Best Practice & Research Clinical Obstetrics and Gynaecology

Vol. 20, No. 1, pp. 7387, 2006

doi:10.1016/j.bpobgyn.2005.09.007
available online at http://www.sciencedirect.com

5
Hysterectomy
R.D. Clayton*

MD, MRCOG

Consultant Gynaecological Oncologist

St Marys Hospital, Whitworth Park, Manchester and Christie Hospital, Wilmslow Road, Withington,
Manchester M20 4BX, UK

Hysterectomy is one of the most commonly performed major surgical procedures;

approximately 100 000 are performed in the UK each year. Hysterectomy can be total or
subtotal. The postulated benefits of subtotal hysterectomybetter pelvic floor and sexual
functionhave not been confirmed in randomised trials. Traditionally, hysterectomy was
performed using either an abdominal or vaginal approach. More recently, laparoscopic techniques
have been used. The decision about the technique used is often related to the surgeons training
and expertise, as the indications for each technique overlap. Vaginal hysterectomy is probably the
preferred route because it is quicker and cheaper than laparoscopic hysterectomy, with no other
clear differences in outcome measures. Laparoscopic hysterectomy has a number of advantages
over abdominal hysterectomy: specifically, shorter hospital stay and quicker return to normal
activities; complication rates, however, appear to be greater. This also seems to be the case with
radical hysterectomy performed for cervical cancer.
Key words: hysterectomy; laparoscopic radical hysterectomy; laparoscopic surgery; laparoscopic-assisted radical vaginal hysterectomy; supracervical hysterectomy; vaginal hysterectomy.

In recent years, a number of trials have addressed the advantages and disadvantages
of alternatives to the established techniques of total abdominal and vaginal
hysterectomy, most notably laparoscopic hysterectomy and supracervical hysterectomy. In addition, a number of alternatives to hysterectomy are now available,
including the levonorgestrel-releasing intrauterine system, a variety of endometrial
ablation techniques, and uterine artery embolisation for fibroids. These alternative
techniques are outside the scope of this review.
Once the decision is made to perform a hysterectomy, the decision about which
hysterectomy technique is used is based on a number of outcome measures, perhaps
the most important being the rate of complications. Other factors to consider
include duration of surgery, time in hospital, overall recovery time, postoperative
* Tel.: C44 161 446 8045; fax: C44 161 276 5075.
E-mail address: richard.clayton@cmmc.nhs.uk.

1521-6934/$ - see front matter Q 2005 Elsevier Ltd. All rights reserved.

74 R. D. Clayton

pain, sexual function, quality of life and overall cost. This chapter will consider these
factors in detail, comparing abdominal, vaginal and laparoscopic approaches. It will
also cover the role of supracervical hysterectomy as an alternative to total
hysterectomy, when to perform oophorectomy concurrently, and new techniques in
the surgical approach to hysterectomy for early stage cervix cancer.

DEFINITIONS OF HYSTERECTOMY
A total hysterectomy includes removal of the uterus and cervix. Removal of the
adnexae (ovaries and fallopian tubes) might or might not be performed in addition; the
cervix is not removed in a supracervical or subtotal hysterectomy. These procedures
can be performed using one of three main approaches: abdominal hysterectomy (AH),
vaginal hysterectomy (VH) or laparoscopic hysterectomy (LH).
The type of laparoscopic hysterectomy is usually defined by the extent of
laparoscopic dissection performed during the procedure. The recently published
Cochrane review of the surgical approach to hysterectomy for benign gynaecological
disease1 uses the description of different techniques detailed by Reich and Roberts2,
which is based on the definitions published by Garry et al.3
Laparoscopically assisted vaginal hysterectomy (LAVH): a combined laparoscopic
and vaginal approach with laparoscopic division of the structures above the uterine
artery; the remainder of the procedure is completed vaginally (Figure 1A).
Laparoscopic hysterectomy (LH(a)): a combined laparoscopic and vaginal approach
with laparoscopic division of the uterine artery; the remainder of the procedure is
completed vaginally (Figure 1B). The letter (a), in parentheses, is inserted to
distinguish this laparoscopic approach to hysterectomy, which involves division of
the uterine artery, LH(a), from laparoscopic hysterectomy (LH) in general, which
includes all three subcategories listed here.
Total laparoscopic hysterectomy (TLH): the operation is performed entirely
laparoscopically (Figure 1C).
To achieve the laparoscopic component of the procedure, a variety of devices
and techniques can be used for haemostasis and cutting, including, diathermy
(monopolar and bipolar), harmonic scalpel, linear stapling devices and argon beam
coagulator. Some surgeons prefer to suture pedicles, either extracorporeally (knot tied
outside patient) or intracorporeally (knot tied internally).
A variation on the standard LAVH is the laparoscopically assisted Doderlein
hysterectomy4; the laparoscopic component is the same as for a standard LAVH but,
vaginally, an anterior vaginal incision (colpotomy) is then performed and the fundus of
the uterus is delivered into the vagina by marching two pairs of Brauns tissue forceps
up the anterior wall to the fundus and rotating the uterus around its remaining
supports. The uterine arteries are then clamped under direct vision followed by the
uterosacral and cardinal complex together with the posterior vaginal wall. The vault is
then closed, incorporating the uterosacral and cardinal complex for vault support. As
with a standard LAVH or LH(a), a laparoscopic check for haemostasis should be made
at the completion of the vaginal component because, theoretically, this could reduce
the risk of vault haematoma, although this has not been formally studied. The potential
advantages of the Doderlein variation on LAVH include clamping of the uterine arteries

