Sun beams on hysterectomies
© Springer-Verlag 2011
Received: 5 October 2010
Accepted: 27 December 2010
Published: 4 March 2011
Are hysterectomies still necessary in 2010 and why and how should they be performed? As every now and then a critical evaluation of routine surgical procedure is necessary, there it is: This review follows the “Perspectives on laparoscopic hysterectomy” by Michelle Nisolle (Gynecol Surg 7:105–107, 2010). Hysterectomies performed in the field of obstetrics and gynaecology until the nineteenth century had always a lethal end. In the twentieth century, they were perhaps too frequently performed whereas the twenty-first century has witnessed a steep decline in hysterectomy numbers. It is therefore an opportune time to review the indications for hysterectomies, hysterectomy techniques and the present and future status of this surgical procedure. There is a widespread consensus that hysterectomies are primarily to be performed in cancer cases and obstetrical chaos situations even though minimal invasive surgical technologies have made the procedure more patient-friendly than the classical abdominal opening. Today, minimally invasive hysterectomies are performed as frequently as vaginal hysterectomies, and the vaginal approach is still the first choice if the correct indications are given. It is no longer necessary to open the abdomen; this procedure has been replaced by laparoscopic surgery with multiple and single port entries. Laparoscopic and robotic-assisted laparoscopic surgery can also be indicated for hysterectomies in selected patients with gynaecological cancers. For women of reproductive age, laparoscopic myomectomies and numerous other uterine-preserving techniques are applied in a first treatment step of menometrorrhagia, uterine adenomyosis and submucous myoma. These interventions are only followed by a hysterectomy if the pathology prevails.
In contrast to the twentieth century, hysterectomy is no longer the major gynaecological surgical procedure. How has this change come about? Historical data on the first hysterectomy vary from country to country.
Probably the first documented medical opening of the abdomen took place on December 25, 1809 by Ephraim McDowell (1771–1830). Data relating to the first vaginal hysterectomy go back to the times of Soranus of Ephesus in Greece in the year 120 ad. The first successful abdominal hysterectomies in Europe were performed by Charles Clay on January 3, 1863 and Eugen Köberle on April 3, 1863 in Strasbourg. Both surgeons claimed to have performed the first successful hysterectomy, but this took some time to prove as Clay’s first patient in 1843 died soon afterwards. A hysterectomy performed by Conrad Langenbeck on a mentally deficient/retarded patient could not be proved until 26 years later after a postmortem examination.
In the early twentieth century, up until 1945, the subtotal hysterectomy as an abdominal procedure was the universal approach. This type of hysterectomy was associated with less pelvic infections, ureter lesions and other complications in the pre-antibiotic period. After these problems had been overcome by the development of antibiotics, total hysterectomy was introduced. The main concern was to prevent the occurrence of cervical stump cancer, even though only 0.4% of 6,600 cases were reported in the USA  and 0.1% in Finland .
The Pfannenstiel incision introduced by Johannes Pfannenstiel from Breslau in 1900 proved to be the only real change in the abdominal procedure. This change was from the lower longitudinal abdominal incision to the lower horizontal abdominal incision. The universal acceptance of this incision occurred only after 1970.
Laparoscopic hysterectomies are the achievement of the late twentieth century (see “Laparoscopic hysterectomy” section)
Methods, techniques and findings to resect the uterus in malignant and benign indications
Throughout the world in the US, Germany, Asia, Africa and Australia, gynaecologists have had ample opportunity over the last 40 years to become acquainted with all surgical methods of hysterectomy.
The first hysterectomy performed at the time of Soranus of Ephesus and the newest technique, performed in the twenty-first century under the name of Natural Orifice Surgery, use the vagina as the entrance and exit point. For all gynaecologists and surgeons, there are many ways to perform an operation, but the lex parsimoniae of William Ockham (1235–1350) is always valuable: “If we have different ways to solve a problem, the simplest way is the right one.” Surgery is no exception.
When Langenbeck first performed a vaginal hysterectomy in 1813, the discipline of gynaecology was founded. Since then, vaginal access has been the privilege of the gynaecological surgeon.
Dysfunctional uterine bleeding
Carcinoma in situ CIN3 of cervix
High risk with endometrial cancer
Cervical fibroids and uterine polyposis
Circumcision of the cervix with the scalpel after grasping the cervix with two sutures or cervical clamps. According to Joel-Cohen 1972  and Stark 2006 , in patients with uterine prolapse, the incision of the vaginal wall can also start below the orificium urethrae externum. If the cut is deep enough, the vaginal wall can be pushed back with the finger and mobilisation is easy. If necessary, the vaginal wall can be separated from the cervix with scissors.
