Clinical Expert Series

Complications of Hysterectomy
Daniel L. Clarke-Pearson, MD, and Elizabeth J. Geller, MD

Hysterectomy is the most common gynecologic procedure performed in the United States, with
more than 600,000 procedures performed each year. Complications of hysterectomy vary based
on route of surgery and surgical technique. The objective of this article is to review risk factors
associated with specific types of complications associated with benign hysterectomy, methods to
prevent and recognize complications, and appropriate management of complications. The most
common complications of hysterectomy can be categorized as infectious, venous thromboem-
bolic, genitourinary (GU) and gastrointestinal (GI) tract injury, bleeding, nerve injury, and vaginal
cuff dehiscence. Infectious complications after hysterectomy are most common, ranging from
10.5% for abdominal hysterectomy to 13.0% for vaginal hysterectomy and 9.0% for laparoscopic
hysterectomy. Venous thromboembolism is less common, ranging from a clinical diagnosis rate of
1% to events detected by more sensitive laboratory methods of up to 12%. Injury to the GU tract
is estimated to occur at a rate of 1–2% for all major gynecologic surgeries, with 75% of these
injuries occurring during hysterectomy. Injury to the GI tract after hysterectomy is less common,
with a range of 0.1–1%. Bleeding complications after hysterectomy also are rare, with a median
range of estimated blood loss of 238–660.5 mL for abdominal hysterectomy, 156–568 mL for
laparoscopic hysterectomy, and 215–287 mL for vaginal hysterectomy, with transfusion only being
more likely after laparoscopic compared to vaginal hysterectomy (odds ratio 2.07, confidence
interval 1.12–3.81). Neuropathy after hysterectomy is a rare but significant event, with a rate
of 0.2–2% after major pelvic surgery. Vaginal cuff dehiscence is estimated at a rate of 0.39%, and
it is more common after total laparoscopic hysterectomy (1.35%) compared with laparoscopic-
assisted vaginal hysterectomy (0.28%), total abdominal hysterectomy (0.15%), and total vaginal
hysterectomy (0.08%). With an emphasis on optimizing surgical technique, recognition of sur-
gical complications, and timely management, we aim to minimize risk for women undergoing
hysterectomy.
(Obstet Gynecol 2013;121:654–73)
DOI: http://10.1097/AOG.0b013e3182841594

H ysterectomy is the most common gynecologic

procedure performed in the United States, with
more than 600,000 procedures performed each year.1
Nearly 90% of hysterectomies are performed for
benign indications. Over the past 20 years in the
United States, there have been changes in practice
patterns regarding route of hysterectomy. Since the
From the Department of Obstetrics and Gynecology, University of North
Carolina, Chapel Hill, North Carolina.
Continuing medical education for this article is available
http://links.lww.com/AOG/A350.
Corresponding author: Daniel L. Clarke-Pearson, MD, CB #7570, University
of North Carolina, Chapel Hill, NC 27514; e-mail: danielcp@med.unc.edu.
Financial Disclosure
The authors did not report any potential conflicts of interest.
© 2013 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/13
introduction of the laparoscopic hysterectomy in
1989, this minimally invasive route has increased
from 0.3% to 14% of all hysterectomies in 2005.2 This
increase has been coupled with a decrease in both
abdominal and vaginal hysterectomy, which were
reported at 64% and 22%, respectively. Abdominal
hysterectomy remains the most common route of sur-
gery despite a longer hospital stay, more postopera-
tive pain, a higher rate of infection, and slower return
to normal activities.3 Vaginal hysterectomy remains
at the least invasive approach, with faster recovery,
fewer febrile episodes, and less expense, and it is sup-
ported by American College of Obstetricians and
Gynecologists Committee Opinion No. 444 as the pre-
ferred route when feasible.3,4 Despite the benefits of
vaginal hysterectomy, from 1990 to 2005 there was a
2% decline in the number of vaginal hysterectomies
performed.5 Laparoscopic hysterectomy, a fast-growing

654 VOL. 121, NO. 3, MARCH 2013 OBSTETRICS & GYNECOLOGY

technique, has similar advantages to vaginal hysterec-
tomy but takes longer to perform, costs more, and has
the risks associated with abdominal incisions.3 The
most common indication for abdominal hysterectomy
in 2005 was uterine leiomyoma (62%); for vaginal
hysterectomy, prolapse accounted for 62% and, for
laparoscopic hysterectomy, abnormal bleeding
accounted for 53% of indications.2 There were no dif-
ferences in route based on hospital setting. Length of
stay and overall hospital charges varied by route of
hysterectomy.2 Laparoscopic hysterectomy had the
shortest length of stay at 1.65 days, but the highest
total charges at $18,821. Abdominal hysterectomy
had the longest length of stay at 3.07 days, and aver-
age charges were $17,839, whereas vaginal hysterec-
tomy had an average length of stay of 1.86 days, with
the lowest total charges being $14,121.
Geographic and demographic differences also
have been noted. In 2005, the South had the highest
hysterectomy rate, with 40% of all procedures per-
formed in the United States, compared with 24% in
the Midwest, 20% in the West, and 16% in the
Northeast.2 Route of hysterectomy did not vary sig-
nificantly based on geographic region. Age was signif-
icantly associated with route of hysterectomy. The
mean age of patients undergoing laparoscopic hyster-
ectomy was 44.2 years, compared with 45.2 years for
abdominal and 49.3 years for vaginal hysterectomy.
A woman’s race also may influence the route of
hysterectomy. For Caucasian women, uterine leio-
myoma was the most common surgical indication
(33%), followed by menstrual disorders (21%) and
prolapse (16%).5 For African American women, the
most common indication also was uterine leiomyoma
(70%), followed by menstrual disorders (12%) and
endometriosis (6%). For Hispanic women, uterine
leiomyoma was again most common (46%), followed
by prolapse (17%) and menstrual disorders (14%). For
all three groups, abdominal hysterectomy was the
most common route. Regarding patient satisfaction,
a recent Cochrane Review found no difference when
comparing abdominal hysterectomy with either the
vaginal or the laparoscopic route. However, these
analyses were limited to one randomized study for
each of the techniques.3
In 2005, the laparoscopic route of hysterectomy
was expanded when the United States Food and Drug
Administration approved the daVinci Surgical System
for robotic gynecologic surgery. Although robotic
surgery is an extension of traditional “straight-stick”
laparoscopy, it has several unique characteristics.6
Advantages include three-dimensional viewing from
two camera heads and increased range of motion with
VOL. 121, NO. 3, MARCH 2013 Clarke-Pearson and Geller
modified laparoscopic instruments. Disadvantages
include lack of haptic feedback and increased cost.
