Types of Hysterectomy

A. Classification by Extent of Tissue Removed

1. Subtotal (Partial / Supracervical) Hysterectomy

• The uterine body (corpus) is removed but the cervix is left in place.
• Also called laparoscopic supracervical hysterectomy (SCH) when done endoscopically.
• The fundus is amputated and mechanically removed.
• Advantages: shorter operating time, preserves some pelvic floor support.
• Disadvantage: ongoing need for cervical smear screening; small risk of residual cervical disease.

2. Total Hysterectomy

• Removal of both the uterine corpus and the cervix.
• The most common type performed for benign disease.
• Can be performed via abdominal, vaginal, or minimally invasive (laparoscopic/robotic) routes.
• The vaginal cuff is closed after excision.

3. Radical Hysterectomy

• Removes the uterus, cervix, parametria (paracervical/pararectal tissues), and a cuff of upper vagina.
• Usually combined with pelvic lymphadenectomy.
• Indicated for early-stage cervical cancer (FIGO IA2, IB1) and occasionally endometrial cancer.

Piver-Rutledge-Smith Classification (most widely used for radical hysterectomy):

• Sabiston Textbook of Surgery, p. 2798-2799

B. Classification by Surgical Route/Approach

1. Total Abdominal Hysterectomy (TAH / Open)

• Access via a low transverse (Pfannenstiel) or vertical midline incision.
• Incision type depends on indication, body habitus, prior surgery, and pathology size.
• Steps: divide round ligaments → develop bladder flap → ligate ovarian/uterine vessels → divide cardinal and uterosacral ligaments → colpotomy → close vaginal cuff.
• Reserved for: significant cardiopulmonary disease precluding laparoscopy, known/suspected uterine malignancy requiring morcellation avoidance, or severely distorted anatomy where minimally invasive approach is unsafe.

2. Vaginal Hysterectomy (VH)

• The uterus is delivered and removed entirely through the vaginal opening - no abdominal incision.
• Considered a minimally invasive approach.
• Associated with shorter hospital stay, less postoperative pain, and faster recovery compared with abdominal hysterectomy.
• Preferred route when uterine descent and vaginal access are adequate.
• Laparoscopy offers no advantage over VH when VH is feasible.

3. Laparoscopic Hysterectomy (LH)

• Laparoscopic-assisted vaginal hysterectomy (LAVH): laparoscopy facilitates upper pedicle dissection, then vaginal completion.
• Total laparoscopic hysterectomy (TLH): entire procedure including colpotomy and cuff closure done laparoscopically.
• Laparoscopic supracervical hysterectomy (LSH): corpus amputated laparoscopically; cervix retained.

4. Robotic Hysterectomy

• Uses the da Vinci surgical system; FDA-approved for gynecologic use in 2005.
• Steps are similar to conventional laparoscopic hysterectomy.
• Benefits include: reduced estimated blood loss, shorter hospital stay, and a conversion rate ~4x lower than conventional laparoscopy.
• Drawbacks: longer operating time in some comparisons, substantially higher cost.
• By 2010, 8.2% of hysterectomies in the US were robotic.

C. Additional Considerations: Adnexal Management

• Bilateral salpingo-oophorectomy (BSO): remove tubes and ovaries (often for malignancy or risk-reduction)
• Bilateral salpingectomy alone: remove tubes, retain ovaries (opportunistic salpingectomy reduces ovarian cancer risk)
• Conservation of adnexa: leave tubes and ovaries intact (common in premenopausal patients with benign disease)

D. Radical Trachelectomy (fertility-sparing alternative)

• Performed like radical hysterectomy but the uterine body is preserved.
• Cervix, parametria, and upper vagina are removed; a cerclage is placed and the uterus is reattached to the superior vagina.
• Indicated for FIGO IA1 with LVSI, IA2, or IB1 cervical cancer in women wishing to preserve fertility, usually for tumors ≤2 cm.

Summary Table

Sources: Sabiston Textbook of Surgery, pp. 2798-2803; Berek & Novak's Gynecology, pp. 1296-1297; ACOG Committee Opinion on route of hysterectomy