Open access peer-reviewed chapter - ONLINE FIRST

Hysterectomy: Past, Present and Future

Written By

Zouhair Odeh Amarin

Submitted: January 14th, 2022Reviewed: February 7th, 2022Published: February 27th, 2022

DOI: 10.5772/intechopen.103086

IntechOpen
Hysterectomy - Past, Present and FutureEdited by Zouhair Amarin

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Hysterectomy - Past, Present and Future [Working Title]

Prof. Zouhair Amarin

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Abstract

Hysterectomy is a major operation and is as old as time. This chapter touches briefly on the history of this procedure, its present aspects and general advice for these women who may need a hysterectomy, and finally the direction of new developments about it.

Keywords

  • hysterectomy
  • vaginal hysterectomy
  • abdominal hysterectomy
  • laparoscopic hysterectomy
  • robotic hysterectomy

1. Preamble

Hysterectomy is the surgical removal of the uterus and, in some circumstances, the ovaries, cervix, fallopian tubes and supporting tissues. It ranks, just behind cesarean section, as the second most common surgery among women, and is the most common non-pregnancy-related major surgery performed on women worldwide.

Hysterectomy is a major surgical procedure that has risks and benefits, and may be classified as abdominal and vaginal according to the route of access. The abdominal route may be through conventional laparotomy, laparoscopy or robotic surgery, or vaginal hysterectomy through the superior part of the vagina. Occasionally both routes are used in combination.

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2. Indications

The indications for hysterectomy include benign conditions such as dysfunctional uterine bleeding, uterine fibroids, endometriosis, adenomyosis and genital prolapse. In addition, it is indicated in cases of gynecological malignancies 0f the uterus, ovaries and cervix, and for future malignancy risk-reducing indications, such as cases of BRCA 1 or 2 mutations or Lynch syndrome [1, 2].

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3. History

The origin of hysterectomy is obscure, but the first operation was vaginal hysterectomy that reputedly was performed by Soranus of Ephesus in the Greek city of Ephesus around 160 AD for the extirpation of an inverted uterus that had become gangrenous [3].

Historically, time passed with no clear record of advancement until the beginning of the 19th century. Lauvariol of France is credited for performing the first vaginal hysterectomy, followed by Baudelocque, who artificially prolapsed and then cut away the uterus and its appendages [3].

It was at the beginning of the 19th century too, in 1809, that the world’s first abdominal surgery was performed on a kitchen table. The operator was Ephraim McDowell from Danville, Kentucky. He removed an ovarian cyst that weighed 10.2 k. The patient survived [3].

Early procedures were performed without anesthesia, with some milk, brandy and prayers for some comfort, but the performance of medical procedures that caused intolerable pain to patients was technically unfeasible until anesthesia became part of the surgery. It enabled patients to undergo an operation safely without experiencing severe distress and intolerable pain.

By 1831, ether, nitrous oxide and chloroform had been discovered, albeit not applied medically yet. The first use of anesthesia in surgery was by Crawford Long of Georgia who, in 1842, used nitrous oxide on a very limited number of minor surgical cases. A few years later anesthesia was considered and implemented as a major breakthrough [3].

Of interest is the fact that dentistry was the first profession to use anesthesia, A Connecticut dentist, Horace Wells, in 1844, tested nitrous oxide by having his own tooth removed whilst under the influence of the gas. Wells’ dental student, William Morton introduced ether to dental procedures in 1846, and is regarded as the world’s first anesthetist, after the name ‘anesthesia’ was suggested by Oliver Holmes [3].

James Simpson of Edinburgh employed anesthesia in childbirth. This was condemned by the Calvinist Church as being against its beliefs. Because of its odor and long induction period, Simpson abandoned ether in favor of chloroform, which was favored in Europe until its hepatic toxicity became clear. Of interest is the fact that John Snow used it for Queen Victoria’s delivery of Princess Charlotte with no apparent ill effects [4].

With the new developments in medicine, in general, anesthesia and surgery in particular, continued their advancements and refinements. The lower transverse abdominal incision along the pubic hairline was introduced by Johannes Pfannenstiel of Breslau in the 1920s. Harry Reich performed the first laparoscopic hysterectomy in Kingston, Pennsylvania in 1988 [5, 6].

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4. Types

There are different types of hysterectomy. A subtotal hysterectomy, also known as supracervical hysterectomy, removes the uterus and leaves the cervix intact. A small proportion of patients undergoing subtotal hysterectomy continue to have cyclical bleeding until menopause [7, 8].

