Transcript Abdominal hysterectomy

16/9/2014
Abdominal hysterectomy
Official reprint from UpToDate®
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Abdominal hysterectomy
Authors
Thomas G Stovall, MD
William J Mann, Jr, MD
Section Editor
Howard T Sharp, MD
Deputy Editor
Sandy J Falk, MD
Disclosures: Thomas G Stovall, MD Nothing to disclose. William J Mann, Jr, MD Nothing to disclose. Howard T Sharp, MD Nothing to disclose. Sandy J Falk, MD Employee of UpToDate, Inc.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to
be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.
Conflict of interest policy
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Aug 2014. | This topic last updated: Dec 25, 2013.
INTRODUCTION — Hysterectomy (surgical removal of the uterus) may be performed using an abdominal, vaginal, or laparoscopic approach. Abdominal hysterectomy refers to
removal of the uterus via a laparotomy. Either total hysterectomy (uterus including cervix) or subtotal (supracervical) hysterectomy may be performed. The ovaries may or may
not be removed at the time of hysterectomy. The choice of surgical approach depends upon clinical circumstances, the surgeon's technical expertise, and patient preference.
(See "Overview of hysterectomy".)
Issues related to abdominal hysterectomy will be reviewed here. Other approaches to hysterectomy are discussed separately. (See "Overview of hysterectomy" and "Vaginal
hysterectomy" and "Laparoscopic hysterectomy" and "Radical hysterectomy".)
INDICATIONS AND ALTERNATIVES — The indications for, and alternatives to, hysterectomy are presented elsewhere. (See "Overview of hysterectomy".)
PREOPERATIVE ISSUES — Complete preoperative evaluation and counseling helps to set patient expectations and prepare for, or prevent, perioperative complications. An
overview of issues pertaining to preoperative preparation and assessment, including women with medical comorbidities, can be found separately. (See "Overview of
preoperative evaluation and preparation for gynecologic surgery".)
Surgical planning — Discussion of a patient's choices regarding surgical approach (eg, retention of ovaries or cervix) should be documented in the medical record and on the
consent form.
Choice of incision — Women should be counseled before surgery about the planned type of abdominal incision, including the possibility that this plan may change
depending on an examination under anesthesia or other clinical factors. If a woman has a previous vertical abdominal surgical scar, most surgeons prefer to use this incision.
However, if the planned procedure can be accomplished via a transverse incision, it is also an option to ask a patient if she would prefer a transverse incision (figure 1 and figure
2). (See "Incisions for open abdominal surgery".)
Elective oophorectomy — Many physicians remove the ovaries in women over the ages of 40 or 45 for prevention of ovarian cancer, however, no data exist to support this
approach in women who are not at a high risk of ovarian cancer. Patients planning hysterectomy should be counseled regarding the risks and benefits of oophorectomy, which
are discussed in detail elsewhere. (See "Risk-reducing bilateral salpingo-oophorectomy in women at high risk of epithelial ovarian and fallopian tubal cancer" and "Elective
oophorectomy or ovarian conservation at the time of hysterectomy", section on 'Introduction'.)
Total versus subtotal hysterectomy — Retention or removal of the cervix should be addressed with a patient preoperatively. There are no proven medical or surgical
benefits of performing subtotal hysterectomy if the cervix can be easily removed with the corpus. Retaining the cervix commits the patient to continued cervical cancer screening
(ie, Pap smear and appropriate follow-up) and may result in persistent post-hysterectomy bleeding.
The only absolute contraindication to subtotal hysterectomy is the presence of a malignant or premalignant condition of the uterine corpus or cervix.
A detailed discussion of total versus subtotal hysterectomy can be found separately. (See "Overview of hysterectomy", section on 'Total versus subtotal (supracervical)'.)
Prophylactic measures prior to hysterectomy
Thromboprophylaxis — Women undergoing abdominal hysterectomy require venous thromboembolism (VTE) prophylaxis. The type of thromboprophylaxis, pharmacologic
or mechanical, depends upon the patient’s risk factors. The risk categories in the guidelines for perioperative thromboprophylaxis published by both the American College of
Obstetricians and Gynecologists (ACOG) and the American College of Chest Physicians (ACCP) differ somewhat, but the recommendations are consistent with each other for
most patients undergoing AH:
● ACOG defines patients undergoing AH as at least moderate risk of VTE and advises either mechanical or pharmacologic prophylaxis [1].
● ACCP defines most patients undergoing AH as at least moderate risk of VTE (Caprini score of 3 to 4) (table 1) and advises either mechanical or pharmacologic
prophylaxis; the exception to this is women who are low risk (Caprini score of 1 to 2; only women ≤40 years-old who have no other risk factors), for whom mechanical
prophylaxis is advised [2].
Thromboprophylaxis for surgical patients is discussed in detail separately. (See "Prevention of venous thromboembolic disease in surgical patients" and "Overview of
preoperative evaluation and preparation for gynecologic surgery", section on 'Thromboprophylaxis'.)
Prophylactic antibiotics — A prophylactic antibiotic to prevent surgical site infection is given as a single intravenous (IV) for abdominal hysterectomy; appropriate antibiotic
agents are shown in the table (table 2).
Prevention of gynecologic surgical site infection is discussed in detail separately. (See "Overview of preoperative evaluation and preparation for gynecologic surgery", section on
'Surgical site infection prevention'.)
Women undergoing hysterectomy do not require antibiotic prophylaxis of bacterial endocarditis, in the absence of high risk conditions indications. (See "Antimicrobial prophylaxis
for bacterial endocarditis", section on 'Clinical approach'.)
Bacterial vaginosis treatment — For women with bacterial vaginosis, treatment of bacterial vaginosis for eight days, starting four days before surgery can reduce the
frequency of vaginal cuff infection in a randomized trial [3,4]. (See "Bacterial vaginosis", section on 'Gynecologic procedures'.)
OPERATIVE TECHNIQUE
Patient positioning and sterile preparation — The initial steps after a patient enters the operating room include:
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Position in the dorsal supine or lithotomy position (preferred by some surgeons so that a second assistant can stand between the patient's legs)
Perform an examination under anesthesia (helps to confirm pelvic findings and guide the final choice of incision) (see "Pelvic examination under anesthesia")
Insert Foley bladder catheter
Perform sterile preparation of the abdomen and vagina
Place surgical draping.
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It is not necessary to remove hair at the planned incision site. If hair is removed, it should be clipped rather than shaved, as patients who are shaved appear to be more likely to
develop surgical site infection. (See "Adjunctive measures for prevention of surgical site infection in adults", section on 'Hair removal'.)