In the only randomized trial published (PubMed
search with terms “hysterectomy” AND “robotic,”
limited to clinical trials from 1 January 2000 to 12
December 2012), robotic hysterectomy had a longer
operative time compared with traditional laparoscopy
but higher postoperative quality-of-life scores, with no
difference in perioperative complications.7
With this background and recognizing changing
trends in surgical techniques, complications of surgery
also may vary according to the surgical method chosen.
This discussion reviews the available literature detail-
ing the frequency of the most common complications
associated with hysterectomy. We review the risk
factors associated with specific complications, methods
to prevent and recognize complications, and appropri-
ate management. When comparative data are available,
we compare and contrast the incidence of complica-
tions between the three most common hysterectomy
techniques: abdominal, vaginal, and laparoscopic.
INFECTIOUS COMPLICATIONS
OF HYSTERECTOMY
The rate of infectious complications after hysterec-
tomy is variable. Rates have been reported at 10.5%
for abdominal hysterectomy, 13.0% for vaginal hys-
terectomy, and 9.0% for laparoscopic hysterectomy.8
These rates are based on multiple factors, including
preoperative antimicrobial prophylaxis, socioeco-
nomic status, body mass index, concurrent proce-
dures, experience of the surgeon, and study site.9
The most common infections include vaginal cuff cel-
lulitis, infected hematoma or abscess, wound infec-
tion, urinary tract infection, respiratory infection,
and febrile morbidity.
Factors that may increase the risk for postoperative
infection include compromised immune status, obesity,
hospitalization, operator experience, increased blood
loss, operative time more than 3 hours, poor nutrition,
devitalized tissue as may be found in larger operative
pedicles, comorbidities such as diabetes mellitus and
smoking, lack of preoperative antibiotics, and the
presence of an infected operative site.9 An important
principle is the distinction between postoperative infec-
tion and febrile morbidity. Febrile morbidity in the
postoperative period is defined as a temperature more
than 38°C on 2 occasions more than 6 hours apart,
more than 24 hours after surgery. However, the pres-
ence of fever alone is not a clear sign of infection
because it also may be the result of a noninfectious
etiology, including atelectasis, hypersensitivity reaction
to antibiotics or anesthetic agents, a pyrogenic reaction
Complications of Hysterectomy 655
to tissue trauma, or hematoma formation. An elevated
white blood cell count, although often present in the
face of infection, cannot be used as a confirmatory tool
because this may be attributable to the same noninfec-
tious etiologies such as elevated body temperature. The
management and treatment plan should be based on
the confirmation of an actual site of infection, rather
than indirect signs such as fever or elevated white
blood cell count. A 2009 Cochrane meta-analysis
found that subtotal abdominal hysterectomy had
a decreased rate of febrile morbidity compared with
total abdominal hysterectomy (odds ratio [OR]
0.43, confidence interval [CI] 0.25–0.75).10 Another
Cochrane meta-analysis assessing route of hysterec-
tomy found that laparoscopic hysterectomy (includ-
ing laparoscopically assisted vaginal hysterectomy)
had a decreased rate of febrile morbidity compared
with abdominal hysterectomy (OR 0.67, CI 0.51–
0.88).3 Vaginal hysterectomy also had fewer febrile
episodes and unspecified infections compared with
abdominal hysterectomy (OR 0.42, CI 0.21–0.83).
There were no differences in infectious complications
between laparoscopic and vaginal hysterectomy.
When comparing subcategories of laparoscopic hys-
terectomy, there were more febrile episodes with total
laparoscopic hysterectomy when compared with lap-
aroscopically assisted vaginal hysterectomy (OR 3.77,
CI 1.05–13.51).
The evaluation of any postoperative patient
suspected of having an infection should begin with
a careful history and physical examination. Physical
examination could include any of the following
elements, based on the patient’s history: examination
of the throat and chest for upper and lower respiratory
tract infection including pharyngitis, bronchitis, and
pneumonia; examination of the abdomen for signs
of peritonitis or incisional infection; examination of
the lower extremity examination for phlebitis or
thrombus; and possible genitourinary (GU) examina-
tion for signs of cystitis, pyelonephritis, cuff cellulitis,
and pelvic hematoma.
Laboratory Tests
Laboratory tests that may help guide diagnosis
include complete blood count with differential to look
for a left shift, and urinalysis with culture if leukocytes
or nitrites are found. Cultures of the surgical site
should be performed with a low threshold of suspi-
cion. Based on the findings of the physical examina-
tion, imaging can be helpful in some cases, including
chest radiograph, abdominal radiograph, pelvic ultra-
sonography, or computed tomography (CT). The
latter may be particularly helpful if planning aspira-
656 Clarke-Pearson and Geller Complications of Hysterectomy
tion and drainage of a hematoma or abscess. Specific
identification, evaluation, and management will be
addressed separately for each category of infection.
Antimicrobial Prophylaxis
Perioperative antimicrobial prophylaxis is indicated for
all types of hysterectomy.11 First-generation cephalo-
sporins are as effective as second-generation or third-
generation agents and are not only less expensive but
also less likely to induce a bacterial b-lactamase
response. Dose adjustment should be based on weight,
specifically doubling the dose from 1 to 2 g at 80 kg or
more.11 If a penicillin allergy exists, alternatives include
a combination of either Clindamycin or metronidazole
plus either Gentamicin or Levofloxacin. Antibiotics
should be administered within 1 hour before the time
of skin incision. Readministration is recommended for
surgical procedures lasting more than 3 hours or those
with an estimated blood loss more than 1,500 mL.
Continued use of “prophylactic antibiotics” beyond
those administered in the operating room has no
proven benefit.
Vaginal Cuff Cellulitis
One of the most common infectious complications
after hysterectomy that is unique to this procedure is
vaginal cuff cellulitis. This usually occurs late in the
hospital course or soon after discharge. The incidence
ranges from 0% to 8.3% after hysterectomy.3 Symp-
toms can include fever, purulent vaginal discharge
(to be distinguished from physiologic discharge), and
pelvic, abdominal, or low back pain. Examination
may reveal tenderness or induration of the vaginal
cuff and purulent discharge.
The bacteria associated with a cuff cellulitis are
polymicrobial.9,11 Whereas cultures should be col-
lected if there is any purulent discharge, treatment
should be started empirically. Antimicrobial therapy
can be either single-agent or multi-agent, depending
both on clinical presentation and clinician preference.
