Hysterectomy

It is 08:30 on a Tuesday theatre list. The next patient is a 44-year-old para 2 with heavy menstrual bleeding refractory to the hormonal IUD and tranexamic acid, a 10-week bulky uterus, and a normal cervical screening test. She has had one previous Caesarean section. You and the consultant have to agree the route before she goes to sleep. This topic is that conversation — and the operation that follows.^[1]

Overview and definition

Hysterectomy is the surgical removal of the uterus. It is the most common major gynaecological operation in high-income settings, with a lifetime risk around 20–25% in the United States and around 17–20% in the United Kingdom, and the Australian pattern mirrors the UK. Hysterectomy can be performed for benign gynaecological disease (heavy menstrual bleeding, fibroids, endometriosis, adenomyosis, pelvic organ prolapse), for gynaecological malignancy (cervical, endometrial, ovarian), or as an emergency obstetric procedure (placenta accreta spectrum, uncontrollable postpartum haemorrhage).^[1]

The contemporary language uses four named routes — abdominal, vaginal, laparoscopic, and robotic-assisted — and a recent addition, V-NOTES (vaginal natural orifice transluminal endoscopic surgery). Each is further subdivided by extent and technique.^[1][7]

References14ShowHide

1. [1]Pickett CM, Seeratan DD, Mol BWJ, Nieboer TE, Johnson N, Bonestroo T, Aarts JW Surgical approach to hysterectomy for benign gynaecological disease Cochrane Database Syst Rev, 2023.PMID 37642285
2. [2]AAGL Practice Committee AAGL practice report: Morcellation during uterine tissue extraction J Minim Invasive Gynecol, 2014.PMID 24865630
3. [3]Brown J AAGL advancing minimally invasive gynecology worldwide: statement to the FDA on power morcellation J Minim Invasive Gynecol, 2014.PMID 25195157
4. [4]AAGL Practice Committee AAGL practice report: Practice Guidelines on the Prevention of Apical Prolapse at the Time of Hysterectomy J Minim Invasive Gynecol, 2014.PMID 24769448
5. [5]Lirk P, Thiry J, Bonnet MP, Joshi GP, Bonnet F Pain management after laparoscopic hysterectomy: systematic review of literature and PROSPECT recommendations Anaesthesia, 2019.PMID 30914471
6. [6]Ekanayake C, Pathmeswaran A, Kularatna S, Herath R, Wijesinghe P Cost evaluation, quality of life and pelvic organ function of three approaches to hysterectomy for benign disease Cost-effectiveness study, 2017.PMID 29178955
7. [7]Chrysostomou A, Djokovic D, Edridge W, van Herendael BJ Evidence-based guidelines for vaginal hysterectomy of the International Society for Gynecologic Endoscopy (ISGE) Gynecol Surg, 2018.PMID 30447552
8. [8]Mahmoud MS Robotic-Assisted Laparoscopic Trachelectomy: A Standard Technique J Minim Invasive Gynecol, 2017.PMID 28254504
9. [9]Kobayashi H, et al. Ureter Injury in Total Laparoscopic Hysterectomy Case Rep Obstet Gynecol, 2023.PMID 37638335
10. [10]Cassani C, Spinillo A, Dominoni M, Gardella B Revisiting Urological Injury Risks in Minimally Invasive Hysterectomy for Benign Indications Urological injury review, 2026.PMID 41882424
11. [11]Sakuragi N, Kaneuchi M Nerve-Sparing Radical Hysterectomy Using the Okabayashi-Kobayashi Method Surg J (N Y), 2021.PMID 35111930
12. [12]Baradwan S, Khadawardi K, Himayda S, Ebeid SM, Badghish E Use of Uterine Manipulators in Total Abdominal Hysterectomy: A Systematic Review and Meta-Analysis Manipulator systematic review, 2026.PMID 41478334
13. [13]Ayhan A, Dursun P, Gultekin M, Yuce K Comparison of midline and Pfannenstiel incision for radical hysterectomy with pelvic and paraaortic lymphadenectomy in cervical carcinoma Surgical comparison, 2007.PMID 17441889
14. [14]Ayhan A, Dursun P, Gultekin M, Esin S Pfannenstiel vs. midline incision for early stage endometrial carcinoma Surgical comparison, 2006.PMID 16524579