Skin preparation had traditionally been accomplished with a preoperative shower, then a scrub with bactericidal soap in the operating room, followed by application of a longacting bactericidal agent. However, high quality data do not support a benefit from preoperative washing with or without antiseptic solutions. Also, there appears to be no added
benefit from a bactericidal scrub in the operating room performed in addition to preoperative povidone-iodine preparation of the abdomen. In addition, the use of an adhesive
plastic drape over the incision site, including iodine-impregnated drapes, does not reduce the risk of surgical site infection. (See "Adjunctive measures for prevention of surgical
site infection in adults", section on 'Skin antisepsis'.)
Vaginal preparation is generally performed using a povidone iodine solution. However, there are few studies evaluating the effect of vaginal preparation on the risk of surgical
site infection prevention. (See "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Vaginal preparation'.)
Incision and exploration — The skin incision may be transverse or midline vertical and is determined by a variety of factors, such as presence of prior surgical scar, need for
exploration of the upper abdomen, size and mobility of the uterus, and desired cosmetic results. If a prior incision exists, most surgeons prefer to use this incision. If the prior
scar is cosmetically unacceptable, it may be excised at the beginning or end of the procedure. This is easily accomplished by elevating the old scar with Allis clamps and making
an elliptical incision around the old scar. (See 'Choice of incision' above and "Incisions for open abdominal surgery".)
The peritoneal cavity is entered and the upper abdomen and pelvis explored for unexpected pathology and to confirm preoperative findings. Peritoneal washings may be
collected for cytologic analysis if a malignancy is suspected.
Exposure — Most surgeons prefer to use a self-retaining retractor for an abdominal hysterectomy, although use of hand held retractors is an option. The type of self-retaining
retractor used depends on surgeon preference. With very large masses, it is often impossible to place a retractor until the mass has been mobilized and freed from adhesions.
(See "Surgical instruments for gynecologic surgery", section on 'Retractors'.)
When positioning retractors, it is important to avoid placing the lateral blades over a femoral nerve as it emerges lateral to the psoas muscle, since this can lead to a peripheral
neuropathy. Surgical personnel should not lean on the retractors for the same reason. Safe placement is assured by lifting the abdominal wall as the retractor is placed, and then
checking to be sure no bowel has been trapped beneath a blade and that the blade is not pressing on the side wall of the pelvis. (See "Nerve injury associated with pelvic
surgery".)
Adhesiolysis — If pelvic or intraabdominal adhesions are present, it is important to mobilize the pelvic organs by dividing omental, intestinal, or abdominal wall adhesions.
Restoring normal anatomy allows for visualization of important pelvic structures (eg, ureter, blood vessels).
Round ligament ligation — Traditionally, a large Kelly clamp is placed across each uterine cornu (fallopian tube and round ligament are included in the clamp). This allows
uterine elevation and prevents back bleeding when the round ligaments are divided (figure 3 and figure 4). An alternative technique, which is essentially identical to the
technique used at laparoscopic procedures, may be more time efficient. Using this approach, the round ligament is clamped and divided using electrosurgery. The
electrosurgical device can then be used to open the anterior peritoneum and mobilize the bladder, and to incise the lateral peritoneum without adding extra time to change
instruments.
A common error is to divide the round ligament too close to the uterus, which limits exposure in the broad ligament and makes incision of the peritoneum over the broad ligament
more difficult. The round ligament is best divided at its mid portion, or more laterally, and then the ligament can be easily lifted to facilitate peritoneal dissection and division.
Broad ligament dissection — The incision in the round ligament is then carried inferiorly through the peritoneum of the broad ligament to the level of the uterine artery, and
then medially along the vesicouterine fold, separating the bladder peritoneum from the lower uterine segment (figure 5).
The retroperitoneum is entered by extending the incision on the posterior leaf of the broad ligament superiolaterally, remaining lateral to both the infundibulopelvic ligament and
iliac vessels. Blunt or sharp dissection clears the loose connective tissue overlying the external iliac artery. The perivesical space and perirectal space can be created at this
time.
The perivesical space is lateral to the bladder, and medial to the external iliac vessels. It is an avascular space created by sharp or blunt dissection that extends down to the
levator ani muscles. The superior vesicle artery is at medial border.
The perirectal space is between the ureter and iliac vessels, is also avascular, and extends down to levator ani muscles. If you create both spaces, placing an index finger into
the perivesical space and the middle finger into the perirectal space will give you the parametrium between your fingers. These spaces delineate the pelvic vasculature and
ureter well.
By following the external iliac artery superiorly to its bifurcation, the ureter can be identified as it crosses the common iliac artery. The ureter is left attached to the medial or
posterior leaf of the broad ligament so as not to disrupt its blood supply (figure 6). The left ureter is always more medial than the right and deeper in the pelvis along the posterior
peritoneum.
Avoiding ureteral injury — For most women undergoing gynecologic surgery, we recommend not using prophylactic ureteral stents. We find ureteral identification and
dissection, if necessary, is adequate for ureteral protection. There are those who suggest use of prophylactic stents for women with severe endometriosis or a history pelvic
irradiation, but we have not found this helpful in our practice. (See "Urinary tract injury in gynecologic surgery: Prevention", section on 'Prophylactic ureteral catheters'.)
We prefer to open the retroperitoneum and visualize the ureter on the posterior leaf of the broad ligament peritoneum to prevent ureteral injury. If palpation alone is used, the
internal iliac artery, ovarian vessels, and vessels of the broad ligament are easily confused with the ureter. The visualization of ureteral peristalsis confirms its identity.
Additionally, when the vesicouterine space is developed, the bladder is displaced inferiorly to laterally displace the ureters. In some women, the ureter is as little as 5 mm from
the uterine artery, and reflecting the bladder downward prior to dividing the uterine artery will slide the ureter laterally, providing more space for placement of clamps.
There is no space between the infundibulopelvic ligaments where they cross the ureter, and clamping down to get these vessels can risk damage to the ureter. Elevating the
infundibulopelvic ligaments prior to division creates a space between the ureter and ovarian vessels and ensures that the ureter is not included in the clamp.
Ureteral identification is particularly important if the patient has had prior pelvic surgery. If the patient has extensive pelvic disease, we dissect the ureter down toward the
bladder until optimal visualization is achieved.
Adnexal conservation or removal
Conserving ovaries and tubes — If the ovaries are to be conserved, with the ureter under direct vision, an opening is created in the posterior leaf of the broad ligament
under the utero-ovarian ligament and fallopian tube (figure 7). The utero-ovarian ligament is clamped, cut, and ligated with a free tie followed by a suture ligature (placed just
medial to the free tie). The medial large Kelly clamp at the uterine cornu will control back bleeding.