An early presentation (within a few days of surgery)
may be a sign of aerobic infection and can be treated
with a broad-spectrum penicillin with b-lactamase
inhibitor or later-generation cephalosporin. If no clin-
ical improvement is seen, a multi-agent regimen can
be instituted, assuming anaerobic involvement, with
gentamicin and clindamycin. Metronidazole is an
alternative to clindamycin, especially if one is con-
cerned about anaerobic resistance, but may necessi-
tate the addition of ampicillin for Gram-positive
coverage. For oral therapy, a regimen of metronida-
zole and fluoroquinolone will provide adequate
coverage.
OBSTETRICS & GYNECOLOGY
 Antibiotic treatment should be continued for
24–48 hours after fever has resolved. Although it is com-
mon to continue oral antibiotics after discharge, no ben-
efit has been shown.12 As with any pelvic infection, if
there has been no clinical improvement after several
days of appropriate antimicrobial therapy, consider
alternatives such as a resistant organism, another source
of infection such as abdominal wound, pelvic abscess,
or, less commonly, a septic pelvic thrombophlebitis.
Prevention includes the methods of good surgical
technique, including aseptic technique, proper tissue
handling, hemostasis, and re-dosing antibiotics based
on the parameters discussed. Other general principles
for preventing postoperative infections at the surgical
site include limiting surgical dead space, avoiding
subcutaneous sutures when not necessary, maintain-
ing small tissue pedicles, and using appropriate
irrigation. Treatment of known preoperative bacterial
vaginosis or trichomoniasis also can reduce the risk of
a cuff infection.13 Cochrane meta-analyses have found
no difference in the rate of vaginal cuff cellulitis based
on route or subtype of hysterectomy.3,10
Infected Pelvic Hematoma or Abscess
An infected pelvic hematoma or abscess usually
presents after discharge from the hospital, often later
than the presentation of a cuff cellulitis. Estimates of the
incidence of a fluid collection after hysterectomy range
from 19.4% to 90%, with estimates for the incidence of
a hematoma ranging from 0% to 14.6%.3 Symptoms
can include fever, chills, pelvic pain, and even rectal
pressure. Laboratory markers may reveal anemia.
Examination may reveal lower abdominal and pelvic
tenderness, a fluctuant mass at the vaginal cuff, and
possibly purulent or bloody discharge at the cuff. Open-
ing the stitches at the vaginal cuff can be both diagnostic
and therapeutic for an infected hematoma or abscess.
If the presence of a mass is not apparent on
vaginal examination, ultrasound or CT imaging can
diagnose and locate the fluid collection as well as rule
out an adnexal abscess. Imaging also can determine
whether the fluid collection is accessible for drainage.
Based on the size of the fluid collection, drainage may
be indicated at the time of diagnosis. Hematomas
larger than 5 cm are more often associated with fever
and have been found to have better outcomes with
immediate rather than delayed drainage.14 The suc-
cess rate of CT-guided percutaneous drainage of a pel-
vic abscess has been reported to be 81%, with a 20%
complication rate, consisting mainly of buttock pain,
leg pain, numbness, or pelvic bleeding.15 Other drain-
age routes to consider include transvaginal, transrec-
tal, and transperineal with ultrasound guidance.
VOL. 121, NO. 3, MARCH 2013 Clarke-Pearson and Geller
Surgical exploration may be necessary if the abscess
either is difficult to access with a drain or is not
responding to more conservative management.
Concomitant antimicrobial therapy should be
based on the assumption of a polymicrobial infection.
Gentamicin and clindamycin should be administered
for 24–48 hours after the patient has become afebrile.
Prevention will be based on the same surgical
principles already discussed. There were no differ-
ences in the rate of hematoma or abscess formation
based on route or subtype of hysterectomy.3,10
Wound Infection
Infection of the surgical wound usually occurs either
late in the hospital course or soon after discharge. Most
hysterectomies are classified as “clean-contaminated”
procedures, with controlled entry into the GU tract
(vagina). Hysterectomy can be a “contaminated” pro-
cedure if infection is present at the time of surgery,
either in the form of a urinary tract infection or in
the form of a bacterial vaginosis infection.11 Rarely
is it considered a “dirty” or “infected” procedure, with
a perforated bowel and fecal contamination or an
acute bacterial infection with purulent discharge (eg,
pelvic inflammatory disease or endometritis). The
incidence of wound infection after hysterectomy
ranges from 0% to as high as 22.6%.3 This incidence
varies greatly depending on the level of contamination
present.
Symptoms of wound infection can include fever,
possibly with a daily spike, and increased pain at the
incision site. Examination may reveal purulent dis-
charge from the incision, skin erythema, or indura-
tion, and possible fascial dehiscence on probing the
deeper layers.
Therapy includes opening the wound and debride-
ment, followed by wet-to-dry dressing changes. Once
the infection is resolved and the wound is granulating,
closure is often by secondary intention. After the
infection has cleared, the use of a wound vacuum
may help speed the healing process.16
Antimicrobial therapy also is necessary. Early-
onset wound infections are more likely group A
b-hemolytic streptococcus or possibly group B b-hemo-
lytic streptococcus. Late-onset infections are more
often attributable to Staphylococcus aureus. Penicillin-
based antibiotics work best for empiric therapy. It is
important to collect a wound culture to rule out Pseu-
domonas or methicillin-resistant S aureus, with the latter
requiring vancomycin.
Prevention of wound infection includes limiting
preoperative hospitalization and avoiding hair removal
when possible.12 If it is necessary to remove hair from
Complications of Hysterectomy 657
the incision site, clippers are vastly preferable to a razor.
Other techniques to reduce wound infection are pre-
operative antimicrobial body wash the night before
surgery and controlling postoperative blood glucose.12
If a procedure has been classified as dirty or infected, it
is often better to leave the incision open, either for
a delayed closure or to heal by secondary intention.
In a Cochrane Review there was a decreased rate of
abdominal wall or wound infection when comparing
laparoscopic with abdominal hysterectomy (OR 0.31,
CI 0.12–0.77).3
Urinary Tract Infection
Infections of the urinary tract usually present early in
the postoperative period. The incidence of urinary
tract infection after hysterectomy ranges from 0% to
13.0%,3 but accounts for up to 40% of nosocomial
infections.17 Signs and symptoms include low-grade
fever, frequency, urgency, and dysuria. Some patients
may be asymptomatic. Examination may reveal
suprapubic tenderness or tenderness to palpation of
the anterior vaginal wall, but again may be normal.
