Hysterectomy—Then and NowCHAPTER 1

It is fascinating to study the journey of this procedures from its humble beginnings to the advances we see today. In the following paragraphs, we will embark on certain milestones in this path with the reader.

The first ever hysterectomy was an abdominal hysterectomy. The surgery took place in Massachusetts in 1853, but by then hysterectomy had already been around as long as 1000 years back.¹ Few gynecologic experts state that hysterectomy had been performed through the vaginal route since 2nd century AD. A physician named Soranus of Ephesus wrote in 120 AD of performing them by removing an inverted uterus that had become gangrenous.² In those days, hysterectomies were carried out sporadically and only for the reason of uterine prolapse or uterine inversion. However, the bladder and the ureter were often torn and the patients rarely survived.

A 46-year-old peasant named Faith Haworth was carrying a heavy load when her uterus prolapsed completely. Frustrated by this frequent occurrence, she grabbed her uterus, pulled as hard as possible, and cut the whole lot of it with a short knife. The bleeding soon stopped and she lived on for many years, but, with a persistent vesicovaginal fistula. This case was well-documented and reported in 1670 by a male midwife Percival Willoughby.³

In early days of hysterectomy, the activity was considered horrific and outlook grim. At that point of time, there were no antibiotics and no one had even heard of pain killers. Many women died of shock, hemorrhage and sepsis. The survival rate was less than 30%. The advent of painkillers, antibiotics, blood transfusion and anesthesia has revolutionized the course of this surgery. The development of chloroform and ether anesthesia and techniques for sterilizing instruments soon became available. In 1890, the first surgical gloves were manufactured by the Goodyear Rubber Company. The availability of better anesthesia and concept of antisepsis made the procedure safer and more acceptable.

Conrad Langenbeck of Gottingen performed the first planned vaginal hysterectomy in 1813 and reported it in 1817 and was subjected to the jibes of his colleagues for many years, without receiving credit for his achievement. His patient made an uneventful recovery. The removed uterus was lost, and the assistant died shortly after the surgery, so none of his colleagues believed in the report of the operation. The postmortem examination of the patient, who died of senility 26 years later, showed that the operation had been performed and that the uterus had indeed been removed in its entirety.³

Walter Burnham performed the first successful abdominal hysterectomy in 1853, in Lowell, Massachusetts, by accident. At the time, Dr Burnham was removing what he thought was an ovarian cyst, when the patient suddenly vomited and pushed the uterus through the abdominal incision. He was forced to perform a subtotal hysterectomy, tying both uterine arteries, because he was unable to return the uterus to the abdomen. The patient survived and made a full recovery. His success encouraged him to try the operation again. Of the next 15 cases only 3 patients survived. These hysterectomies were performed without the benefit of anesthesia or aseptic technique. These early hysterectomies were all subtotal procedures, performed usually without anesthesia, and with the mortality rate of 70–90%, even as late as 1880.³ With the development of anesthesia, antisepsis and surgical instruments, the situation had slowly improved by the end of the 19th century. In 1929, Richardson in the United States performed the first total abdominal hysterectomy. He recommended the excision of the cervix, to avoid cervical stump carcinoma.³ Despite Richardson's recommendation, subtotal hysterectomy remained the preferred surgical technique until the late 1940's. Supracervical hysterectomies were preferred for the prevention of peritoneal contamination with vaginal bacterial flora and for the prevention of peritonitis, with reduced risk of bladder and ureter injury.³ The advent of antibiotics, blood transfusion, modern anesthesia and improved surgical techniques in the 1940's, and the recognition that cancer occasionally developed in the cervical stump, encouraged and emboldened surgeons to carry out total hysterectomy. Apart from the transition from subtotal to total hysterectomy during the 20th century, the only change in the abdominal procedure was the almost universal adoption of the transverse incision introduced by Johann Pfannenstiel, in 1900, which gives better cosmetic result with fewer surgical complications.³

Kurt Semm in Germany, first described a technique for laparoscopic assistance in vaginal hysterectomy, in 1984. The adnexa were separated laparoscopically in order to simplify vaginal hysterectomy.⁴ This was later called laparoscopically assisted vaginal hysterectomy.

In 1988, Harry Reich performed the first total laparoscopic hysterectomy in Pennsylvania. The ligaments and uterine vessels were coagulated with bipolar forceps and cut with scissors. The vagina was opened and closed laparoscopically. The total operating time was 180 minutes, the uterus weighed 230 g and the patient was discharged on the fourth postoperative day.⁹ Reich published his article the following year and demonstrated his technique world-wide.

Laparoscopy appears to be a real alternative of hysterectomy by laparotomy, worthy of becoming a routine intervention. The generic advantages of avoiding a large laparotomy are now well established. For the patient, a laparoscopic procedure is invariably less painful, and the recovery and return to normal activities are more rapid.³ There are also significant gains in short-term quality of life measures associated with laparoscopic aproach.⁴ In addition to the patient-oriented benefits, there are significant benefits for the surgeon. Modern laparoscopes give a view of the pelvic anatomy and pathology, particularly in relatively inaccessible areas of the deep pelvis, anterior cave of Retzius and pelvic sidewalls. Thus, for the surgeon, improved visualization offers the opportunity of more precise and accurate surgery.

The growing safety of laparoscopic hysterectomy suggests that it will be increasingly used in the future, although development of less invasive alternatives, such as hysteroscopic surgery, endometrial ablation techniques, levonorgestrel-releasing intrauterine device, gonadotropin releasing hormone analogues, and interventional radiology, may reduce the traditional indications for hysterectomy.