Hysterectomy 75

under direct vision before the uterosacralcardinal complex, which makes ureteric
injury less likely, and reducing the traction on the uterine arteries when the uterine
arteries are the final pedicles, as in an LAVH, and are therefore at more risk of tearing.
Additionally, blood loss may be reduced because the posterior vaginal wall is clamped.
To successfully undertake TLH, it is necessary to maintain a pneumoperitoneum
after incision of the vagina. Additionally, it is helpful to visualise the fornices to allow the

Figure 1. (A) Laparoscopically assisted vaginal hysterectomy (LAVH), showing vaginal and laparoscopic
components. (B) Laparoscopic hysterectomy (LH(a)), showing vaginal and laparoscopic components. (C)
Total laparoscopic hysterectomy (TLH), showing laparoscopic component.

76 R. D. Clayton

Figure 1 (continued)

colpotomy to be performed. Some form of vaginal tube or manipulator that delineates

the vaginal fornices and prevents CO2 leakage is useful for this. One such device is
illustrated in Figure 2. TLH is of particular use in patients in whom vaginal access is too
difficult for a vaginal or a combined laparoscopic and vaginal procedure, e.g. morbidly
obese5 or nulliparous patients.1

Figure 2. McCartney tubee (45 mm).

Hysterectomy 77

In the management of early-stage cervical cancer (and occasionally stage 2

endometrial cancer), a radical hysterectomy can be performed. The most commonly
used definition was proposed by Piver et al in 1974.6 Five classes (class IV) of extended
hysterectomy were described. Class II and Class III are the most commonly employed
and are generally combined with a pelvicGparaaortic lymphadenectomy:
Class II: the ureters are freed from the paracervical position but are not dissected
out of the pubovesicle ligament. The uterine vessels are divided just medial to the
ureter. The medial half of the uterosacral and cardinal ligaments are removed
together with the upper third of the vagina.
Class III: the uterine vessels are divided at their origins from the internal iliac vessels.
The ureter is completely freed down to its entry into the bladder. The uterosacral
and cardinal ligaments are divided at the sacrum and pelvic wall, respectively. The
upper half of the vagina is removed.
In practice, the extent of the dissection will be tailored according to the size and
position of the tumour, for example, in a relatively small central tumour with no
evidence of vaginal involvement by tumour or preinvasive disease, removal of only the
upper 2 cm of the vagina is generally necessary.7
By far the most common approach to radical hysterectomy is abdominal, although
there are now a number of published series detailing radical laparoscopic hysterectomy
(RLH)8,9 and laparoscopic assisted radical vaginal hysterectomy (LARVH).1013