Diagnosis is supported by a urinalysis revealing
nitrites and is confirmative with a midstream clean
catch urine culture revealing at least 100,000 colony-
forming units of a single organism that is not consid-
ered skin flora or at least 100 colony-forming units on
catheter specimen.
Therapy can be initiated with symptoms and a
suspicious urinalysis, but a urine culture should be
sent to confirm infection and to determine antimicro-
bial sensitivities. Likely pathogens include facultative
anaerobes originating from bowel flora. The most
common pathogen is Escherichia coli. Although more
common in community-acquired urinary tract infec-
tion, E coli is still the most common cause of hospital-
acquired urinary tract infection, ranging from 30% to
56% of all cases.18,19
For an uncomplicated urinary tract infection,
trimethoprim-sulfamethoxazole and nitrofurantoin
are inexpensive and well-tolerated options. Nitrofur-
antoin reaches high concentrations in the urinary tract
while having low serum concentrations, therefore
conferring few side effects on bowel and vaginal flora.
It is not effective against Pseudomonas or Proteus spe-
cies. Fluoroquinolones provide another treatment
option. This class is more expensive but may be con-
sidered first-line treatment if resistance to other agents
is a concern.
Prevention of a postoperative urinary tract infec-
tion is based on early removal of an indwelling catheter
and aseptic technique for clean intermittent catheteri-
zation.12,20 No difference has been shown in the rate
658 Clarke-Pearson and Geller Complications of Hysterectomy
of bacteriuria with intermittent self-catheterization
compared with suprapubic catheter use,21 Cochrane
meta-analyses have found no difference in the rate of
urinary tract infection based on route or subtype of
hysterectomy.3,10
Routine preoperative screening urinalysis, culture,
or both are not recommended. One meta-analysis
found that perioperative urinalysis revealed abnormal-
ities in 1–34.1% of cases but only led to changes in
management in 0.1–2.8% of cases.22 The American
Heart Association guidelines state that preoperative
evaluation may be indicated in procedures involving
the urinary tract.23
Respiratory Infection
Pneumonia can occur early in the postoperative period.
In a patient without pulmonary disease, the incidence
of pneumonia after hysterectomy is low (0–2.16%),24
The risk is significantly increased in patients with
underlying pulmonary disease. Symptoms include
shortness of breath, chills, chest pain, cough, and puru-
lent sputum. Patients also may be asymptomatic.
Examination may reveal decreased breath sounds,
rales, hypoxia, tachycardia, and fever. Imaging in the
form a chest radiograph can confirm and localize the
infection, whereas sputum cultures can provide organ-
ism identification.
The major causative agents for hospital-acquired
pneumonia include Haemophilus influenzae and Strepto-
coccus and Staphylococcus species, as well as E coli, and
Enterobacter, Klebsiella, Proteus, and Serratia species.
Treatment of these pathogens includes a second-
generation or third-generation cephalosporin, penicil-
lin in combination with a b-lactamase inhibitor, or a
fluoroquinolone. Alternatively, postoperative patients
presenting after discharge to home who are found to
be minimally symptomatic with an otherwise normal
examination likely have community-acquired pneu-
monia. Although Streptococcus pneumonia is the most
common pathogen, consideration must be made for
possible resistance attributable to recent antibiotic use.
Thus, treatment should consist of either a fluroquino-
lone or penicillin in combination with a b-lactamase
inhibitor plus a macrolide or doxycycline.
Another type of postoperative pneumonia that
bears consideration is aspiration pneumonia. These
cases often involve Staphylococcus species as well as
Gram-negative aerobes. As a result, penicillin is not
as effective. Agents such as piperacillin or ticarcillin
are indicated, in addition to a b-lactamase inhibitor.
Alternatives include clindamycin plus either gentami-
cin or ciprofloxacin, or an expanded-spectrum ceph-
alosporin plus metronidazole.
OBSTETRICS & GYNECOLOGY
 Prevention of postoperative pneumonia includes
discontinuation of nicotine before surgery, treatment
of any upper respiratory infection, encouragement of
coughing and deep breathing in the postoperative
period, adequate pain control to allow for deep
breathing, and pulmonary treatment with bronchodi-
lators as indicated. No difference has been seen in the
rate of upper respiratory infection based on route of
hysterectomy.3
Preoperative chest radiograph has not been shown
to be useful in preventing postoperative infectious
complications in any age group.25 In one meta-analysis
of 46 studies, chest X-ray abnormalities were found in
2.5–37% of cases but only resulted in change in man-
agement in 0–2.1% of cases.21 American Heart Associ-
ation guidelines recommend preoperative chest
radiograph based on clinical indication (asthma, smok-
ing history) even if elderly (aged older than 80 years),
but state that it may be reasonable to screen in patients
older than 60 years who are undergoing major surgery,
of which hysterectomy is included.22
VENOUS THROMBOEMBOLIC
COMPLICATIONS
Although venous thromboembolic complications after
hysterectomy are common and can be life-threatening,
they are preventable events. The precise incidence of
venous thromboembolism (deep venous thrombosis
[DVT] or pulmonary embolism) after hysterectomy is
unclear. This is because of the lack of studies focused
only on hysterectomy and controlling for risk factors.
Further, the diagnosis of venous thromboembolism
has varied across studies and has ranged from the
diagnosis of a clinically recognized event (1%) to
events detected by sensitive prospective methods such
as I-125 fibrinogen uptake test (12%).26 Given the lack
of specific data regarding the incidence of venous
thromboembolism after hysterectomy, it is reasonable
to extrapolate this incidence from studies of patients
undergoing major gynecologic surgery. When com-
pared with other major gynecologic surgical proce-
dures, a large prospective trial evaluating risk factors
for postoperative venous thromboembolism did not
identify hysterectomy as an independent risk factor.26
Clinical variables known to influence the incidence of
venous thromboembolism include age, history of
venous thromboembolism, duration of anesthesia,
presence of leg edema or varicose veins, history of
radiation therapy, and nonwhite patients. In other
studies, obesity, use of oral contraceptives or other
hormones, pregnancy, and thrombophilias have been
identified as risk factors.27
VOL. 121, NO. 3, MARCH 2013 Clarke-Pearson and Geller
The route of hysterectomy may influence the
incidence of venous thromboembolism, although in
the trial cited there was no difference between vaginal
and abdominal hysterectomy when other risk factors
were considered. Whereas laparoscopic surgery is
considered by some authors to be at lower risk for
venous thromboembolism, retrospective studies that
focus specifically on laparoscopic hysterectomy found
the incidence of clinically significant venous throm-
boembolism to range between 1% and 2.9%.28 There
was an increased risk of venous thromboembolism
associated with the following risk factors: age older
than 60 years; cancer; or medical comorbidities.29 In
a Cochrane meta-analysis, there was no difference in
the incidence of venous thromboembolism between
abdominal, vaginal, or laparoscopic hysterectomy.3
Preoperative Evaluation
Preoperative evaluation should be focused on identi-
fying factors that would place the patient at higher
risk for postoperative venous thromboembolism.