To minimize the possibility of this, the procedure of supracervical hysterectomy is combined with a reverse cone excision of the endocervical endometrium to avoid having very light menstruation.

A total hysterectomy removes the uterus and cervix. A radical hysterectomy may be indicated in certain cases of malignancy where the uterus, cervix and part of the vagina, ovaries, fallopian tubes, and nearby lymph nodes are removed.

A peripartum hysterectomy or emergency peripartum hysterectomy is a life-saving procedure to remove the uterus after 20 weeks of gestation, occurring during or after delivery or during the puerperium due to severe hemorrhage that fails to respond to conservative medical therapy and other modalities. Uterine atony and morbid placentation are the leading abnormalities [9, 10, 11].

Compared with non-obstetric hysterectomy, peripartum hysterectomy is associated with a six-fold increase in blood loss, and a 25-fold increase in mortality due to the increased incidence of coagulopathies and other perioperative complications [12].

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5. Techniques

Regarding hysterectomy techniques, the procedure can be performed through the vagina, the abdomen or by laparoscopy. The decision will depend on the indication for the operation, past abdominal surgery, current medical conditions, weight, available equipment and surgeon’s expertise.

Abdominal hysterectomy, also known as traditional open surgery, is performed through an abdominal incision, mostly by Pfannenstiel incision, and less frequently through an up and down incision. It is more recommended in cases of very large uterus, in cases of malignancies, and associations with other organ pathologies. This traditional approach is associated with relatively more post-operative pain and slightly longer hospital stay.

At vaginal hysterectomy the uterus is excised through an incision at the vaginal vault, thus avoiding an abdominal incision. This procedure is preferred in cases of uterine prolapse, vaginal walls laxity, stress incontinence and deficient perineum. To be eligible for a vaginal hysterectomy, the uterus must be of a certain size as it is not very suitable in cases of large pelvic masses and suspected malignancies.

Laparoscopic hysterectomy is a minimally invasive procedure using laparoscopic surgery where the uterus is removed through the vagina. The procedure seems to combine “the best of both worlds”. It is associated with fewer complications in the suitably selected cases and the availability of adequate instruments, surgical expertise and assistance.

Robotic hysterectomy is laparoscopic surgery that is aided by a robot that allows the performance of more complex procedures with better precision. The technology includes specialized arms for instrument holding, a camera, and a magnified screen and a console. This allows a greater range of motion and dexterity for better access to the area of interest. Recovery is similar to traditional laparoscopic surgery.

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6. Implications and general advice

The hospital stay after hysterectomy is usually 3 days. Postoperatively, prophylactic anticoagulation should be administered for about 10 days, and may be for longer in cases of hysterectomy due to cancer. Post hysterectomy, it may take 4–6 weeks to recover. The age and overall health will influence recovery time. In general, after a hysterectomy, an individual should not drive for 2 weeks, and not lift heavy objects for 6 weeks. Recovery may be aided by gentle exercise and gentle cleaning of the abdominal surgical incision. At follow-up, except for subtotal hysterectomy, the vaginal vault is checked for any granulation tissue, and if present it could be touched with silver nitrate.

When deciding on the route of hysterectomy, it has to be taken into account that, compared with abdominal hysterectomy, vaginal hysterectomy, as well as laparoscopic hysterectomy, are associated with less blood loss, shorter hospital stay, less post-operative pain, quicker return to usual activities and fess abdominal incisional infections [13, 14, 15].

Because of these findings, a recent review advocated that vaginal hysterectomy is preferable to abdominal hysterectomy. Furthermore, when vaginal hysterectomy is neither advisable nor practical, then laparoscopic hysterectomy should be considered [6].

In general, vaginal hysterectomy is not as expensive as abdominal hysterectomy, but it can be more difficult if adnexal masses are present, or in women with previous abdominal surgery or endometriosis. In addition, vaginal hysterectomy can be more challenging in cases of minimal uterine descent and patients with a narrow sub-pubic arch.

The adoption of the laparoscopic approach for the performance of hysterectomy has been slow. This, in part, has been attributed to the need for specialized highly technical equipment that is more delicate than those used in conventional surgery, and is in more need for routine maintenance. In addition, training programs lack a requirement that trainees need to have performed a certain number of laparoscopic procedures before graduating [16, 17].

For postoperative care, the best analgesic regimens are those that offer broad coverage, safe and are easy to administer. For moderate to severe pain, a centrally acting synthetic opioid analgesic with lower opiate-like dependence than Morphine would be appropriate. Non-steroidal anti-inflammatory drugs that possess analgesic and anti-pyretic activity are equally suitable. For nausea and vomiting patients are given the appropriate prophylactic and therapeutic antiemetics, such as dexamethasone and ondansetron [18, 19, 20].