Separation of bladder from uterus and opening of the spatium vesico uterinum or the spatium recto uterinum. If the spatium vesico uterinum cannot be opened easily, it is easier to open the spatium recto uterinum with scissors until the sacrouterine ligaments are visible.
Clamping, dissection, suturing or coagulation of the sacrouterine ligaments. The sacrouterine ligaments and paracervical tissue must not bleed. In patients with uterine prolapse, the uterine vessels are directly visible.
Identification of the uterine vessels, separation by knife or scissors, suturing or, often today, the use of the biclamp, followed by sharp dissection. If the peritoneum in the area of the vesico-uterine space was not opened, it is now opened by sharp dissection.
Extraction of the uterus through the vagina after separation from the round ligaments, the ovarian ligaments or from the infundibulopelvic ligaments. This step is sometimes performed with clamps, dissection and suturing or with the Biclamp® (thermofusion).
The peritoneum is left open and only the vagina is closed with individual sutures. If necessary, a reconstruction of the pelvic floor is performed to prevent consecutive vaginal prolapse or formation of a Douglas-cele by placing an extra suture between the two sacrouterine ligaments and the vaginal stump.
According to the data collected by the Center for Disease Control in the USA [9, 10] the mortality rate for a vaginal hysterectomy—excluding cancer patients or obstetrical chaos situations—is 2.7/10,000 compared to 8.6/10,000 for an abdominal hysterectomy.
After the first unintended abdominal supracervical hysterectomies of Charles Clay (1843) and Ellis Burnham (1853), the first deliberate hysterectomy, with the patient surviving, was carried out in 1855 by Kimball. This was an abdominal supracervical hysterectomy. After the introduction of anaesthesia by William Morton on October 16, 1846, there were several reports of abdominal hysterectomy but with a mortality of 25%. Charles Clay performed his first successful hysterectomy with a patient surviving on January 3, 1863 and Eugen Köberle on April 3, 1863. Both of these doctors are considered the fathers of abdominal hysterectomy.
In 1880, T. G. Thomas reported on 365 collected cases of abdominal hysterectomy which revealed a staggering mortality of 70%. In comparison, vaginal hysterectomy had a mortality rate of 15% in 1886. Nevertheless, in 1878, Mikulicz and Wilhelm Alexander Freund  provoked progress in abdominal hysterectomy. They placed three ligatures on the broad ligaments, and through the introduction of new techniques for subtotal hysterectomy, the mortality rate went down in the period 1896 until 1906, from 22% to 3.4%.
In the middle of the twentieth century, apart from the change from subtotal which dominated through 1945 with Cutler and Zolenger  to total hysterectomy, the only change in the abdominal procedure was the almost universal adoption of the less disfiguring suprasymphysary incision introduced by Johannes Pfannenstiel.
The procedure of abdominal hysterectomy is tailored to the indication. The uterus has to be visualized and freed in the first step. In the second step, the round ligaments are separated from the uterus. In the third step, the adnexa are separated from the uterus or from the pelvic wall. In the fourth step, the parametrium is opened, and the bladder is pushed down in the fifth step. The uterine vessels are clamped, separated and sutured. In the sixth step, the uterus is separated from the vagina trying to preserve the uterine ligament connection. In the seventh step, the vagina is closed and the sacrouterine ligaments are fixed to/through the vagina to prevent Douglas-cele (Moskowitsch technique). In the eighth and last step, after rinsing of the minor pelvis, the visceral peritoneum is left open.
The minilaparotomy procedure may be considered a time-saving technique for total hysterectomy for benign uterine pathology. It offers some of the advantages of a minimally invasive procedure (low morbidity, short hospital stay and good cosmetic results) and the benefits of open access (for example, shorter learning curve than laparoscopy). It is a minimally invasive, feasible option, particularly in countries where laparoscopic hysterectomies are not available. In many reports, minilaparotomy hysterectomy has been compared to laparotomy and laparoscopic-assisted vaginal hysterectomy [12, 13].
This technique was developed over the last 25 years. As early as 1984, our teacher, Kurt Semm, was already using laparoscopic assistance in difficult vaginal hysterectomies .