Virchow first described the general factors associated
with thromboembolism to include the triad of venous
stasis, venous endothelial injury, and hypercoagulable
states. A comprehensive list of factors that increase
the risk of venous thromboembolism is presented in
Box 1.
The importance of identifying risk factors pre-
operatively cannot be overemphasized because the
selection of appropriate thromboprophylaxis is based
on the level of an individual patient’s risk. That is,
the choice of the most effective thromboprophylaxis
varies from one patient to another.
Prevention of Venous Thromboembolism
Over the past four decades, numerous clinical trials
have investigated several strategies to reduce post-
operative venous thromboembolism in a wide variety
of surgical populations. There is a limited number of
prospective trials in gynecologic surgery and none
that specifically focus on hysterectomy alone.
Thromboprophylaxis may be generally divided
into methods that reduce hypercoagulability (pharma-
cologic) and reduce stasis (mechanical). The seminal,
prospective, randomized, controlled trial, published in
1975, clearly demonstrated that the administration of
“low doses of heparin” significantly reduced fatal pul-
monary emboli in a general surgery and gynecologic
surgery population.30 A dose of 5,000 units heparin
was administered subcutaneously 2 hours preopera-
tively and then every 8 hours throughout the hospital
stay. Subsequent trials have demonstrated efficacy in
preventing DVT in surgery for benign gynecologic
Complications of Hysterectomy 659

Box 1. Venous Thromboembolism Risk Factors
Increasing age*
Previous venous thromboembolism*
Malignancy*
Surgery*
Treatment for cancer: chemotherapy or radiation*
Duration of anesthesia*
Nonwhite race*
Venous insufficiency (leg edema, varicose veins)*
Hormone use: oral contraceptives, hormone replace-
ment therapy, selective estrogen receptor modulators†
Inherited or acquired thrombophilia†
Major lower extremity trauma†
Pregnancy or postpartum period†
Obesity†
Smoking†
Prolonged immobility or paresis†
Acute medical illness†
Pulmonary or cardiac failure†
Inflammatory bowel disease†
Nephrotic syndrome†
Myeloproliferative disorders†
Paroxysmal nocturnal hemoglobinuria†
Central venous catheterization†
* Data from Clarke-Pearson DL, DeLong ER, Synan IS, Coleman
RE, Creasman WT. Variables associated with postoperative
deep venous thrombosis: A prospective study of 411
gynecology patients and creation of a prognostic model.
Obstet Gynecol 1987;69:146–50.
† Modified from Geerts WH, Pineo GF, Heit JA, Bergqvist D,
Lassen MR, Colwell CW, et al. Prevention of venous
thromboembolism: the Seventh ACCP Conference on
Antithrombotic and Thrombolytic Therapy. Chest
2004;126:338-400S.
conditions. In these trials, the heparin was administered
every 12 hours postoperatively.31–33
However, in a prospective study that included
patients at higher risk with gynecologic malignancies,
the 12-hour regimen was found to result in no benefit
when compared with the control group.34 A subse-
quent randomized trial found that administering the
heparin every 8 hours postoperatively was effective in
significantly preventing venous thromboembolism in
a gynecologic oncology population.35 Similar findings
have been reported in other high-risk surgical popu-
lations and subsequent management guidelines advise
more “intense” low-dose heparin regimens in patients
at higher risk.27
Although low-dose heparin rarely has a measurable
effect on coagulation (prolonging partial thromboplastin
time), an increase in bleeding complications—especially
wound and injection site hematomas—is reported. How-
ever, serious hemorrhagic complications are not
increased in patients receiving low-dose heparin.
An alternative to low-dose unfractionated heparin
is low-molecular-weight heparin. When compared
660 Clarke-Pearson and Geller Complications of Hysterectomy
with unfractionated heparin, low-molecular-weight
heparins have more anti-Xa and less anti-thrombin
activity, leading to less effect on partial thromboplas-
tin time. An increased half-life of 4 hours results in
increased bioavailability when compared with unfrac-
tionated heparin and therefore allows the convenience
of dosing once per day dosing. Randomized con-
trolled trials in gynecologic surgery comparing low-
molecular-weight heparin with unfractionated heparin
have shown no difference in the incidence of DVT or
frequency of bleeding complications.36
Reduction in venous stasis during and after gyne-
cologic surgery has been investigated using either
graded compression stockings or intermittent pneu-
matic compression devices. If fitted properly, graded
compression stockings provide modest benefit in reduc-
ing the incidence of venous thromboembolism.37
Should the upper portion of the stocking roll down
the leg, a tourniquet effect could actually increase stasis
and result in an increase in venous thromboembolism.38
Intermittent pneumatic compression devices have
been shown to reduce the incidence of venous
thromboembolism with little or no risk. The use of
intermittent pneumatic compression in the perioper-
ative period (intraoperatively and into the first post-
operative day) has been shown to be effective in
patients at moderate risk. However, in patients at
higher risk (women with gynecologic cancers), peri-
operative use was found to be ineffective.39 In these
higher-risk gynecologic surgery patients, using inter-
mittent pneumatic compression in the operating room
and continuing its use throughout the hospital stay has
been shown to reduce venous thromboembolism by
approximately threefold.40
Two trials in gynecologic surgery directly compar-
ing low-dose unfractionated heparin or low-molecular-
weight heparin with intermittent pneumatic compres-
sion showed equivalent efficacy.41,42 The potential ben-
efit of combining intermittent pneumatic compression
and a pharmacologic agent has been investigated in
general surgery and was found to be beneficial in
high-risk patients. Although there are no trials of “com-
bination prophylaxis” in gynecologic surgery, it is rea-
sonable to combine both a pharmacologic agent and
intermittent pneumatic compression in patients at very
high risk for venous thromboembolism complications
(age older than 60 years, cancer, previous venous
thromboembolism, or a combination of these).