After laparoscopic hysterectomy, it is normal to have some shoulder or back pain that is caused by the pneumoperitoneum. Patients tend to get tired easily or have less energy that lasts for several weeks after surgery, and may take about 4 to 6 weeks to fully recover. It’s important to avoid lifting while recovering. Patients are advised to be active where walking is a good choice, and to rest when feeling tired. Diet should be normal. In cases of an upset stomach, bland, low-fat foods and yogurt is advisable. Drinking plenty of water may avoid constipation.

To avoid venous thromboembolism, antiplatelet medication, in the form of acetylsalicylic acid, or low molecular heparin should be prescribed.

Abdominal incisions could be washed daily with warm, soapy water, and patted dry. Hydrogen peroxide or alcohol should be avoided as they can slow wound healing. The area may be covered with a gauze bandage that should be changed daily, if it oozes any discharge or rubs against clothing.

Follow-up after hysterectomy is mandatory. Light vaginal bleeding is not unusual. Patients should use sanitary pads if needed and avoid vaginal douches or the use of tampons. Intercourse is not allowed for six weeks, and after being cleared at the follow-up check.

Bilateral oophorectomy in premenopausal women would cause an abrupt loss of ovarian hormones which may alter some fundamental aging processes at the cellular and system levels [21]. An association of bilateral oophorectomy with increased DNA methylation has been reported [22].

Other than DNA methylation studies, further new research is needed to investigate the association of bilateral oophorectomy with aging using brain imaging, in addition to physical and functional measures of balance, gait, limb strength, cognitive function, markers of Alzheimer’s disease and of cerebrovascular disease [23].

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7. Present day issues

Nowadays, newer surgical options and techniques include laparoscopic incisions, single umbilical incisions, and robotic-assisted procedures. Such minimally-invasive hysterectomy approaches require a shorter hospital stay, with full recovery in four to six weeks.

Regarding hysterectomy for heavy and prolonged menstruation, endometrial curettage has been proven ineffective as a treatment as a reduction in bleeding may last for only one menstrual period and not after this. Curettage is utilized as a diagnostic procedure to determine the cause of the heavy bleeding.

The need to curette the uterus for histopathological purposes could be replaced by endometrial sampling where a fine plastic tube is passed inside the uterine cavity as an outpatient procedure. Vaginal ultrasound and hysteroscopy are the most commonly used procedures for reaching a histopathological diagnosis.

Endometrial ablation of the uterus is a day procedure, where a slightly lower proportion of women perceive improvement in bleeding symptoms, but it results in an improvement in pictorial blood loss assessment charts compared to their baseline score. Repeat surgery resulting from the failure of the initial treatment is more likely to be required after endometrial ablation than after hysterectomy, and the satisfaction rate is lower after endometrial ablation [24].

Regarding morbidity, it is more likely after hysterectomy. Women after endometrial ablation are less likely to experience sepsis, blood transfusion, pyrexia, vault hematoma and wound hematoma before hospital discharge, and a higher rate of infection after hospital discharge [24].

Unfortunately, not many clinicians are proficient in performing endometrial ablation, Alternatives to surgery include tranexamic acid in the first few days of heavy bleeding each month, progestogen tablets and progesterone impregnated intrauterine devices. In additions oral contraceptive pills and anti-prostaglandins may result in a sizable reduction in bleeding.

Second to menorrhagia, the most common reason for the hysterectomy is the presence of fibroids. Alternatives to hysterectomy that should be considered are laparoscopic myomectomy, myolysis and laparoscopic uterine artery ligation, and radiological uterine artery embolization. Hysterectomy remains an option for a small percentage where other modalities would have failed.

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8. Future considerations

Worldwide, there are so many hysterectomized women, where developed countries have higher hysterectomy rates than their developing counterparts. There are some alternatives to hysterectomy for patients with heavy bleeding and for fibroids to decrease the frequency of non-hysterectomy solutions for these patients. There is a need for better training programs for all gynecologists about the alternative methods and new techniques that require more skill. Although, hysterectomy has full success in dealing with abnormal and heavy uterine bleeding and fibroids, it is associated with certain morbidity and, to a much lesser degree, mortality.

Finally, the vast majority of patients do not want to have a hysterectomy. All important information should be given to them about alternative procedures. Patients can decide themselves what is best for them.

References

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Written By

Zouhair Odeh Amarin

Submitted: January 14th, 2022Reviewed: February 7th, 2022Published: February 27th, 2022