LAPAROSCOPIC VERSUS ABDOMINAL VERSUS VAGINAL APPROACH

FOR TOTAL HYSTERECTOMY IN BENIGN DISEASE
A number of randomised trials have been published principally comparing the
laparoscopic approach with the abdominal approach1433; a smaller number compare
laparoscopic with vaginal.17,19,25,28,3437 Three trials included in both the above reference
groups compare laparoscopic versus abdominal versus vaginal19,25,28; two randomised
trials compare abdominal hysterectomy and vaginal hysterectomy alone.38,39
The largest of all these trials, the Evaluate trial17, consists of two parallel randomised
trials; the first arm comparing laparoscopic with abdominal and the second arm
comparing laparoscopic with vaginal. The trial used a 2:1 randomisation (LH:VH or AH)
in each arm and recruited 1380 women, with 876 in the abdominal trial and 504 in the
vaginal trial. The primary outcome measure of this study was the major complication
rate. The abdominal arm of the trial was powered to detect a difference in complication
rates assuming a 50% relative reduction from a rate of 9%. The vaginal arm of the trial
was not sufficiently powered to detect a difference. In each arm of the trial, the choice
about what form of LH to perform was left to the surgeon and therefore the LH group
in the two arms includes LAVH, LH(a) and TLH together with some subtotal
hysterectomies. The number of each type was not reported.
Recently, the Cochrane Collaboration has published an excellent review on the
surgical approach to hysterectomy for benign gynaecological disease1, which includes a
detailed analysis of all these trials. Reporting of a number of factors that may have
influenced outcomes was variable across trials. These included:
The degree of surgical experience in performing the different techniques used in
different trials. For example, in some trials, a number of surgeons performed just

78 R. D. Clayton

Table 1. The complications of hysterectomy.

Intraoperative

Short-term

Long-term

Complications
Bladder injury
Ureteric injury
Bowel injury
Vascular injury
Bleeding
Unintended laparotomy
Transfusion

Transfusion
Haematoma
Vaginal cuff infection
Urinary tract infection
Wound infection
Febrile episode
Thromboembolism

Fistula
Chronic pain
Bladder dysfunction
Bowel dysfunction
Prolapse
Sexual dysfunction

one approach, such as LH, and different surgeons performed another, such as AH.
Some trials addressed these issues in their design; in the Evaluate trial17, procedures
in both arms of the trial were stratified by surgeon, i.e. the surgeon needed to be
capable of performing both types of procedure. In addition, to randomise into the
trial, the surgeon had to document 25 laparoscopic procedures.
Type of anaesthesia used: in some trials, the anaesthetic technique differed
depending on the procedure to which the patient was randomised.
Various factors decide the approach to hysterectomy, but perhaps most influential is
the training and experience of the surgeon. When viewed objectively, several outcome
measures should allow a decision as to the best route; arguably the most important is
the risk of complications, whether intraoperative, short-term or long-term (Table 1).
Other considerations include duration of surgery, length of stay in hospital and time
taken to return to normal daily activities, postoperative pain, sexual function, quality of
life and overall cost.
Abdominal versus vaginal
In the five trials reviewed by the Cochrane group19,25,28,38,39, vaginal hysterectomy
resulted in fewer unspecified postoperative infections or febrile episodes (PZ0.01) and
a more rapid discharge from hospital (P!0.00001) and return to normal activities (P!
0.00001). Benassi et al38 found a significant reduction in pain (P!0.05), judged by lower
analgesic requirements, in the vaginal arm of their study; only 66% of patients required
postoperative analgesia, compared with 86% in the abdominal arm. Interestingly,
different anaesthetic techniques were utilized: spinal anaesthesia for vaginal
hysterectomy and general anaesthesia in the abdominal arm. It is possible that this
influenced analgesic requirements. Other studies have confirmed reduced pain scores
with the vaginal approach.19,39 The data on duration of surgery was conflicting38,39, with
no consistent pattern. There were no differences in urinary tract injury rates or other
short- or long-term outcomes, although the small numbers involved were unlikely to
allow a difference to be noted.
Laparoscopic versus vaginal
Vaginal hysterectomy is quicker than using a laparoscopic approach1,17,25,34,36,37; this
applies to both LAVH and LH(a). Ottosen et al25 found that VH took 21 minutes less