Diagnosis and Management of
Venous Thromboembolism
The clinical signs and symptoms of DVT (leg pain,
edema, erythema) are often misleading and may
OBSTETRICS & GYNECOLOGY
represent other conditions. Further, it is estimated that
nearly 50% of patients who have DVT have no
symptoms at all. Likewise, pulmonary emboli may
be clinically occult and only suggested by a decrease
in pulse oximetry or mild tachycardia. In patients with
any suspicion of DVT, the first line of evaluation is
a duplex Doppler venous ultrasonography. In symp-
tomatic patients, this noninvasive testing is accurate,
especially when the thrombus is located in the femoral
vein. Doppler is less accurate in detecting thrombi in
the calf or pelvis. In this case, alternative studies to
evaluate for DVT include magnetic resonance imag-
ing or contrast venography. Patients suspected of
having a pulmonary embolus should be studied with
chest CT scan or a ventilation-perfusion lung scan.
Pulmonary arteriogram is the “gold standard” of diag-
nostic methods for pulmonary embolism but is rarely
necessary.
Management of either DVT or pulmonary embo-
lism is based on supportive care (respiratory support,
leg elevation, pain control) and immediate anticoagu-
lation. In acute situations, intravenous heparin is the
primary mode of initial treatment. The treatment goal
is to achieve an activated partial thromboplastin time of
two-times to three-times the control value. In less acute
situations, subcutaneous low-molecular-weight heparin
has been shown to be equally effective. The use of low-
molecular-weight heparin may eliminate the costs of
hospitalization and monitoring the activated partial
thromboplastin time.43 In most cases, patients may be
quickly transitioned to oral therapy using warfarin for
3–6 months.
GENITOURINARY AND GASTROINTESTINAL
TRACT INJURIES
Injury to the GU tract (bladder or ureter) is estimated
to occur at a rate of 1–2% for all major gynecologic
surgeries.44 It is estimated that 75% of these injuries
occur during hysterectomy, which leads to approxi-
mately 5,000 injuries per year in the United States.45
Based on route of surgery, one randomized trial of
more than 1,300 hysterectomies reported a rate of
bladder injury of 1% for abdominal, 2.1% for laparo-
scopic, and 1.2% for vaginal hysterectomy.46 Other
estimates range from 0.3% to 1.2% for abdominal,
0.2% to 8.3% for laparoscopic, and 0.7% to 4% for
vaginal hysterectomy.3 A 2009 Cochrane Review
found no difference in the rate of GU tract injury
(bladder or ureter) based on subtype of hysterectomy.3
There also was no difference between abdominal
and vaginal hysterectomy. There was an increased
risk of GU (combined bladder and ureter) injury dur-
ing laparoscopic hysterectomy when compared with
VOL. 121, NO. 3, MARCH 2013 Clarke-Pearson and Geller
abdominal hysterectomy, with an OR of 2.41 (CI
1.24–4.82), and compared with vaginal hysterectomy,
with an OR of 3.69 (CI 1.11–12.24).
Ureteral injury occurs less frequently than bladder
injury, but also is grossly underestimated.44,47 Studies
have shown that, on average, two-thirds of ureteral
injuries go unrecognized at the time of surgery.44 With
that in mind, the incidence of ureteral injury is esti-
mated at 0.05–0.5% for gynecologic surgery, with
the laparoscopic route having the highest rate and
the vaginal route having the lowest rate.47,48 The
2009 Cochrane Review found no difference in the rate
of ureteral injury based on route of surgery.3 Injuries
are most likely to occur during dissection along the
pelvic sidewall, especially when dissecting along the
infundibular-pelvic ligament. Less frequent sites of
injury include the lower uterine segment during liga-
tion of the uterine vessels and the bladder base during
ligation of the cardinal and uterosacral ligaments. Risk
factors that increase the rate of ureteral injury include
previous pelvic surgery, hemorrhage, endometriosis,
cancer, compromised exposure attributable to large
pelvic masses or leiomyomas, and obesity.
Bladder injury most often occurs when dissecting
in the prevesical plane, especially during creation of a
bladder flap during abdominal or laparoscopic hys-
terectomy or during anterior colpotomy at the time of
vaginal hysterectomy. These types of injuries are often
apparent at the time of surgery, although serosal
injuries that do not create a full-thickness defect in
the bladder wall can lead to delayed cystotomy and
vesicovaginal fistula formation in the postoperative
period.49 Previous cesarean delivery, endometriosis,
pelvic adhesive disease, and cancer increase the risk
of cystotomy during hysterectomy.
Prevention of Genitourinary Tract Injury
The mainstay of prevention of GU tract injuries is
proper identification of these structures to avoid
them during dissection. Placing a Foley catheter at
the beginning of the case and verifying drainage will
decrease the rate of bladder injury no matter what
route of hysterectomy is performed. Alternatively,
identification of the Foley bulb or filling the bladder
retrograde also can help to identify the boundaries of
the bladder during dissection, whether through direct
visualization in the pelvis or from the vaginal route
before anterior colpotomy. This identification also
can be accomplished by placing a blunt metal probe
into the bladder through the urethra to delineate its
borders.
When entering the peritoneal cavity, either
through an abdominal incision or with a laparoscopic
Complications of Hysterectomy 661
trocar, bladder location should be considered and entry
should be placed sufficiently cephalad. This placement
can be confirmed laparoscopically by applying pres-
sure at the site of the proposed trocar placement before
making any incisions or with the use of a needle when
injecting a local anesthetic agent. During abdominal or
laparoscopic hysterectomy, it is important to mobilize
the bladder flap before uterine artery ligation and
cervical amputation to avoid inadvertent incorporation
of any bladder tissue into these incisions. Sharp
dissection will allow more careful identification of the
anatomic planes, especially if scarring is encountered
from previous cesarean delivery or other surgery.
During vaginal hysterectomy, sharp dissection at the
time of anterior peritoneal entry is recommended to
mobilize the bladder base and reduce the risk of injury.
Subsequent placement of a retractor in this vesicova-
ginal plane is recommended to elevate the bladder
away from further dissection.