It is our practice to use measures to prevent the ovaries and fallopian tubes from adhering to the vaginal apex (a possible cause of dyspareunia). Some surgeons place a suture
through the stump of the utero-ovarian ligament and then sew the stump to the psoas muscle or to the round ligament stump using an absorbable suture [5]. Alternatively, the
bilateral utero-ovarian stumps may be sutured together in the midline. There is no evidence that this decreases the risks of dyspareunia following hysterectomy.
Salpingo-oophorectomy — If the ovaries are to be removed, the broad ligament opening is extended superiorly to the infundibulopelvic ligament. A curved clamp is placed
lateral to the ovary, making certain that the entire ovary is included in the surgical specimen (figure 8). This is facilitated by elevating the infundibulopelvic ligament and creating
a generous space in the posterior pelvic peritoneum between the ureters and vessels. Each infundibulopelvic ligament is cut and ligated with a free tie followed by a suture
ligature (placed just medial to the free tie) (figure 9). Tying the pedicle before suturing it prevents formation of an expanding hematoma through inadvertent puncture of the
ovarian vessels. Sutures on vascular pedicles should not be used to elevate the pedicle, as this may compromise knot strength and hemostasis.
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Perivesical and perirectal dissection — It is beneficial to dissect the perivesical and perirectal spaces to separate the bladder and rectum from the uterus, thereby avoiding
injury of these organs. Developing these spaces is particularly important if there is distortion of anatomy by pelvic pathology (eg, endometriosis, pelvic inflammatory disease,
prior surgery). Identification and mobilization of the structures which surround the uterus allow prompt identification and control of any problems encountered intraoperatively.
(See "Complications of gynecologic surgery" and "Urinary tract injury in gynecologic surgery: Prevention".)
The bladder is dissected off the lower uterine segment and cervix (figure 10). An avascular plane exists between the lower uterine segment and bladder, which allows for its
mobilization. We prefer sharp dissection, as the use of a blunt dissection with a sponge stick may lead to a cystostomy, particularly if there has been prior surgery (eg, cesarean
delivery). In addition, an incision into the bladder is more easily repaired than a tear from blunt dissection. After this dissection, a lap sponge can be placed beneath the bladder
retractor to tamponade any small bleeding vessels.
If the rectum requires mobilization from the posterior cervix, the posterior peritoneum between the uterosacral ligaments just beneath the cervix and rectum is incised. A
relatively avascular tissue plane exists in this area, which allows mobilization of the rectum inferiorly out of the operative field (figure 11).
Uterine vessel ligation — Sharp dissection is used to skeletonize the uterine vessels, removing any loose overlying connective tissue. This allows visualization of the uterine
vessels, thereby ensuring that clamps are placed on these vessels and not on the ureter (as it passes below the uterine vessels). As noted previously, the bladder is reflected
inferiorly with sharp dissection prior to dividing the uterine arteries.
A curved clamp is placed perpendicular to the uterine artery at the junction of the cervix and lower uterine segment. Care is taken to place the tip of the clamp adjacent to the
uterus at this site of anatomic narrowing (figure 12). The uterine artery is cut and ligated. Some surgeons place two curved clamps and ligate the uterine artery twice. Given the
proximity of the ureter to the uterine artery, we prefer single clamping. The same procedure is then carried out on the opposite side.
To control back bleeding and aid visualization, a large Kelly can be placed immediately adjacent to the uterus on each side, incorporating the attachments of the tube, ovarian
ligament and round ligament, extending down to the level of the uterine artery. Once placed, the clamp is not removed until the uterus is amputated.
The cardinal ligament and any remaining broad ligament are divided by placing a straight clamp medial to the uterine vascular pedicle and parallel to the cervix for a distance of
2 to 3 cm. The pedicle is cut and ligated with a suture ligature (figure 13). The number of bites needed to reach the vagina can vary depending on the length of the cervix.
Use of electrosurgery — An alternative to suture ligation of vascular pedicles is use of electrocautery coagulation [6]. Use of this approach for hysterectomy requires a
device that can achieve hemostasis in large vessels. As an example, the Ligasure™ bipolar sealing device can be used in vessels up to 7 mm in diameter.
However, there are no data that show that use of this device for abdominal hysterectomy improves surgical outcomes. Two small randomized trials (n = 30 and 57) that
compared the use of Ligasure in abdominal hysterectomy with traditional suture ligature found no benefits regarding operative time, blood loss, or complication rate [7,8];
however, they were underpowered to detect clinically significant differences. Postoperatively, one study found that pain scores during the first three days after surgery were
reduced by more than 20 percent with use of Ligasure™ [7]; postoperative outcomes were not assessed in the other study. (See "Overview of electrosurgery", section on
'Ligasure device'.)
Cervical amputation or removal — At this point in a hysterectomy for benign indications, if a large uterus is impeding visualization or a supracervical hysterectomy is planned,
the cervix can be amputated and the uterus removed.
Supracervical (subtotal) hysterectomy — If a supracervical hysterectomy is planned, the cardinal and broad ligaments are clamped until a point is reached midway
between the level of the internal and external cervical ostia. The cervix is then amputated with a scalpel or cautery. Care is taken to avoid injury to surrounding structures.
To avoid continued cyclical bleeding from retained lower uterine segment endometrium, some surgeons will cauterize or resect the endocervix [9]. Resection can be done with
an electrocautery loop.
The cervical stump is then closed with a size 0 absorbable suture in a running or interrupted fashion. Some surgeons will cover the stump with peritoneum. Comparison of total
and supracervical hysterectomy is discussed separately. (See "Overview of hysterectomy", section on 'Total versus subtotal (supracervical)'.)
Total hysterectomy — If a surgeon is proceeding with a total hysterectomy, the cardinal and broad ligaments are clamped, cut and ligated bilaterally until the level of the
external cervical os is reached. A series of pedicles may be required depending upon the size of the uterus.
To remove the cervix, the uterus is pulled cephalad and the tip of the cervix is palpated. Care should be taken to avoid foreshortening the vagina.
● Extrafascial technique — This is the most commonly used approach to total abdominal hysterectomy [10]. The cervicovaginal junction at the level of the external cervical os
is palpated, and an incision is made, entering the vaginal apex. A circumferential vaginal incision is made with the Jorgenson scissors, amputating the cervix and uterus.
