hysterectomy is the term used to describe an operation involving the removal of the
uterus. This normally involves excision of the body of the uterus and the cervix (
total hysterectomy). Occasionally just the body of the uterus is removed, leaving the cervix (
subtotal hysterectomy). The
ovaries and
Fallopian tubes may also removed during a hysterectomy (total hysterectomy with
bilateral salpingoopherectomy).
Hysterectomy was first described in the fifth century
bc when Soranus of Ephesus is said to have amputated a gangenous uterus through the vagina. Vaginal hysterectomy was reported in the medical literature sporadically over the next 2000 years. Perhaps the most famous of these was Faith Howard, who in around 1670 amputated her own uterus which repeatedly prolapsed out of her vagina. Not only did she survive this, but she went on to live for several years afterwards, despite having rendered herself incontinent from a hole in her bladder.
This operation was first established as acceptable practice in Britain by Isaac Baker Brown and Spencer Wells, surgeons working in London in the late nineteenth century. At this time vaginal surgery was considered the safest way for the operation to be performed, since abdominal surgery had a very high mortality rate and was to be avoided wherever possible. Abdominal hysterectomy was first described by Charles Clay in Manchester in 1843, when a massive fibroid uterus was mistaken for an ovarian tumour and an abdominal incision had already been made. Unfortunately this patient died, and it was another 10 years before a woman successfully survived this operation.
The advent of antiseptics and anaesthetics meant that abdominal surgery began to become safer, and the abdominal hysterectomy was established in the latter part of the nineteenth century, principally through Lawson Tait, Scottish gynaecologist working in Birmingham. In 1884 Tait published his series of 1000 abdominal operations including 54 hysterectomies, the first such report in the medical literature. Subsequently this has become the most frequently used route for this procedure, as it allows easier access, especially if the uterus is enlarged. Today the most common form of abdominal hysterectomy is performed through a transverse cut in the lower abdominal wall (bikini line incision). This approach allows easy removal of the ovaries, which is not always possible vaginally.
Vaginal hysterectomy is still used in around 1 in 5 hysterectomies in the UK, and allows a quicker recovery. This operation is usually preferred for prolapse or heavy periods where removal of the ovaries is not essential and the uterus is of normal size (although some surgeons will remove some enlarged wombs vaginally).
Hysterectomies are performed for a variety of benign (non-cancerous) conditions, most commonly including heavy, painful periods and prolapse of the uterus. The painful, heavy periods can be caused by a variety of conditions including endometriosis, fibroids, chronic pelvic infections, and adhesions. A hysterectomy may also be advised when a woman has an ovarian cyst or where she has precancerous changes to the cervix that have not resolved with simple treatments.
A more radical type of abdominal hysterectomy, called a Wertheim's hysterectomy, is used to treat women with cancer of the cervix. (It was named after the Austrian gynaecologist who pioneered it in 1900.) This operation allows the wider removal of the tissue either side of the uterus and the removal of lymph nodes to check whether the cancer has spread. Hysterectomy is also used in the treatment of cancer of the uterus or ovary.
Over the last 20 years interest has grown in minimal access or ‘keyhole’ surgery. This led Dr Reich, a gynaecologist in Pennsylvania, to perform the first laparoscopic hysterectomy in 1989. This operation allows the easier removal of the ovaries vaginally at the time of the hysterectomy and the removal of a larger uterus vaginally. Total and subtotal laparoscopic hysterectomies have also been described, although none of these are commonly performed at the present time.
Philip Toozs-Hobson, and Linda Cardozo