Hysterectomy 79

(95% CI 8.134.0) than LAVH. In the Cochrane meta-analysis, LH(a) took 54 minutes
longer than VH (95% CI 43.763.5).1,34,36,37 Garry et al17 found a 29.9-minute
difference (95% CI 23.935.9), with LH taking longer than VH. There are no specific
data comparing TLH with VH. There do not appear to be any differences in
intraoperative complications, short-term complications or long-term outcomes.
Overall recovery from surgery and pain scores was similar with both approaches,
although Summitt et al37 noted a significant reduction in analgesic requirements on day
2 in the vaginal arm. Overall costs for LH are higher.1,40 Vaginal hysterectomy does not
allow direct visualisation of the peritoneal cavity, therefore conditions such as
endometriosis might not be diagnosed at the time of surgery. In the vaginal arm of the
Evaluate study17, additional pathology was diagnosed in significantly more patients
undergoing LH (16.4%) than VH (4.8%) (P!0.01). The practical significance of this
finding is unclear.1
Laparoscopic versus abdominal
AH takes less time to perform than LH1, although when the Cochrane group looked at
the different classes of LH, LAVH was slower in some trials16,25,27, whereas a metaanalysis of four trials showed that LAVH was possibly quicker.20,23,25,32 LH(a) was found
to be slower overall.1
LH leads to shorter inpatient stay and quicker return to normal activities than
AH18,20,2326,3032, The Cochrane meta-analysis of these trials showed a difference of
2.0 days (95% CI 1.92.2 days)1 for inpatient stay and 13.6 days in return to normal
activities (95% CI 11.815.4 days).1,18,19,24,25,30,31
Because of the nature of the data, it was not possible to perform a meta-analysis
of the pain associated with the two approaches.1 However, a number of trials showed
a reduction in pain scores17,23,24,26,29 and a reduction in analgesic requirements for
LH.1517,21,27,31
Assessment of complication rates from individual trials is difficult because they are
usually underpowered and are often performed in single centres of excellence, so the
results might not be generally applicable.41 The Cochrane group found a number of
significant differences in complication rates1: intraoperative bladder and ureteric injury
showed a trend towards a lower rate for AH, although neither was significant
individually. When ureteric injury and bladder injury rates were pooled as urinary tract
injury, there was a significantly lower rate for AH (odds ratio (OR) 2.61, 95% CI 1.22
5.60). A large, non-randomised retrospective study of 62 379 hysterectomies in
Finland42 showed a ureteric injury rate of 13.9 injuries per 1000 LH and 0.4 per 1000
AH. Although the accuracy of retrospective reporting of complications can be debated,
clearly this high rate of ureteric injury is of concern. In a prospective study of 10 100
hysterectomies in Finland, Makinen et al43 found an increased risk of ureteric injury
(relative risk (RR) 7.2) for laparoscopic compared with abdominal hysterectomy. They
noted that the rate of ureteric injury was greater for surgeons who had performed
fewer than 30 laparoscopic procedures (2.2% compared with 0.5%).
The Value study prospectively analysed a series of 37 512 women undergoing
hysterectomy in the UK during a 12-month period starting in 199444; 67% of
procedures were abdominal, 30% vaginal and 3% laparoscopic. Operative complications
occurred in 6% of laparoscopic procedures, significantly greater than vaginal (3.1%) or
abdominal (3.6%) (PZ0.002). No significant differences were noted in the rate of
bladder or ureteric injury between the three techniques (0.50.6%). LH (1.7%) had

80 R. D. Clayton

significantly higher postoperative complication rates than AH (0.9%) or VH (1.2%) (PZ