The same principles of identification hold true for Fig. 1. Vascular and ureteral anatomy encountered during
hysterectomy. Illustration by John Yanson.
preventing ureteral injuries. The ureters pass over the
Clarke-Pearson. Complications of Hysterectomy. Obstet Gynecol
bifurcation of the common iliac vessels before diving 2013.
below the uterine artery and passing anterior and
lateral to the cervix50 (Fig. 1). Identification of the
ureter on the medial leaf of the broad ligament is but rather a thinning of the bladder wall. A full-
critical when operating in the pelvis. If not seen thickness injury will usually reveal leakage at the site
directly, a retroperitoneal approach can be used by of injury.
opening the para-rectal space. Maintaining surgical Ureteral injuries can be classified according to
principles such as avoiding aggressive surgical ped- type of injury—thermal, obstructive, or mechanical
icles and remaining medial to all previous surgical transection—as well as location in relation to the pelvic
pedicles when performing the hysterectomy also will brim. These classifications will help to determine what
help to prevent ureteral injury. In addition, if hemor- type of repair will ensure a tension-free anastomosis.
rhage is encountered in the pelvis, applying pressure
is more prudent than clamping and ligating when Identification of Injury
the surgical field is obscured. Preoperative ureteral Identification of a bladder injury can be obvious, with
stenting has not been shown to decrease the rate of extravasation of urine at the time of cystotomy.
ureteral injury during hysterectomy.51 However, intra- However, a small injury might go unrecognized.
operative stenting in cases in which identification of Retrograde injection of 300 mL of indigo carmine,
the ureters is not otherwise possible can be useful. methylene blue, or sterile milk into the bladder
through a Foley catheter should identify the presence
Type of Genitourinary Tract Injury of a bladder injury, the number of sites of injury, and
Injury to the bladder is often classified by location in the presence of any serosal or muscularis injuries
reference to the dome and the trigone, as well as the (which would appear as a thinning of the bladder wall
depth of injury, including whether it is full-thickness without actual leakage). Cystoscopy with a 30-degree
or isolated to the serosa and underlying muscularis. or 70-degree scope also is a useful adjunct in the
Injuries to the bladder that occur during hysterectomy diagnosis of a bladder injury. Again, at least 300 mL
are usually intraperitoneal and usually occur near the of saline should be used to distend the bladder walls
dome of the bladder. Bladder injuries that are near the sufficiently to uncover smaller defects. This method is
trigone may require more extensive evaluation to particularly useful during vaginal surgery when full
avoid concomitant ureteral injury during repair. inspection of the bladder is difficult. The finding of air
Injuries to the serosa or muscularis of the bladder in the Foley collection bag during laparoscopic
can be distinguished from full-thickness mucosal surgery is highly suspicious for a bladder injury and
bladder injuries in that there is no leakage of urine calls for careful inspection as described.

662 Clarke-Pearson and Geller Complications of Hysterectomy OBSTETRICS & GYNECOLOGY

 A ureteral injury can be more subtle than a
bladder injury. Unless the transected lumen of the
ureter is seen during dissection, a partial-thickness or
full-thickness injury can go unnoticed. Intravenous
injection of indigo carmine can reveal both transec-
tion (with extravasation of dye) or obstruction (lack of
flow of dye into the bladder as visualized by cystos-
copy). Usually 1 or 2 ampule (2.5 mL) of intravenous
indigo carmine is sufficient to make a diagnosis. This
dose can be repeated if necessary. There is a small risk
of anaphylaxis attributable to indigo carmine, and
therefore the anesthesiologist should be made aware
of any use of this dye. If an injury is suspected based
on lack of flow, intraoperative ureteral stenting with
retrograde ureterogram under fluoroscopy can be
performed to localize the injury. Ureteral stenting
not only is helpful for diagnosis but also can aid in
ureteral repair.
If the diagnosis of a GU tract injury is missed
during the intraoperative period but is suspected
during the postoperative period, either a cystogram
or an abdominal or pelvic CT with contrast should
help identify the site of injury.
If injury to the bladder or ureter is suspected
postoperatively, there are several symptoms that
should increase suspicion. Postoperative fever, hema-
turia, abdominal or flank pain, ileus, signs of ascites, an
acute abdomen, or a combination of these may be
present on examination. Depending on the extent of
damage and the status of the other kidney, a chemistry
panel may reveal an elevated creatinine, hyponatremia,
and possibly hyperkalemia. “Ascites” may be evaluated
for creatinine levels in comparison with serum creati-
nine. Urine leaking into the peritoneal cavity will result
in a much higher creatinine level in the peritoneal fluid
when compared with serum creatinine.
Treatment and Repair of Genitourinary
Tract Injuries
A general principle of repair of an intraperitoneal
bladder injury is a tension-free two-layer closure with
patency confirmed after closure of the first layer.52
Any damaged tissue at the site of the injury should
be removed before closure. This is especially impor-
tant with an electrosurgical injury. After viability of
the edges of the cystotomy is confirmed, a running
layer of 3-0 delayed absorbable suture can be used
to close the defect in a tension-free manner. At this
point, 300 mL of either sterile milk or saline mixed
with indigo carmine or methylene blue should be
instilled retrograde through the Foley catheter into
the bladder. The catheter is then clamped, and the
closure site is examined for sites of leakage. If no
VOL. 121, NO. 3, MARCH 2013 Clarke-Pearson and Geller
leakage is seen, the bladder is drained and a second
imbricating layer of 2-0 delayed absorbable suture is
placed in the same orientation as the first layer. If
leakage is noted, interrupted sutures can be placed
until complete closure is achieved. This always should
be performed before placement of the second layer of
sutures.
If the bladder defect consists of a serosal or
muscularis tear (but with the underlying mucosal
layer intact), a single-layer closure with interrupted
2-0 delayed absorbable suture is usually adequate. It is
preferable to fill the bladder as described, not only to
confirm that the injury is purely serosal or muscularis
but also to verify that there are no other sites of injury
to the bladder. Injuries near the trigone may involve
or potentially compromise the ureteral orifice. Eval-
uation of the trigone with either cystoscopy or open
cystotomy should be undertaken before and after
repair of the cystotomy. Placement of ureteral stents
may be required to ensure patency of the ureter. For a
trigonal injury, we usually insert a suprapubic catheter
for longer-term drainage to avoid having the catheter
rest on the cystotomy repair.
Based on the size of the bladder injury, prolonged
postrepair catheter drainage may be necessary. A
simple cystotomy at the dome that is smaller than
1 cm can be drained for 3–5 days with a transurethral
Foley catheter. A larger injury or one located at the
trigone will necessitate approximately 2 weeks of
drainage, preferably with a suprapubic catheter to
avoid any trauma to the repair site. Bladder compe-
tency should be confirmed with a cystogram before
removal of the catheter.
Repair of a ureteral injury depends not only on
the nature of the injury but also on its location within
the pelvis. Ureteral obstruction attributable to kinking
with a suture often can be resolved by removing the
stitch and confirming ureteral efflux on cystoscopy.
