. 1990;97:608-612.
14. 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;173:1807-1811.
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; 176:591-593.
16. Kalbfleish RE. Prospective randomized study to compare a closed vault technique using absorbable staples at the time of abdominal hysterectomy versus open vault technique. Surg Gynecol Obstet. 1992;175:337-340.
17. Stovall TG, Summitt RL, Libscomb GH, Ling FW. Vaginal cuff closure at abdominal hysterectomy: comparing sutures with absorbable staples. Obstet Gynecol. 1991;78:415.
18. Heniford BT, Matthews BD. Basic instrumentation for laparoscopic surgery. In: Greene FL, Heniford BT, eds. Minimally Invasive Cancer Management. New York City: Springer-Verlag; 2000;36-44.
19. McLellan R, Anania C, Birdsall M, et al. LigaSure versus suture in total abdominal hysterectomy. Obstet Gynecol. 2001;97 (S4):7S-8S.
20. Dessole S, Rubattu G, Capobianco G, et al. Utility of bipolar electrocautery scissors for abdominal hysterectomy. Am J Obstet Gynecol. 2000;183:396-399.
21. Papanicolau GN. A new procedure for the staining of vaginal smears. Science. 1942;95:438-439.
22. Telvilla L. Carcinoma of the cervical stump. Acta Obstet Gynecol Scand. 1963;42:200-219.
23. Scott JR, Sharp HT, Dodson MK, et al. Subtotal hysterectomy in modern gynecology: a decision analysis. Am J Obstet Gynecol. 1997;176:1186-1192.
24. Storm HH, Clemmensen IH, Manders T, et al. Supravaginal uterine amputation in Denmark 1978-1988 and risk of cancer. Gynecol Oncol. 1992;45:198-201.
25. Lynge E, Poll P. Incidence of cervical cancer following negative smear. A cohort study from Maribo County, Denmark. Am J Epidemiol. 1986;124(3):345-352.
26. Munro MG. Supracervical hysterectomy: …a time for reappraisal. Obstet Gynecol. 1997;89:133-139.
27. Hasson MM. Cervical removal at hysterectomy for benign disease: risks and benefits. J Reprod Med. 1993;38(10):781-790.
28. Johns A. Supracervical versus total hysterectomy. Clin Obstet Gynecol. 1997;40(4):903-913.
29. Mant J, Painter R, Vessey M. Epidemiology of genital prolapse: observations from the Oxford Family Planning Association Study. Br J Obstet Gynaecol. 1997;104:579-585.
30. Richardson EH. A simplified technique for abdominal panhysterectomy. Surg Obstet Gynecol. 1929;48:248.
31. Webb MJ. Surgery of the uterus. In: Mayo Clinic Manual of Pelvic Surgery, ed 2. Philadelphia: Lippincott Williams & Wilkins; 2000;55-72.
32. Mundy AR. An anatomical explanation for bladder dysfunction following rectal and uterine surgery. Br J Urol. 1982;54:501.
33. Bradley WE, Teague CT. Innervation of the vesical detrusor muscle by the ganglia of the pelvic plexus. Urol Clin N Am. 1974;1:3.
34. Kilkku P. Supravaginal uterine amputation versus hysterectomy with reference to subjective bladder symptoms and incontinence. Acta Obstet Gynecol Scand. 1985;64:375-379.
35. Kilkku P, Hirvonen T, Gronroos M. Supra-vaginal uterine amputations vs. abdominal hysterectomy: the effects on urinary symptoms with special reference to pollakisuria, nocturia and dysuria. Maturitas. 1981;3:197-204.
36. Lalos O, Bjerle P. Bladder wall mechanics and micturition before and after subtotal and total hysterectomy. Eur J Obstet Gynecol Rep Biol. 1986;21:143-150.

back to top