0.015). Overall complication rates were more common in younger women and those
undergoing surgery for fibroids.
The Cochrane group1 demonstrated fewer wound or abdominal wall infections (OR
0.32, 95% CI 0.120.85) and fewer unspecified infections or episodes of pyrexia (OR
0.65, 95% CI 0.490.87) for LH. There was lower mean blood loss and less fall in
haemoglobin levels.
The Evaluate trial17 showed a difference in overall complication rates, with a higher
rate for abdominal hysterectomy (11.1 versus 6.2%, PZ0.02, 95% CI 0.99.1%). This
trial has been criticised because the primary endpoint is a composite measure, which
cannot be applied symmetrically to each arm of the trial45; 3.9% of laparoscopic
hysterectomies underwent an unintended intraoperative laparotomy, whereas
abdominal hysterectomy cannot have an unintended intraoperative laparotomy.
Conversion to laparotomy might indeed be a prudent decision in some cases and
perhaps should not be included as a complication. However, Chien et al45 point out that
if this complication is excluded from the analysis, then the difference in complication
rates is no longer significant. In a recent editorial, Garry41 acknowledges this criticism
of the study but points out that there are still differences in complication rate in favour
of abdominal hysterectomy even after exclusion of these cases. For example, there
were six ureteric injuries in the study, all of which occurred during laparoscopic
hysterectomy.
Comparison of different types of laparoscopic hysterectomy
Long et al46 compared LH(a) and LAVH. The only difference noted was a significantly
shorter operating time for LAVH (25.3 minutes, 95% CI 1040.6). There were no
differences in intraoperative and short-term complications, or in long-term outcomes.
The decision on how much laparoscopic dissection to perform will be based on the
surgeons judgement and training. Given that the vaginal approach appears to be best
overall, perhaps as much laparoscopic dissection should be performed as is necessary
to then allow the procedure to be completed vaginally.
The TLH procedure has recently been considered by the National Institute for
Clinical Excellence (NICE) in the UK. The provisional recommendations in the NICE
consultation document on laparoscopic hysterectomy state that Current evidence on
the safety of total laparoscopic hysterectomy does not appear adequate to support the
use of this procedure without special arrangements for consent and for audit or
research. Further research on the place of different classes of laparoscopic
hysterectomy would be of use.
Cost of surgery and quality of life
This can be difficult to assess because of the nature of different healthcare systems in
different countries. The costs of disposable equipment and differences in inpatient stay
specifically need to be considered. The Evaluate group, in a separate paper40, found that
LH cost more (higher unit cost 396 more expensive) than VH with no differences in
quality of life outcomes. LH was also more expensive than AH (by 190), but LH was
associated with better short-term quality of life scores at 6 weeks. Garry41 states that
the overall costs in terms of patients loss of productivity by requiring a greater period
of time for overall recovery after AH were not taken in to account. Lumsden et al22

Hysterectomy 81

found AH to be significantly less expensive than LH, although the difference became
non-significant if the cost of disposable equipment was not considered. Other authors
have found no significant difference in overall costs.31,47 Ellstrom et al14 noted that
when indirect costs such as loss of productivity by the patient are taken into account,
these lead to an overall cost saving in favour of laparoscopic hysterectomy.
Hysterectomy, regardless of method, results in an overall improvement in quality of
life and relief of gynaecological symptoms.17,48 Although the Evaluate group17 noted
short-term differences in quality of life depending on the chosen method, there were
no differences between abdominal and laparoscopic at 12 months. This has also been
confirmed in a smaller randomised trial.49

OVARIAN CONSERVATION
Conservation of the ovaries at the time of hysterectomy should be an informed
decision by the woman undergoing surgery. When a woman is postmenopausal, the
usual recommendation is for bilateral adnexectomy if possible; this is based on the
potentially prophylactic effect of oophorectomy in preventing ovarian cancer, which
carries a life-time risk of approximately1%.50 In the premenopausal woman, sexual
activity can be impaired by oophorectomy41, particularly under the age of 45 years.
There is some evidence, however, that removal of the ovaries in postmenopausal
women might also adversely affect sexual response due to androgen deficiency51, and
patients should therefore be counselled regarding this.
In oncological practice, bilateral adnexectomy is generally recommended for women
with endometrial cancer because of the risk of occult metastases and, in premenopausal
women, the risk of oestrogenic stimulation of any residual tumour deposits. Despite
this, there is no evidence that prescribing hormone replacement therapy (HRT) for
these patients compromises survival.52 It has been suggested that adnexectomy should
be performed in cervical adenocarcinoma because of an increased risk of ovarian
metastases compared with squamous cell cancers.53,54 Natsume et al, however, in
reviewing the published series, found a low rate of metastases (1.6%) in stage 1B lesions
and recommend that oophorectomy is not performed routinely in premenopausal
women if the ovaries appear grossly normal.53 However, bilateral oophorectomy is a
part of standard management for ovarian cancer in younger women with epithelial
ovarian cancer. Specifically, in those who are thought to have stage 1A grade 1 lesions,
conservation of the remaining ovary and uterus can be considered, as the chance of
recurrence is low.55,56 Consideration should be given to a conservative staging
procedure with node sampling, omentectomy and peritoneal biopsies.
The need for oophorectomy might influence the approach to hysterectomy.
Although oophorectomy can be accomplished at vaginal hysterectomy, many surgeons
prefer to perform a laparoscopic or open procedure to achieve this.

