Surgical Approaches to Hysterectomy

Hysterectomy is among the most commonly performed gynecologic surgical procedures worldwide and is indicated for a variety of benign and malignant conditions, including abnormal uterine bleeding, leiomyomas, adenomyosis, endometriosis, pelvic organ prolapse, premalignant lesions, and gynecologic malignancies. Multiple surgical approaches are available, including abdominal, vaginal, laparoscopic, and robotic-assisted hysterectomy. The selection of the surgical route depends on several factors, including the indication for surgery, uterine size and mobility, pelvic anatomy, prior surgical history, patient comorbidities, surgeon expertise, available resources, and patient preferences. Current evidence demonstrates that minimally invasive approaches, particularly vaginal and laparoscopic hysterectomy, are associated with decreased postoperative pain, shorter hospital stays, faster recovery, reduced blood loss, and lower overall morbidity compared with abdominal hysterectomy when feasible. Robotic-assisted hysterectomy provides an additional minimally invasive option that may facilitate complex procedures through enhanced visualization, ergonomics, and instrument dexterity. Appropriate patient selection and individualized surgical planning are essential to optimize outcomes, minimize complications, and improve patient satisfaction. This activity reviews the indications, advantages, limitations, outcomes, and complications associated with the various surgical approaches to hysterectomy and highlights the role of the interprofessional healthcare team in perioperative care, patient counseling, and surgical decision-making. Hysterectomy Approaches The following surgical approaches may be used when performing a hysterectomy: Abdominal hysterectomy: This approach involves an open laparotomy and represents the traditional route for hysterectomy. Abdominal hysterectomy provides direct surgical exposure and may be preferred in selected complex cases, including large uterine size, extensive pelvic adhesive disease, or suspected malignancy requiring broad operative access. Vaginal hysterectomy: This approach involves removal of the uterus through the vaginal canal without abdominal incisions. Vaginal hysterectomy is often preferred for patients with uterovaginal prolapse and favorable pelvic anatomy and is associated with lower morbidity, shorter hospitalization, and faster postoperative recovery when feasible. Laparoscopic hysterectomy: Laparoscopic hysterectomy includes total laparoscopic hysterectomy (TLH), laparoscopically assisted vaginal hysterectomy (LAVH), and related minimally invasive techniques. These procedures use abdominal ports and endoscopic instrumentation to facilitate uterine removal while minimizing operative trauma. Robotic-assisted hysterectomy: This approach utilizes a robotic surgical platform that allows the surgeon to perform laparoscopic procedures through wristed instruments controlled from a console. Robotic assistance may improve visualization and surgical dexterity, particularly in anatomically complex cases or patients with obesity. Subtotal (supracervical) versus total hysterectomy: These terms describe whether the cervix is retained (supracervical hysterectomy) or removed (total hysterectomy) during uterine removal. Current evidence demonstrates comparable outcomes for many postoperative measures; however, procedure selection should be individualized based on patient preference, underlying pathology, cervical disease risk, and surgical considerations.