He called this technique laparoscopic assistance for vaginal hysterectomies. In fact, many vaginal hysterectomies were performed in Kiel with laparoscopic assistance to dissect the uterus from the round ligaments, the adnexa, the sacrouterine ligaments and the cardinal ligaments. However, worldwide discussion on laparoscopic hysterectomy began after the first published laparoscopic-assisted vaginal hysterectomy by Harry Reich in 1989 . We began to perform supracervical laparoscopic hysterectomy in 1989, but the first publication did not appear until 1991 . Prior to this, a few journals had turned down our submitted papers, referring to the absurdity of such a surgical technique.
Nezhat et al. in the United States described their first radical hysterectomy in 1991, but a publication did not appear until 1992 .
Laparoscopic-assisted vaginal hysterectomy (LAVH)
Total laparoscopic hysterectomy (TLH) or laparoscopic hysterectomy (LH)
Intrafascial supracervical hysterectomy (CISH), subtotal or supracervical hysterectomy (LSH)
Laparoscopic radical hysterectomy (LRC) according to Wertheim or Schauta, with further specifications according to different schools
Robotic assistance in oncologic hysterectomy.
Robotic laparoscopic radical hysterectomy is a variation of LRH. A trachelectomy is performed in lymph node-free cases, whereby the total cervix is dissected and the vagina attached to the uterus.
Laparoscopic-assisted vaginal hysterectomy
In this case, the uterus is mobilised laparoscopically and resected transvaginally. The dissection is carried down to but excluding the uterine vessels which are secured vaginally. Similarly, uterosacral and cardinal ligaments are clamped and transfixed ligated transvaginally. LAVH is performed in four laparoscopic and three vaginal surgical steps [18, 20].
Total laparoscopic hysterectomy or LH
The intrafascial supracervical hysterectomy and the laparoscopic subtotal hysterectomy
In recognition of the CISH technique, performed at the Kiel University Hospital from 1991 to 1995  and still practised with interesting modifications in many countries, we would like to describe the CISH technique and the currently more frequently used LSH technique.
The advantage of the LSH procedure is that it can be performed on nulliparous patients, patients who have not previously had a vaginal delivery and patients who have had previous abdominal surgery. In these cases, the uterus is morcellated, but no colpotomy is performed. The technique is used mainly for fibroids, therapy-resistant dysfunctional uterine bleeding and adenomyosis. This technique is now practised routinely in Kiel according to the standardised safe minimally invasive technique [22, 23]. In a retrospective study on the clinical significance of adhesions, the effect of SprayShield as an adhesion prophylaxis has been evaluated .
Laparoscopic radical hysterectomy (Wertheim or Schauta technique)
Following the lead of earlier surgeons, a few skilled European and American gynaecologic surgeons have further refined the technique of radical hysterectomy, partly using robotic assistance. In addition to the Nezhat brothers  and Jo Childers [25, 26], who have been propagandists for radical endoscopic surgery worldwide, European colleagues such as Daniel Dargent , Denny Querleu , Achim Schneider and Mark Possover  have also put intensive work into oncologic endoscopic surgery. However, it is a colleague of the third world, Shailesh Puntambekar, who has successfully brought world attention to the possibility of radical oncological surgery via laparoscopy .
In 1986, Dargent already began to perform laparoscopic trachelectomy in cases of small cervical cancers with no iliac lymph node metastases .
A few of us have had the opportunity to work with Shailesh Putambekar in India and in Germany. He performs excellent anterior exenterations endoscopically and proves repeatedly that radical hysterectomies are possible via the endoscopic approach.
The results of radical laparoscopic  and radical robotic cancer surgery  compare well with the outcome of radical abdominal and vaginal cancer surgery. Radical laparoscopic vaginal hysterectomy according to Schauta is successfully practised in Germany by Schneider et al. and Possover et al.
Endoscopic surgery for malignant alterations has the same chance of success as open surgery, with less surgical trauma. It depends as much on subsequent chemo or radiation therapy as open surgery does. Molecular genetic progress in the therapy of malignant disease will show the real role endoscopic surgery can take.
Robotic assistance in oncologic hysterectomies
- (1)Surgeon’s console: the surgeon sits viewing a magnified three-dimensional image of the surgical field (Fig. 4a–c).
Patient-side cart: this system consists of three instrument arms and one endoscope arm (Fig. 4d).
Detachable instruments (EndoWrist instruments and Intuitive Masters): these detachable instruments allow the robotic arms to manoeuvre in ways that simulate fine human movements. There are seven degrees of freedom which offer considerable choice of rotation in full circles. The surgeon is able to control the amount of force applied, which varies from a fraction of a gramme to several kilos. Tremor and scale movements are filtered out. The movements of the surgeon’s hand can be translated into smaller ones by the robotic device (Fig. 4e).