TOTAL VERSUS SUBTOTAL HYSTERECTOMY

The rationale for subtotal hysterectomy is that women may have better pelvic floor
function and sexual function if the cervix is retained. Complication rates can be reduced
by the less extensive dissection but there is a risk of cyclical bleeding, which might
necessitate removal of the cervix (trachelectomy). There also remains a risk of

82 R. D. Clayton

subsequent invasive cancer when the cervix is retained, although this risk is extremely
low in properly screened patients.
Thakar et al57 included 279 women in a randomised trial comparing an abdominal
approach to the two procedures. They assessed urinary, bowel and sexual function,
none of which was significantly different in the two groups. Inpatient stay was shorter in
the subtotal group (5.2 days versus 6 days, PZ0.04) and there was a lower rate of
postoperative pyrexia in the subtotal group (6 versus 19%, PZ0.001). There was a 7%
incidence of cyclical bleeding in the subtotal group. Gimbel et al58 also performed a
randomised trial and demonstrated a 20% rate of cyclical vaginal bleeding 1 year after
surgery in the subtotal arm. Symptoms of urinary incontinence were more common in
the subtotal arm (9 versus 18%, OR 2.08, 95% CI 1.014.29, PZ0.043). No other
differences in quality of life, including sexual function, were noted. Learman et al59 found
no differences in the two groups, except for a tendency for women undergoing TAH to
be readmitted less frequently; however, this difference was not significant. There was a
general improvement in both groups in pelvic pain, back pain and urinary symptoms,
however, they did not report on any assessment of sexual function.
There are no randomised trials comparing laparoscopic supracervical hysterectomy
(LSH) with LH.60 An interesting variation on the technique of LSH is known as CISH
(classic intrafascial supracervical hysterectomy), in which an endocervical resecting
device is placed on a guide rod inserted through the cervix. This allows the
endocervical canal to be entirely removed in a coring fashion. Theoretically, this should
reduce the chances of persistent cyclical bleeding, although rates of up to 10% have
been reported.61 In some cases, diathermy is applied to the top of the endocervical
canal in the hope that this will destroy any cycling endometrium.60 A laparoscopic
morcellation device is usually utilized to allow removal of the specimen piecemeal
through the laparoscopic ports.

ALTERNATIVES TO ABDOMINAL RADICAL HYSTERECTOMY

In an attempt to apply the potential advantage of minimally invasive surgery to radical
hysterectomy, a variety of techniques have been employed. Common to all these
techniques is laparoscopic pelvicGpara-aortic lymphadenectomy. This is then
combined with either laparoscopic-assisted radical vaginal hysterectomy (LARVH) or
laparoscopic radical hysterectomy (LRH).
LARVH is a combined laparoscopic and vaginal procedure and consists of a classical
Schauta radical vaginal hysterectomy except with initial laparoscopic dissection.62 After
a laparoscopic node dissection, the pararectal and paravaginal spaces are opened
laparoscopically. The uterine artery is divided at its origin. The operation is then
completed vaginally. A vaginal cuff is defined and the vesicouterine space developed.
The paravesical spaces are opened and the bladder pillars transacted after identification
and mobilisation of the ureters. The uterine artery, which has previously been divided,
is mobilised. After opening the pouch of Douglas, the uterosacral ligaments and cardinal
ligaments are divided. Finally, after entering the anterior cul-de-sac, the utero-ovarian
or infudibulopelvic ligaments can be divided, the specimen removed and the vagina
closed. A check for haemostasis should then be performed laparoscopically.
LRH is performed entirely laparoscopically.9 In the technique described by Spirtos
et al9, the initial steps are similar to the LARVH with node dissection and division of the
uterine artery at its origin after reflection of the bladder and rectum. The procedure