● Intrafascial technique — This technique may preserve the neurovascular supply at the cervicovaginal junction by preserving the pubovesicocervical fascia [10]. Transverse
incisions are made on the anterior and posterior surfaces of the cervix, below the level of the uterine vasculature. The pubovesicocervical fascia is then dissected off the
lower uterine segment and cervix with the handle of the scalpel or with gauze-covered index finger. Care is taken to avoid incising too deeply into the cervix, as the loose
fascial plane would be missed, causing the dissection to be difficult and bloody. A curved Heaney clamp is placed inside the fascia on each side of the uterus to incorporate
the uterosacral ligaments and upper vagina just below the cervix (figure 14). The vagina is incised and the cervix and uterus are then resected using heavy curved scissors
(figure 15).
Treatment of the vaginal cuff — Numerous techniques have been described for management of the vaginal cuff closure. Randomized trials have found no difference in
postoperative infectious morbidity with an open or closed cuff technique [11,12]. Three methods are described below:
● Kocher clamps are placed bilaterally at the cuff angles. A figure-of-eight suture of 0 or 2-0 gauge synthetic absorbable suture is placed in the midline. This suture is used
for both traction and hemostasis. Sutures are then placed at the tip of each clamp and the angle pedicle is transfixed with the suture ligature. This suture incorporates the
uterosacral and cardinal ligament at the angle of the vagina (figure 16). Additional figure-of-eight sutures are placed along the cuff to close gaps and ensure hemostasis.
● An alternative approach minimizes blood loss and avoids spillage of vaginal content into the peritoneal cavity; however, the vaginal length is somewhat shortened [13]. Two
Munion or curved Heaney clamps are placed from lateral to medial at the level of the external cervical os; care is taken to avoid incorporating bladder tissue in the clamps.
The cervix is amputated with a scalpel or scissors. (Note that this is a variation from the procedure for removing the cervix described above) (see 'Total hysterectomy'
above). Using a size 0 absorbable suture, a running stitch is placed from medial to lateral on each side, oversewing the clamp (the suture ends are left untied and long).
The clamps are then removed and the sutures pulled tight. Continuing with the same needle, a running, locked stitch is placed from lateral to medial on each side, and then
tied in the midline.
● Some surgeons prefer to leave the cuff open to heal secondarily. If this method is used, a running suture is used for hemostasis along the cuff edge and the peritoneal
defect superior to the cuff is sutured closed. There appears to be no difference in postoperative febrile morbidity whether the vaginal cuff is closed or remains open [14].
Apical prolapse prevention — The association between hysterectomy and subsequent pelvic organ prolapse is controversial. Experts agree that the vaginal apex should be
suspended at the time of hysterectomy to minimize subsequent apical support loss. However, the optimal technique for suspension is not known.
Common techniques for vaginal apex suspension include: intrafascial hysterectomy (to preserve the uterosacral-cardinal ligament complex) and incorporating the uterosacral
ligaments into the vaginal cuff angle at the time of closure [15-17]. However, as there are no high quality data evaluating these approaches in abdominal hysterectomy, clinical
decisions are based on individual surgeon experience. (See "Vaginal hysterectomy", section on 'Closure'.)
A full discussion of hysterectomy and pelvic organ prolapse can be found separately. (See "Overview of hysterectomy", section on 'Outcome'.)
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Final examination and closure — The pelvis is thoroughly irrigated with warm saline or Ringer's lactate solution. Meticulous hemostasis at all pedicles is confirmed. The
bladder and ureters are inspected.
Strategies to prevent postoperative adhesions include meticulous surgical technique (ie, hemostasis and minimal tissue handling) and the application of anti-adhesive barriers.
(See "Postoperative peritoneal adhesions in adults and their prevention".)
It is not necessary or desirable to reapproximate the visceral or parietal peritoneum [18]. The fascia and skin are reapproximated in standard fashion. (See "Complications of
abdominal surgical incisions".)
SPECIAL CIRCUMSTANCES — In technically difficult surgeries, all pelvic surgeons, no matter their experience level, occasionally benefit from assistance.
Malignancy — Prior to surgery, patients should have standard screening tests and, if symptoms are present, appropriate evaluation to exclude gynecologic cancer or other
malignancies which commonly metastasize to the pelvis (eg, breast, stomach, colorectal). (See "Screening for breast cancer: Strategies and recommendations" and "Screening
for cervical cancer: Rationale and recommendations" and "Screening for colorectal cancer: Strategies in patients at average risk" and "Epithelial carcinoma of the ovary, fallopian
tube, and peritoneum: Clinical features and diagnosis", section on 'Excluding an extraovarian primary cancer'.)
For patients in whom diagnosis or treatment of a malignancy is the indication for surgery, informed consent and preparation are made for staging and initial surgical
management. (See "Invasive cervical cancer: Staging and evaluation of lymph nodes" and "Endometrial carcinoma: Pretreatment evaluation, staging, and surgical treatment"
and "Uterine sarcoma: Classification, clinical manifestations, and diagnosis" and "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Clinical features and
diagnosis".)
In cases where an unsuspected malignancy is discovered at time of surgery, management depends upon the type of cancer and experience level of the surgeon. Intraoperative
consultation from a gynecologic oncologist should be requested if available. Staging procedures performed by a gynecologic oncologist appear to lead to better patient
outcomes [19].
If a gynecologic oncologist is not available and a surgeon is not experienced in operative management of the cancer (eg, lymphadenectomy, radical hysterectomy), it is prudent
to close the patient and arrange for prompt consultation with a specialist for a second procedure. As an example, in a patient with cervical cancer, a standard versus radical
hysterectomy will worsen prognosis.
Large uterus — A large leiomyomatous uterus (typically defined as ≥16 weeks' size or 350 gm) may limit the choice of skin incision and may result in increased intraoperative
blood loss [20,21]. It is generally possible to remove a uterus that is ≤16 gestational week-size (fundus midway between the pubic symphysis and the umbilicus) through a
transverse incision (Pfannenstiel, Cherney, or Maylard). While some surgeons will remove a large uterus through a transverse incision [22], many prefer to use a midline vertical
incision. In addition, the incision may need to be extended above the umbilicus if a uterus is 20 gestational weeks-size (fundus at the umbilicus) or larger [23]. Removal of a very
large uterus is associated with concealed blood loss (ie, volume of blood contained within the uterus). Awareness of this facilitates fluid and blood replacement, and can help
with resuscitation in the immediate postoperative period.
Preoperative GnRH analogues — Uterine size can be reduced with preoperative treatment for three to four months with gonadotropin-releasing hormone (GnRH)
analogues, and may permit a transverse rather than a midline vertical incision (or a vaginal approach) [24]. Benefits regarding intraoperative hemorrhage and operating time are
minimal.