Three-dimensional vision system: the camera unit or endoscope arm provides enhanced three-dimensional images with the result that the surgeon knows the exact position of all instruments in relation to the anatomical structures (Fig. 4f).
The patients lie in a horizontal position with both arms tucked alongside their body. Four trocars are placed next to the optic trocar. The surgeon sits at the console and the first surgical assistant is seated in most cases on the patients’ left side. This assistant controls the left accessory ports into which the instruments that are used for vessel sealing, retraction, suction, irrigation and suturing are inserted. The middle robotic arm is attached to the optical trocar with two lateral working arms to the right and one to the left. The robotic arms are connected at the beginning of the procedure and disengaged from the trocars at the end of the operation. The incisions are stitched, and the incision lines are reapproximated.
Results of robotic-assisted procedures in gynaecological oncology (comparative studies)
The team from University of North Carolina reported on 43 robotic-assisted laparoscopic hysterectomies with pelvic and paraaortic lymph node dissection for women with endometrial cancer as a simple case report. There were no conversions to laparotomy in the robotic group compared with 3% in the laparoscopy group. There were significantly more nodes recovered in the robotically staged patients (29.8 versus 23.2). The mean blood loss in the robotic group was 63 ml (25–300), with 45% of patients having no measurable blood loss compared with 142 ml (50–700) in the laparoscopy group. Mean operative time was 163 min compared with 213, and hospital stay was 1.0 compared with 1.2 days, respectively. There were 4.6% major complications in the robotic group compared with 12.8% in the laparoscopy group .
The team from Mayo Clinic in Scottsdale compared robotic-assisted surgery, laparoscopic surgery and open laparotomy in patients undergoing radical abdominal hysterectomy with bilateral lymphadenectomy for cervical cancer. They operated on 27 patients robotically with a mean operative time of 189.6 min, 31 patients laparoscopically with a mean operative time of 220.4 min and 34 patients had an open laparotomy, with a mean operative time of 166.8 min; the mean blood loss was 133.1, 208.4 and 443.6 ml, respectively. In this team, robotic lymphadenectomy in 27 patients resulted in a mean of 25.9 excised lymph nodes, and this appeared to be equal to that observed in laparoscopic lymphadenectomy in 31 patients, in which a mean of 25.9 lymph nodes was excised. These results compare well with open abdominal lymphadenectomy, with the mean number of excised lymph nodes being 27.7.
The robotic and laparotomy operating time was significantly shorter as compared with laparoscopy in the subgroup of patients undergoing the modified radical but not the radical technique . In contrast, Boggess and colleagues reported that open abdominal pelvic lymphadenectomy in 48 patients resulted in a mean of 22.3 lymph nodes being excised, which was significantly less than the mean of 38.4 lymph nodes when robotic lymphadenectomy was used in 31 patients. As compared with laparoscopy, patients having robotically assisted surgery experienced reduced blood loss (176 versus 328 ml) and reduced hospitalisation (1.9 versus 2.9 days), though the lymph node count was higher for the laparoscopy group. There were no intraoperative or major postoperative complications in either group .
Alternative techniques to hysterectomies
Over the last 10 years, the techniques of uterine artery embolization (UAE) and magnetic resonance imaging (MRI) guidance of focussed ultrasound for uterine leiomyoma treatment have been developed. Descriptions of MRI-guided focussed ultrasound therapy treatment of fibroids indicate that it is an effective treatment for uterine leiomyomata and results in sustained symptomatic relief [46–48].
Uterine artery embolization
Is an alternative to hysterectomy in women seeking treatment for symptomatic uterine myomas [49, 50]. It is associated with a good success rate in properly selected patients, with few major complications [51, 52].
Because of the high risk of infection, women who have had UAE and present with necrotic myoma adjacent to the endometrium should not undergo endometrial biopsy. Routine evaluation of the myoma in relation to the endometrium by means of imaging is recommended.
Endometrium ablation techniques
Endometrium ablation techniques of the first generation = hysteroscopic endometrial resection and coagulation. In long-term studies, a success rate of 80% was achieved in reducing, but not eradicating, dysfunctional bleedings. Hysteroscopic endometrial techniques, such as the YAG laser, the resectoscope and rollerball technique (also a combination of both techniques), cryoablation and microwave techniques are available.