Hysterectomy 83

then follows the steps of an open radical hysterectomy. An endoscopic stapler with
vascular cartridges is used to transect the paracervical soft tissues and uterosacral
ligaments. An argon beam coagulator and laparoscopic countertraction permit
mobilisation of the ureter from the overlying uterine artery and vesicouterine
ligament. This then allows resection of the medial paracervical/vaginal tissue. The vagina
is incised after delineating the necessary length of vaginal cuff using the surgeons nondominant hand. The vagina is then closed laparoscopically with interrupted or
continuous sutures.
There are no randomised trials comparing these new techniques with conventional
open surgery. Some studies describe type II radical hysterectomy and some type III or a
combination of type II and III. In the largest comparative series Steed et al13
prospectively compared LARVH and open radical hysterectomy in stage 1A and B
cervical cancer. Seventy-one patients underwent LARVH and 205 open surgery. Steed
et al found no differences in 2-year recurrence-free survival (94% in both arms). The
intraoperative complication rate was higher in the laparoscopic arm (13 versus 4%, PZ
0.03). Specifically, a high rate of cystotomy (10%) was noted. Overall postoperative
complication rates were higher in the laparoscopic arm (14 versus 7%). The authors
split these into infective and non-infective complications for comparison and these
differences were not found to be statistically significant. In the open arm, blood loss was
greater (500 versus 300 ml, P!0.001), median length of hospital stay was longer (5 days
versus 1 day, P!0.001) and duration of surgery was shorter (2.5 versus 3.5 hours, P!
0.001). Other authors have noted intraoperative complication rates ranging from 2 to
13%813,6366, with postoperative complication rates of 616%.813,6366 Five-year
disease-free survival rates range from 85 to 94%.8,9,13,66 Fewer studies assess LRH8,9,63,
including only one small comparative study63 of 19 LRH and 205 open cases. This
showed a lower blood loss for LRH and shorter intraoperative stay.
Although it is difficult to make firm conclusions about the laparoscopic approach
because of the poor quality of the available studies, there appears to be no difference in
survival.67 The usual advantages of laparoscopic surgery seem to apply; shorter
inpatient stay and lower blood loss, whereas the complication rates are probably higher.

SUMMARY
Despite the development of treatments providing a potential alternative to
hysterectomy, the incidence of hysterectomy does not appear to be declining.41 In
benign gynaecological disease, vaginal hysterectomy should be the preferred option if
possible. Compared to AH, there are fewer complications, quicker recovery and less
pain. LH takes longer to perform and is more expensive than VH. LH leads to quicker
recovery, better short-term quality of life and less pain than AH. Of concern, however,
is the higher complication rate found with LH; urinary tract injuries (bladder and
ureteric trauma) appear to be more common.
Despite the available evidence, the decision on which approach to use is probably
most influenced by the experience and training of the surgeon, but clearly the patient
should be informed of the advantages and disadvantages of the available methods.
Although practices vary, LH is probably more expensive than VH or AH, much of this
increase being related to the use of expensive disposable equipment. Oophorectomy
should be discussed, and the decision individually based on age and indication for
hysterectomy. Subtotal hysterectomy does not lead to improved pelvic floor or sexual

84 R. D. Clayton

function when compared with total hysterectomy; there is some evidence that stay in
hospital may be shorter, with lower incidence of postoperative pyrexia. Persistent
cyclical bleeding can be a problem following subtotal hysterectomy and might
necessitate removal of the cervix. The quality of data assessing laparoscopic alternatives
to open radical hysterectomy is poor and it is not possible to draw firm conclusions;
survival rates appear to be similar, although complication rates may be greater.

Practice points
vaginal hysterectomy should be the preferred route where applicable
laparoscopic hysterectomy should be considered as an alternative to abdominal
hysterectomy because recovery is quicker and it is less painful. However,
complication rates might be higher
the route of hysterectomy should be decided by the woman after a full
discussion of the relative merits of different approaches
the decision regarding oophorectomy should be individualised
subtotal hysterectomy has no advantage over total hysterectomy and might
result in persistent cyclical bleeding
the role of laparoscopic assistance in radical hysterectomy for early cervical
cancer is unproven

Research agenda
which type of laparoscopic hysterectomy is the best option, i.e. are
complication rates increased when the extent of laparoscopic dissection is
greater? Is TLH as safe as other approaches?
randomised trials comparing newer endometrial ablation techniques with
hysterectomy
randomised trials of open radical hysterectomy versus laparoscopically assisted
radical hysterectomy, specifically looking at survival and complication rates
safety and efficacy of laparoscopic hysterectomy in endometrial cancer
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2. Reich H & Roberts L. Laparoscopic hysterectomy in current gynaecological practice. Rev Gynaecol Pract
2003; 3: 3240.
3. Garry R, Reich H & Liu CY. Laparoscopic hysterectomydefinitions and indications. Gynaecol Endosc
1994; 3: 13.
4. Hawe JA, Clayton R, Phillips G et al. Laparoscopic-assisted Doderlein hysterectomy: retrospective
analysis of 300 consecutive cases. Br J Obstet Gynaecol 1999; 106(10): 10831088.
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