A systematic review of randomized trials of women undergoing hysterectomy, reported the following findings for patients pretreated with GnRH analogues versus either no
treatment or placebo [24]:
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Preoperative hematocrit was increased (3.1 percent, 95% CI 1.8-4.5)
Uterine size was decreased (-2.2 gestational weeks, 95% CI -2.3 to -1.9)
Proportion of vertical incisions was reduced (OR 0.36, 95% CI 0.2-0.6)
Intraoperative blood loss was decreased (-58 ml, 95% CI -75.7 to -40.3)
Duration of surgery was decreased (-5.2 minutes, 95% CI -8.6 to -1.8)
Duration of hospital stay was shorter (-1.1 days, 95% CI -1.2 to -0.9)
Intraoperative vasopressin — Blood loss from a leiomyomatous uterus can be decreased by using intramyometrial (IMM) vasopressin [20]. A randomized trial assigned
women with uterine fibroids who were undergoing abdominal hysterectomy to vasopressin (5 mL IMM, 10 units in 10 mL normal saline) or normal saline. Injections were made
bilaterally, 1 cm medial to the uterine vessels in the most inferior area of the lower uterine segment that did not reach the bladder. If this site was obstructed, the midline at the
fundus was used. Mean total blood loss was significantly lower with use of vasopressin compared to normal saline (445 versus 748 mL).
Emergency or unplanned hysterectomy — An unplanned or emergency hysterectomy may need to be performed in certain clinical circumstances (eg, acute uterine bleeding,
conversion from another planned gynecologic procedure), if all alternative medical and surgical measures have been exhausted. In such cases, it may not be possible to
complete a full preoperative evaluation and consent process. Discussion with, and notification of, a family member or friend may be appropriate, depending upon patient consent
for disclosure of medical information to this person. (See "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Informed consent and
patient expectations'.)
Emergency situations require meticulous and efficient surgical technique. Communication with members of the surgical team (eg, anesthesiologist, nurses, scrub technicians)
regarding anticipated need for blood products, surgical equipment, and postsurgical care (eg, intensive care) is of critical importance. It is optimal to have an experienced first
assistant.
A midline vertical abdominal incision provides the best exposure and can be easily extended superiorly. This may be useful, particularly in cases where preoperative examination
and imaging are limited. Hemostasis should by achieved quickly by ligating the ovarian and uterine vessels as soon as it is safely possible to do so [23].
Obesity — Incision placement in the overlapping fold of a panniculus should be avoided. Panniculectomy makes the surgical procedure much easier to perform, but may require
a long period to time postoperative for complete wound healing. (See "Incisions for open abdominal surgery", section on 'Special considerations for obese patients' and
"Complications of abdominal surgical incisions", section on 'Panniculectomy'.)
Exposure may be more challenging in an obese patient. A surgeon who usually uses a smaller self-retaining retractor may choose to use a larger retractor in obese patients (eg,
Bookwalter retractor). Oversized laparotomy pads exist and are ideal in obese patients. They are easier to place and allow the use of fewer pads. The combination of obesity
and a deep pelvis is particularly challenging. Long instruments will be required, most ties will require use of a pass, and exposure of the cardinal ligaments can be challenged.
Exposure can be aided by placing one or more wet lap pads high in the vagina prior to beginning surgery. This elevates the uterus and makes the surgical procedure much
easier. The pads are tagged with a long clamp and removed by an assistant prior to closing the vaginal cuff.
Mass fascial closure (incorporating the fascia along with a small amount of subcutaneous fat, rectus muscle, rectus sheaths, and peritoneum) may reduce the risk of wound
dehiscence in obese patients. Also, closure of the subcutaneous layer in obese patients reduces the risk of superficial wound disruption according to randomized trials. Similarly,
the use of a subcutaneous drain may decrease wound disruption risk, however, this has not been confirmed. If drains are used, they are closed suction systems and not placed
through the incision. (See "Principles of abdominal wall closure", section on 'Mass closure' and "Principles of abdominal wall closure", section on 'Subcutaneous' and
"Complications of abdominal surgical incisions".)
COMPLICATIONS — The rate of unintended major surgical procedures after AH, such as intraoperative injury to intraabdominal organs requiring repair or return to the
operating room within eight weeks postoperatively, is approximately 0.3 to 0.7 percent [25,26]. Incidence and management of complications specific to AH are discussed here
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(table 3). Complications associated with other approaches to hysterectomy or general complications of gynecologic surgery are reviewed separately. (See "Vaginal
hysterectomy" and "Laparoscopic hysterectomy" and "Radical hysterectomy" and "Complications of gynecologic surgery".)
The following three large studies illustrate the frequency of complications associated with abdominal hysterectomy performed for benign indications:
● In the United Kingdom, the VALUE study (Vaginal, Abdominal, or Laparoscopic Uterine Excision) included over 37,000 hysterectomies performed from 1994 to 1995 for
benign disease; over 24,000 of the procedures were performed abdominally [25]. The crude rates for severe intraoperative and postoperative complications for AH were
3.6 and 0.9 percent, respectively. The risk of severe complications was significantly lower in abdominal versus laparoscopic procedures (4 versus 6 percent). Severe
complications were defined as death, thromboembolism, myocardial infarction, stroke, renal failure, severe infection, secondary hemorrhage, fistula, ureteral obstruction,
and visceral damage.
● The eVALuate trial was a concurrent pair of large multicenter randomized trials of hysterectomy in women with benign disease [26]. One trial included 292 women assigned
to AH and 584 women assigned to laparoscopic hysterectomy; the other arm compared vaginal with laparoscopic hysterectomy. Women were excluded from participation if
they had 2nd or 3rd degree prolapse, required bladder or pelvic support surgery, a uterine size larger than 12 weeks, or a contraindication to laparoscopic surgery. In the
abdominal trial, the number of patients with at least one major complication was significantly less in abdominal than laparoscopic hysterectomy (6 versus 11 percent). The
most common major complications of AH were hemorrhage (2 percent), bladder injury (1 percent), and bowel injury (1 percent). The major findings from this trial are shown
in the table (table 4). (See "Laparoscopic hysterectomy".)
● A retrospective study of gynecologic hospital inpatients in England included over 61,000 elective abdominal hysterectomies [27]. The rate of emergency readmissions
within 30 days postoperatively was 5.7 percent.
Hemorrhage — Average intraoperative blood loss is 300 to 400 mL [28,29]. Excessive bleeding complicates approximately 2 percent of abdominal hysterectomies [25,30]. In a
systematic review of randomized trials, blood loss was slightly less (85 mL) in subtotal compared with total hysterectomy; no difference was found in risk of requiring blood
transfusion [31].
● Evaluation and management — Careful inspection of all pedicles before abdominal closure is the best method to prevent intraoperative and postoperative hemorrhage.
