Perioperative management - Supracervical hysterectomy, bilateral salpingectomy, robot-assisted laparoscopy (DaVinci)

A hysterectomy can be performed in different ways:

• Abdominal
• Vaginal
• Laparoscopically-assisted vaginal
• Laparoscopic/robot-assisted

Additionally, a distinction is made between a total hysterectomy preserving the cervix and a supracervical hysterectomy.

Uterine fibroids are the most common indication for a hysterectomy, approximately 75% of all hysterectomies.

Bleeding disorders

Adenomyosis uteri

Endometriosis

Genital prolapse

Precancerous changes of the endometrium and cervix

Suspicious changes indicating malignancy

The occurrence of an accidental uterine sarcoma during a hysterectomy or myoma surgery ranges between 1/205 and 1/7400 (0.49%-0.014%). In a meta-analysis of 10,120 patients, a frequency of 0.29% was found. Due to this risk, electromechanical morcellators were withdrawn, by Ethicon in 2014 and Karl Storz in 2021.

In imaging, there is no reliable preoperative distinction between benign and malignant findings. However, with clinical examinations, "soft markers" in transvaginal ultrasound, possibly MRI, and a detailed medical history, the risk can probably be reduced. Benign uterine fibroids do not contraindicate morcellation. It is therefore important to preoperatively inform about the potential dangers of morcellation, alternative approaches and their respective perioperative risks (morbidity and mortality of other surgical techniques), and on the other hand, the low incidence of sarcomas.

The use of retrieval bags also cannot exclude the dissemination of tumor cells. There are different techniques of morcellation:

Manual in bag Morcellation: Insertion of the retrieval bag, luxation of the uterus into it, minilaparotomy, and fragmentation using a scalpel (extra-abdominal).

Contained power Morcellation: Insertion of a retrieval bag, luxation of the uterus into it, electromechanical morcellation within the bag (intra-abdominal).

Morcellation should not be performed in postmenopausal patients with newly developed fibroids or fibroids with a tendency to grow or newly symptomatic fibroids.

Conducting an adequate medical history and a gynecological examination. The examination is intended to identify other pathologies of the uterus or adnexa, in order to possibly avoid a hysterectomy (e.g., submucosal fibroids or pedunculated fibroids, polyp of the corpus uteri). Additionally, determining the actual level of distress and providing information about alternative treatment options.

Laboratory examination (depending on the needs of the clinic)

Further examinations (MRI, CT) are only useful for corresponding indications.