Total Abdominal Hysterectomy in Benign Conditions: Hysterectomy Techniques for the Normal-Sized and Small Uterus

Not too many years ago this would have been one of the prime chapters in a book about hysterectomy, a fact that only highlights how much progress has been made in terms of technique, concept and attitude to surgery of the uterus that this piece now reads already like something slightly anachronistic and almost historic. Are there still indications for open abdominal hysterectomy in a normal-sized or small uterus for benign conditions? At first sight there are none. A few absolute indications remain and there are special chapters in this book dealing with those, with the exception of the still more experimental uterine explantation for transplantation, possibly the most complex type of hysterectomy ever performed up to now [1]. Often, when thinking of open hysterectomy the uterus will be enlarged or a malignant or otherwise difficult condition, like endometriosis or dense adhesions present; but even in these clinical situations one will always want to carefully consider vaginal or laparoscopic approaches first and seek contraindications to these – which are becoming increasingly rare – before resorting to laparotomy. As far as indications are concerned, there are no differences to those for laparoscopic hysterectomy in benign, premalignant or – like in a few cases of early invasive cancer of the cervix or endometrium – malignant conditions. This is to say that given adequate mobility and vaginal compliance in these indications, the vaginal approach should always be favoured and tested for feasibility – if necessary under anesthesia – also in nulliparous patients. Some rare opportunities to come across a normal-sized or small uterus in a patient with an indication for hysterectomy may include an operation by another surgical specialty with a need for laparotomy. In some low resource settings, however, open abdominal hysterectomy may still be an acceptable alternative, when laparoscopic equipment is unavailable and a vaginal approach not feasible.