Postoperative hemorrhage may be plainly visible, in the case of bleeding from the vagina or wound. Intraabdominal bleeding should be suspected if hemodynamic
alteration or oliguria develop. (See "Management of hemorrhage in gynecologic surgery".)
Each bleeding site is approached differently in evaluation and treatment, but all involve prompt stabilization of vital signs, laboratory evaluation of hematocrit, platelets, and
clotting parameters (prothrombin time, activated partial thromboplastin time, and fibrinogen), fluid and blood product replacement, and constant surveillance of the patient's
condition.
The patient should be taken promptly to an examining room to inspect the operative site, the abdomen, and the vaginal cuff. Bleeding from the vaginal cuff can usually be
sutured in the examination room.
Intraabdominal bleeding should be evaluated in the operating room. An intraperitoneal hematoma in a stable patient can be managed either expectantly or with surgical
exploration. A patient who does not stabilize rapidly with fluid and blood product replacement requires surgical exploration.
If diffuse bleeding is encountered and clotting parameters confirm a coagulopathy, appropriate replacement of blood products and medical therapy are initiated. (See "Clinical
features, diagnosis, and treatment of disseminated intravascular coagulation in adults".)
In some patients, radiographic embolization of the hypogastric vessels may be attempted in addition to, or in place of, surgery. (See "Interventional radiology in management of
gynecological disorders".)
Infection — Approximately 11 percent of women undergoing AH without antibiotic prophylaxis develop fever or infection [31,32]. However, in a large prospective study, patients
undergoing AH selectively received prophylactic antibiotics (79 percent of patients); the following sites of infection were identified: urinary tract (4 percent), wound (3 percent),
unknown fever (3 percent), vaginal infection (0.2 percent), and intraabdominal (0.1 percent) [30]. Prompt catheter removal postoperatively may reduce the risk of urinary tract
infection [33].
● Evaluation and management — Evaluation of a postoperative patient with an oral temperature above 100.4ºF (38ºC) includes examination of potential sites of infection (eg,
lungs, abdomen, wound, vagina) and appropriate laboratory evaluation. Evaluation of postoperative fever is discussed separately (see "Postoperative fever" and
"Complications of gynecologic surgery", section on 'Infectious morbidity').
Most women will have an increase in cul-de-sac or other peritoneal fluid following hysterectomy. The importance of these fluid collections is uncertain. If a fluid collection is found
in a patient who is febrile despite antibiotic therapy, it may be drained either percutaneously or the vaginal cuff can be opened using a Kelly clamp or uterine dressing forceps.
Pelvic or ovarian vein thrombophlebitis may be detected on computed tomography (CT) or suspected clinically, and may require the addition of heparin to antibiotics. In these
patients, the heparin may be discontinued when the patient becomes afebrile for 24 hours; warfarin is not indicated. (See "Septic pelvic thrombophlebitis".)
Thromboembolic disease — Without thromboprophylaxis, the risk of deep vein thrombosis in patients after major general or gynecologic surgery is 15 to 30 percent; the risk of
fatal pulmonary embolism is 0.2 to 0.9 percent [34]. In a population of patients who selectively received prophylactic anticoagulants (38 percent of patients), the rate of venous
thromboembolism was 0.2 percent [30].
● Evaluation and management — A postoperative patient who develops localized tenderness, asymmetric swelling in an extremity, dyspnea, pleuritic pain, tachypnea or
tachycardia should be evaluated for venous thromboembolism. (See "Diagnosis of suspected deep vein thrombosis of the lower extremity" and "Diagnosis of acute
pulmonary embolism".)
Urinary tract issues — Suspected intraoperative ureteral injury should be evaluated and, if present, repaired. Postoperatively, ureteral injury may be asymptomatic or may
present as flank or groin pain, fever, prolonged ileus, or abdominal mass. Urinary tract injury in gynecologic surgery is discussed separately. (See "Urinary tract injury in
gynecologic surgery: Evaluation and management".)
Ureteral injury — In a retrospective study including over 62,000 hysterectomies, the total incidence of ureteral injury after all hysterectomies was 1.0 of 1000 procedures:
13.9 of 1000 after laparoscopic, 0.4 of 1000 after total abdominal, 0.3 of 1000 after supracervical abdominal, and 0.2 of 1000 after vaginal hysterectomy [35]. Injury detection
rates may be higher with routine use of cystoscopy [36].
Bladder injury — The incidence of bladder injury in AH is 0.02 to 1 percent [26,30,35]. Bladder injury may occur upon opening the peritoneum or, more frequently, during
dissection of the bladder off the lower uterine segment, cervix, and upper vagina.
Urinary incontinence — The role of hysterectomy in subsequent urinary incontinence is controversial. A full discussion of this topic can be found separately. (See "Overview
of hysterectomy", section on 'Complications'.)
Gastrointestinal tract issues
Bowel injury — Bowel injuries occur in approximately 0.2 to 1 percent of cases [26,30]. These injuries occur primarily during lysis of adhesions involving bowel or dissection
of the posterior cul-de-sac (pouch of Douglas).
● Management — Serosal abrasions do not need repair, but injuries involving the muscularis and/or mucosa should be repaired. In large bowel injury, lack of preoperative
bowel prep is not by itself an indication for colostomy. (See "Complications of gynecologic surgery", section on 'Bowel injury'.)
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There are no postoperative dietary restrictions unless the bowel injury and repair involved a large area. We do not use a nasogastric tube postoperatively.
Ileus — Ileus is common following abdominal surgery. This is discussed in detail separately. (See "Postoperative ileus".)
Bowel obstruction — The risk of bowel obstruction after AH was 13.6/1000 in a multihospital series of small bowel obstruction due to intraabdominal adhesions in nononcologic patients [37]. The median interval between hysterectomy and small bowel obstruction was four years.
● Evaluation and management — The most common symptoms of small bowel obstruction are abdominal distention, vomiting, crampy abdominal pain, and inability to pass
flatus. Patients may or may not complain of obstipation and inability to pass flatus since the colon requires 12 to 24 hours to empty after the onset of bowel obstruction. As
a result, flatus and even passage of feces may continue after onset of symptoms. (See "Epidemiology, clinical features, and diagnosis of mechanical small bowel
obstruction in adults".)
The diagnosis can be made by history and physical examination in the majority of patients. Plain abdominal radiography is used to confirm the diagnosis; in most patients, no
further radiologic tests are needed.
Management of small bowel obstruction is discussed in detail separately. (See "Overview of management of mechanical small bowel obstruction in adults".)
Vaginal cuff dehiscence — Evisceration of the small intestine into the vagina is a rare complication; eviscerated bowel can become incarcerated. In a large retrospective study,
the risk of vaginal cuff dehiscence after AH was 0.12 percent [38].
