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Procedure Overview

Box 25-1 Master Surgeon's Corner

  • Dorsal lithotomy position is preferable when distorted pelvic anatomy or extensive disease is anticipated.

  • Optimize surgical exposure via an adequate incision and appropriate self-retaining retractor from the very beginning.

  • "Normalize" anatomy with lysis of adhesions prior to initiating hysterectomy.

  • Hold vaginal cuff sutures until completely reassured of hemostasis at the cuff and cardinal ligaments.

Approximately 600,000 hysterectomies are performed annually—second only to cesarean delivery as the most frequently performed major surgical procedure for women of reproductive age in the United States. An estimated 20 million US women have had a hysterectomy, more than one-third of them by age 60. Approximately half will undergo concomitant bilateral oophorectomy.1

The 5 classes (or types) of hysterectomy were originally defined by Piver et al2 to more accurately describe the technical features involved when tailoring surgical treatment of women with cervical cancer. Type I hysterectomy, also known as extrafascial or simple hysterectomy, removes the uterus and cervix, but does not require excision of the parametrium or paracolpium. Within gynecologic oncology, a simple hysterectomy is usually performed for benign conditions, preinvasive cervical disease, stage IA1 cervical cancer, and most instances of endometrial or ovarian cancer. Occasionally, a planned simple hysterectomy must be adapted to a type II or III procedure based on intraoperative findings.

Abdominal hysterectomy was the foundation of gynecologic surgery for the latter half of the 20th century. However, several recent developments have resulted in fewer of these procedures being performed each year, a trend that is expected to continue into the future. Nonoperative techniques, such as office endometrial ablation, insertion of levonorgestrel-releasing intrauterine devices, and outpatient uterine artery embolization, have enabled many women to avoid hysterectomy. Additionally, the rapid introduction of minimally invasive surgery over the past decade has decreased the number of abdominal hysterectomies being performed. In many training programs, abdominal cases are now often mainly performed in extreme circumstances, such as a frozen pelvis or massively enlarged uteri. As a result, residents currently graduating may have more experience using a laparoscopic approach. Since trainees in obstetrics and gynecology are increasingly confronted with a wider range of techniques that must be mastered, and fewer hysterectomies are being performed each year, the need for improved surgical education to achieve competency is increasingly recognized.3

Despite the recent paradigm shift to minimally invasive surgery, approximately two-thirds of uteri in the United States are still removed through an abdominal incision. As high-volume surgeons, the majority of gynecologic oncologists have increasingly incorporated laparoscopic and robotic techniques into their practice.4 However, one-quarter of hysterectomies are performed by gynecologic surgeons who perform fewer than 10 per year. Such lower volume surgeons continue to perform the vast majority of their hysterectomies abdominally.5

Abdominal hysterectomy allows the greatest ability to manipulate pelvic organs and thus is often preferred ...

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