Second-generation methods of endometrial ablation include a number of global ablation techniques. One of the most effective appears to be the NovaSure™ System which was introduced to Germany in 1998 by A. Gallinat . It consists of a bipolar ablation device and a radio-frequency controller that enables endometrial ablation in an average of 90 s.
MRI-guided focussed ultrasound
MRI-guided focussed ultrasound is a non-invasive treatment in which ultrasound energy, focussed on the fibroid in multiple focal spots, raises the temperature of tissue within the focal zone and causes coagulative necrosis. MRI guides and monitors the procedure, thus, providing a closed loop anatomical and thermal feedback. MRI is used to identify tumours or fibroids in the body before they are destroyed by ultrasound. Therapeutic ultrasound is a minimally invasive or non-invasive method to deposit acoustic energy into tissue.
Conclusions and recommendation
Limits for hysterectomies
Are there limits for hysterectomies or for which indications are hysterectomies still recommended? According to present medical standards, malignant disease of the ovaries, tubes and uterus is to be treated by hysterectomy. According to Dargent, trachelectomy can replace hysterectomy in younger women with early cervical cancer (smaller than 2 cm and without lymph node lesions in the cervix).
Contraindications for vaginal hysterectomy are a very large uterus that cannot be vaginally morcellated and non-descent of uterus. In these cases, laparoscopy, in combination with vaginal hysterectomy, can be performed. Abdominal hysterectomy has become less important and is mainly performed for cancer cases. The size of the uterus, multiple adhesions, endometriosis and obstetrical chaos situations can limit the feasibility of laparoscopic hysterectomy. In cases of massive bleeding, abdominal access is still the chosen route. Natural Orifice Surgery, with one instrument panel applied transvaginally, may open new doors for vaginal surgery.
Hysterectomy for benign indications, irrespective of surgical technique, increases the risk for stress urinary incontinence which may occur through damage to nerves, vascular supply or uterine descent . It is also associated with an increased risk for subsequent pelvic organ prolapse leading to enterocele prolapse . LSH or LASH seems to meet best patient satisfaction .
Considering how long Homo sapiens has inhabited the planet earth, the history of hysterectomy is a short one. This surgical technique began with a high mortality rate and a high morbidity rate, but with technological advances in the twentieth and twenty-first centuries, particularly after antisepsis and antibiotic prophylaxis eradicated infections and safe anaesthesia and infusion therapy decreased the high mortality rates, the procedure has now become very safe, with a mortality rate of approximately 12 per 10,000 . Hysterectomy, with a few exceptions (cancer cases), is increasingly performed to improve quality of life, rather than to save life.
It is difficult to foresee the future, but almost certainly, other alternatives to hysterectomy will continue to evolve. For example, a better understanding of endometriosis has already produced a new therapy basis for this disease. The development of a HPV vaccine, early cervical cancer detection and the effective recognition of endometrium carcinoma also influence therapy. No surgical alternative for ovarian cancer has so far been found, and hysterectomy, in addition to lymphadenectomy and omentum resection, prevails. These techniques, however, can be performed laparoscopically [29, 58].
In the twenty-first century, abdominal hysterectomy as a surgical intervention for benign indications belongs in the past. With appropriate indications and modern morcellation techniques, even large uteri up to 1 kg and more can be surgically removed with laparoscopic assistance transvaginally or totally laparoscopically. Vaginal hysterectomy is still the favoured route. It should only not be used if symptoms of the patient, the expected morbidity or the inexperience of the surgeon with the vaginal technique demand laparoscopic assistance.
Malignant disease of the vagina, cervix, uterus, tubes or ovaries is the primary indication for abdominal hysterectomy as centres which are able to perform laparoscopic and robotic-assisted laparoscopic techniques for malignant disease are still rare. The further development of laparoscopic vaginal surgery in oncology, as developed by Dargent, remains a challenge for the endoscopic surgeon in the twenty-first century.
Alternative techniques to hysterectomy, such as endometrium ablation, have emerged and should always be considered before a hysterectomy is performed. For benign indications with an intact cervix, no endometriosis and no previous cervical surgery, laparoscopic subtotal hysterectomy leaving the cervix in place (LSH, CISH) provides a minimally invasive alternative to all other methods of total hysterectomy in benign conditions.
However, if the patient cannot have regular controls postoperatively, laparoscopic total hysterectomy is preferable as with subtotal hysterectomy regular pap or thin-prep controls are necessary.
We highly acknowledge the excellent assistance of our office managers, Dawn Rüther and Nicole Guckelsberger. We thank them for their lasting and continuous support.
Declaration of interest
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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