Eviscerations usually occur in the early postoperative period, although in one series of 12 patients after various pelvic surgeries, the mean time of occurrence was 27 months
(range 5 to 48 months) [39]. Symptoms include abdominal or pelvic pain, vaginal bleeding or discharge, vaginal pressure, or protrusion of bowel.
Management of vaginal cuff dehiscence is discussed separately. (See "Vaginal cuff dehiscence after hysterectomy".)
Adhesions — Postoperative adhesion formation is a common cause of small bowel obstruction and may contribute to pelvic or abdominal pain. However, adhesiolysis does not
appear to be an effective treatment for symptomatic patients. (See "Treatment of chronic pelvic pain in women", section on 'Adhesions'.)
● Prevention — Meticulous surgical technique is the first defense against adhesion formation. Physical barriers may also prevent adhesion formation associated with
laparotomy. (See "Postoperative peritoneal adhesions in adults and their prevention".)
Reproductive system
Earlier menopause — Hysterectomy appears to impair ovarian function over the long-term, at least in some women, so that menopause occurs earlier. (See "Overview of
hysterectomy", section on 'Earlier menopause'.)
Fallopian tube prolapse — Posthysterectomy prolapse of the fallopian tube is an uncommon complication often confused with granulation tissue at the vaginal apex.
Development of a hematoma or abscess at the vaginal apex is a predisposing factor. A patient with tubal prolapse generally presents with one or more of the following: vaginal
bloody discharge and/or leukorrhea, dyspareunia, and persistent pelvic pain [5]. These symptoms usually arise in two weeks to six months postoperatively, but can appear
several years after surgery.
If the tissue at the top of the vaginal cuff does not respond to conservative treatment, such as silver nitrate application or cryotherapy, a biopsy of the area can be done to
confirm tubal epithelium. Treatment is surgical; the surrounding vaginal epithelium is opened and widely undermined, and the tube is resected. Concurrent laparoscopy may be
helpful [5].
Cardiovascular disease — A large nested cohort study found that hysterectomy was not associated with a significantly altered risk of mortality from cardiovascular disease,
cancer, or all causes [40]. There was no adjustment for oophorectomy. (See "Determinants and management of cardiovascular risk in women", section on 'Hysterectomy'.)
Mortality — A retrospective study of hospital admissions in England included over 61,000 elective abdominal hysterectomies, the mortality rate was 0.5 per 1000 [27]. Similarly,
in the VALUE study of over 24,000 abdominal hysterectomies performed for benign conditions described above, eight deaths were reported within six weeks of AH (mortality
rate 0.32 per 1000 procedures); four deaths were due to either cardiac events or pulmonary embolism [25]. No deaths occurred intraoperatively and six deaths occurred before
hospital discharge. In addition, data for abdominal hysterectomy from the 1998 to 2010 United States Nationwide showed a mortality rate of 0.17 percent [41].
The mortality rate, standardized for age and race, is higher for hysterectomies associated with pregnancy or cancer than for procedures not associated with these conditions
(2.9, 3.8, and 0.6 per 1000 procedures, respectively); 61 percent of deaths occurred among women with these conditions [42]. Since almost all hysterectomies performed during
pregnancy or for cancer are done abdominally, this contributes to the higher mortality rate of AH compared to the vaginal procedure (15 versus 4 per 10,000 procedures) [42].
The types of pelvic pathology (eg, severe endometriosis, tubo-ovarian abscess, large tumors) for which the abdominal route is undertaken also contribute to the higher mortality
of this procedure.
INPATIENT POSTOPERATIVE CARE — The average length of hospital stay after AH in the United States is three days [43]. Routine postoperative care includes monitoring of
a patient's hemodynamic and fluid status, pain control, and reintroducing normal diet and activity. Evidence-based specifics of postoperative care are discussed below.
Postoperative pain is managed initially with parenteral administration of analgesics. Patient-controlled anesthesia is an option. This is transitioned to the oral route when a
patient can tolerate oral intake, usually on the first postoperative day. (See "Management of postoperative pain".)
The bladder catheter can be removed during the first 24 hours postoperatively. A systematic review of randomized trials was conducted regarding use of urinary catheterization
after urogenital surgery in adults [44]. Fewer urinary tract infections resulted when a catheter was removed after one versus three days (RR 0.50, 95% CI 0.29-0.87). Also,
decreased risk of recatheterization was associated with use of a postoperative catheter versus no catheter, as well as with a suprapubic catheter versus a urethral catheter.
However, placement of a suprapubic catheter involves an additional incision. (See "Placement and management of urinary bladder catheters".)
Postoperative colonic stasis after major abdominal surgery lasts approximately three days, but does not typically require nasogastric decompression or preclude early feeding
[45]. In fact, early feeding of a regular diet can stimulate the bowel and decrease the length of hospitalization, although emesis is common. Early feeding is efficacious, even in
cases in which there has been extensive bowel manipulation or resection.
Preventive measures are appropriate for patients at high risk of postoperative pulmonary complications. All patients are also encouraged to ambulate as soon as is feasible.
(See "Strategies to reduce postoperative pulmonary complications".)
Management of specific postoperative complications is discussed in this and in separate topic reviews. (See 'Complications' above and "Postoperative fever" and "Complications
of abdominal surgical incisions".)
FOLLOW-UP
Discharge instructions — A woman is encouraged to resume her normal daily activities as quickly as is comfortable. She may return to work as soon as she has regained
sufficient stamina and mobility.
We ask that patients avoid heavy lifting (>13 pounds of weight from the floor) for four to six weeks to minimize stress on the healing fascia. We advise that if the patient cannot
easily lift an object with one hand, she should ask for help. (See "Complications of abdominal surgical incisions", section on 'Fascial dehiscence'.)
Vaginal intercourse is also discouraged for six weeks to prevent cuff infection and allow the vaginal cuff to heal completely. There is not high quality evidence to specify the
period of abstinence from vaginal intercourse, however, intercourse appears to be the most common initiating event in vaginal cuff dehiscence in premenopausal women [38,46].
(See "Vaginal cuff dehiscence after hysterectomy".)
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Routine discharge instructions for patients can be found separately. (See "Patient information: Care after gynecologic surgery (Beyond the Basics)".)
Postoperative visit — We see patients for a follow-up visit at one to two weeks postoperatively. The follow-up visit includes an evaluation for potential complications and an
examination of the abdomen, wound, and vaginal cuff, as well as removal of skin staples, if necessary. We review the details of the surgery and pathology results with the
patient.
OUTCOME — After hysterectomy, most women report relief of symptoms, no change in sexual function, and satisfaction with the procedure. (See "Overview of hysterectomy",
section on 'Outcome'.)
A comparison of outcome after hysterectomy versus medical therapy for abnormal uterine bleeding can be found separately. (See "Managing an episode of severe or prolonged
uterine bleeding".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are
written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are
best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and
more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical
jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education
articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)
● Basics topics (see "Patient information: Hysterectomy (The Basics)")
● Beyond the Basics topics (see "Patient information: Abdominal hysterectomy (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
Preoperative preparation
Surgical planning
● Surgical planning for (abdominal hysterectomy) AH includes patient and surgeon decision-making regarding choice of incision, salpingo-oophorectomy, and subtotal versus
total hysterectomy. (See 'Surgical planning' above.)
● In women undergoing AH in whom a decrease in uterine size would enable a transverse rather than a midline vertical abdominal incision, we suggest GnRH analogue
therapy for three to four months preoperatively (Grade 2B). (See 'Preoperative GnRH analogues' above.)
Thromboprophylaxis
● Thromboprophylaxis is required for women undergoing abdominal hysterectomy. (See 'Thromboprophylaxis' above and "Prevention of venous thromboembolic disease in
surgical patients" and "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Thromboprophylaxis'.)
Prevention of surgical site infection
● In women undergoing AH, we recommend antibiotics for surgical site infection prevention rather than no antibiotics (Grade 1A). (See 'Prophylactic antibiotics' above and
"Antimicrobial prophylaxis for prevention of surgical site infection in adults" and "Overview of preoperative evaluation and preparation for gynecologic surgery", section on
'Surgical site infection prevention'.)
● In women planning AH who have bacterial vaginosis, we recommend treatment for eight days, starting four days preoperatively with metronidazole rather than no treatment
(Grade 1A). Clindamycin may be used as an alternative if there is a contraindication or resistance to metronidazole. (See 'Bacterial vaginosis treatment' above and
"Bacterial vaginosis", section on 'Gynecologic procedures'.)
● Vaginal preparation with povidone-iodine solution is common practice before hysterectomy. However, there is no high quality evidence to confirm that vaginal preparation
alone or in combination with antibiotics is effective in preventing surgical site infection. In addition, there are conflicting data regarding the use of povidone-iodine gel in
addition to solution. (See 'Patient positioning and sterile preparation' above.)
Operative technique
● The following are the basic steps of AH:
• Patient positioning, examination under anesthesia, and sterile preparation
• Incision, exploration, and adhesiolysis
• Round ligament ligation
• Broad ligament dissection
• Adnexal removal (if indicated or elected by patient)
• Perivesical and perirectal dissection
• Cervical amputation or removal (subtotal versus total AH)
• Treatment of the vaginal cuff
• Final examination and closure
● Hemostasis is achieved during AH by visualization and ligation of the ovarian and uterine vessels. (See 'Adnexal conservation or removal' above and 'Uterine vessel
ligation' above.)
● To prevent ureteral injury, we prefer to open the retroperitoneum and visualize the ureter. If palpation alone is used, the internal iliac artery, ovarian vessels, and vessels of
the broad ligament are easily confused with the ureter. Additionally, when the vesicouterine space is developed, the bladder is displaced inferiorly to laterally displace the
ureters. If the patient has extensive pelvic disease, we dissect the ureter down toward the bladder until optimal visualization is achieved. (See 'Avoiding ureteral injury'
above.)
● Dissecting the perivesical and perirectal spaces helps to avoid injury of these organs. We prefer sharp perivesical dissection, as the use of a blunt dissection with a sponge
stick may lead to a cystostomy, particularly if a patient has had prior pelvic surgery. In addition, an incision into the bladder is more easily repaired than a tear from blunt
dissection. (See 'Perivesical and perirectal dissection' above.)
● Numerous techniques have been described for management of the vaginal cuff closure. High quality studies have found no difference in postoperative infectious morbidity
with an open or closed cuff technique. (See 'Treatment of the vaginal cuff' above.)
● In patients undergoing laparotomy who have a 2 cm or greater subcutaneous fat layer, we recommend closure of the subcutaneous layer (Grade 1A). (See 'Obesity' above
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and "Cesarean delivery: Technique", section on 'Subcutaneous tissue layer'.)
● In obese patients undergoing a midline laparotomy, we suggest a mass fascial closure (incorporating the fascia along with a small amount of subcutaneous fat, rectus
muscle, rectus sheath, and, possibly, peritoneum) rather than a fascia-only closure (Grade 2B). (See "Principles of abdominal wall closure", section on 'Mass closure' and
"Principles of abdominal wall closure", section on 'Subcutaneous'.)
● In women with a large leiomyomatous uterus (≥16 weeks' size), we suggest prevention of excessive blood loss with intramyometrial (IMM) vasopressin (Grade 2B). (See
'Large uterus' above.)
Postoperative care
● In women undergoing AH, the bladder catheter is typically removed 24 hours or less postoperatively. (See 'Inpatient postoperative care' above.)
● Increase in intraabdominal pressure is dependent on the amount of weight lifted, as well as the position of the person relative to the object. We ask that patients avoid
heavy lifting (>13 pounds of weight from the floor) for four to six weeks to minimize stress on the healing fascia. (See 'Follow-up' above.)
Complications
● The most common major complications of AH are hemorrhage, urinary tract injury, and bowel injury. (See 'Complications' above.)
● Careful inspection of all pedicles before abdominal closure is the best method to prevent intraoperative and postoperative hemorrhage. Depending on the site of
hemorrhage, hemostasis may be reestablished by local treatment (eg, vaginal cuff bleeding, wound hematoma) or by surgical exploration. (See 'Hemorrhage' above.)
● If a ureteral injury is suspected intraoperatively, confirmation may be obtained by intravenous injection of indigo carmine, or opening the dome of the bladder.
Postoperatively, ureteral injury may be asymptomatic or may present as flank or groin pain, fever, prolonged ileus, and abdominal mass. Postoperative serum creatinine
concentration rises ≥0.3 mg/dL above preoperative values support this diagnosis. (See 'Ureteral injury' above.)
● Small bladder injuries in the bladder dome can be repaired with a running closure with a small caliber absorbable suture (eg, 3-0). When dealing with an injury which is
extensive, in the trigone, or occurs in a patient with previous bladder injury (eg, trauma, surgery, irradiation), intraoperative consultation with an experienced surgeon is
warranted. (See 'Bladder injury' above.)
● Bowel injuries occur primarily during lysis of adhesions involving bowel and dissection of the posterior cul-de-sac. Serosal abrasions do not need repair, but injuries
involving the muscularis and/or mucosa are to be repaired. (See 'Bowel injury' above.)
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