A minor crush injury often can be managed by
stenting, whereas a major crush injury will require
resection of the injured portion of ureter with rean-
astomosis. A partial laceration of the ureter can be
repaired with an absorbable suture after stenting. A
complete laceration will require reanastomosis with
stenting. The type of repair will depend not only on
the location of the laceration but also on how much
length of the ureter is involved in the injury. Impor-
tant points to remember when repairing the ureter
include careful mobilization to avoid ureteral devas-
cularization. As with bladder injuries, the edges of the
ureteral injury should be viable. Any devascularized
tissue should be removed. Stenting is another impor-
tant step in the repair to assure patency during
Complications of Hysterectomy 663
healing. A critical point is that the repair must be
tension-free. If this step is not addressed, failure of the
repair is likely.
To assure a tension-free repair, the location of the
injury dictates the type of anastomosis that will take
place. Injuries that occur in the proximal two-thirds of
the ureter usually can be repaired using an end-to-end
reanastomosis with 4-0 absorbable suture. This is called
a ureteroureterostomy. If a large segment of ureter has
been removed, it may be necessary to implant the
damaged ureter into the lumen of the contralateral
ureter. This is called a transureteroureterostomy. If
ureteral injury occurs in the distal one-third of the
ureter, as is most common during gynecologic proce-
dures, the proximal end of the ureter can be tunneled
through the full thickness of the bladder and affixed
to the mucosal surface with a 3-0 absorbable suture.
This is called a ureteroneocystostomy. If there is any
concern for tension at the repair site, the bladder can be
brought cephalad and fixed to the psoas muscle in what
is called a psoas hitch.
With any of these repairs, a stent should be placed
in the ureter and a closed suction drain should be
placed at the site of anastomosis. A catheter also
should be placed in the bladder to avoid urinary
retention and back-flow of intravesicular pressure.
These drains should be left in place for at least 1 week.
A CT scan with contrast also should be performed not
only to confirm patency of the repair but also to look
for any areas of stenosis.
Gastrointestinal Tract
Injury to the GI tract after hysterectomy ranges from
0.1% to 1%, with estimates of 0.3% for abdominal and
0.2% for laparoscopic hysterectomy.8 The occurrence
of bowel injury with vaginal hysterectomy ranges
from 0.1% to 1.0%.3,10 There was no difference in rate
of bowel injury based on subtype or route of hyster-
ectomy according to a 2009 Cochrane Review.3
Prevention of Gastrointestinal Tract Injury
Prevention of a bowel injury can be accomplished
through understanding the potential sites of harm as
well as good surgical technique, such as gentle tissue
handling, careful dissection along anatomic planes,
judicious use of electrosurgery, and compression of
bleeding rather than clamping when the surgical field
is obscured.
In the past, mechanical bowel preparation was
advised. Advantages were thought to include improved
exposure in the pelvis with decompressed bowel and
deceased bacterial load if bowel injury were to occur.
However, randomized trials have shown no clinical
664 Clarke-Pearson and Geller Complications of Hysterectomy
benefit to bowel preparation, even when bowel surgery
is anticipated.53,54 Oral antimicrobial administration
also is not necessary before hysterectomy because par-
enteral antibiotics are administered.
Intraoperatively, the use of a nasogastric or
oralgastric tube also can help to decompress the
stomach and possibly prevent injury during the place-
ment of laparoscopic trochars. If performing laparo-
scopic surgery, care should be taken not only with
placement of insufflating needles and trocars but also
with manipulation of any laparoscopic instruments,
especially electrosurgical instruments. These instru-
ments should be inspected for any signs of disruption
of their protective insulation. This is true for abdominal
and vaginal cases as well as laparoscopic surgery. If
intra-abdominal adhesions are expected, an alternative
entry technique is a 2-mm to 5-mm incision at the
Palmer point, followed by insufflation, trocar, and
camera placement at this site to survey the lower
abdomen. An “open” entry technique also might be
considered. However, open entry for the initial port
has not been shown to reduce the incidence of GI
injury; it will reduce the incidence of vascular injury.
Type of Gastrointestinal Tract Injury
There are three major types of bowel injury that can
occur during hysterectomy: thermal injury; direct
mechanical damage; and indirect injury through inter-
ruption of vascular supply. Thermal damage can occur
with all types of hysterectomy but will most often go
undiagnosed during laparoscopic surgery. This is most
common with conductance of current from a monop-
olar instrument to the bowel during pelvic dissection,
especially deep in the pelvis, at the cuff, or in the
cul-de-sac, where visualization is not as clear.
Direct mechanical damage to the bowel can occur
both with sharp and blunt instruments. This type of
injury most commonly occurs during adhesiolysis.
Although more likely to be recognized at the time
of surgery, some serosal tears can go unnoticed.
Mechanical injuries also can occur with placement of
laparoscopic instruments.
Vascular injuries can occur with interruption of
the blood supply coursing through the mesentery to
the bowel. Such dissection rarely is indicated with
a benign hysterectomy, but the risk of devasculariza-
tion always should be recognized.
Identification of Injury
Thermal injuries to the bowel can go unrecognized at
the time of surgery. However, inspection may reveal
blanched spots on the serosal surface of the bowel. If
left unrepaired, a thermal injury often has a delayed
OBSTETRICS & GYNECOLOGY
course. The typical signs of bowel injury, including
fever, elevated white blood cell count, nausea, vomiting,
abdominal distention, and acute abdomen usually do
not develop for several days to weeks postoperatively.
Direct mechanical injury to the bowel is more
often recognized at the time of surgery, either as
a denuding of the serosal surface or as a full-thickness
defect in the bowel wall. However, even with careful
inspection of the bowel, smaller defects may go
unnoticed. Denuded areas may develop into perfo-
rations postoperatively. The classic signs and symp-
toms of a bowel perforation include fever, elevated
white blood cell count, nausea, vomiting, and an acute
abdomen. The diagnosis can be confirmed by an
abdominal and pelvic CT with oral contrast.
Vascular injury to the bowel usually will have an
indolent course, being diagnosed later in the post-
operative period. The classic signs and symptoms of
bowel injury often will be seen, although the response
may be blunted.
When injury to the recto-sigmoid colon is sus-
pected, a “bubble test” may be most instructive. A
proctoscope is inserted transanally, and saline is
placed in the pelvis to cover the area of colon in
question. Proximally, the colon is occluded by hand
compression or a bowel clamp. The recto-sigmoid is
then insufflated with air through the proctoscope. If
bubbles appear in the saline, a defect in the colon
must then be located and repaired.
Treatment and Repair of Gastrointestinal
Tract Injuries
Management of a perioperative bowel injury depends
on the nature and severity of the insult. Bowel rest and
antibiotics are useful adjuncts. If delayed signs and
symptoms of a bowel injury develop, operative
exploration with resection of the damaged segments
is required. If a significant thermal injury is observed,
immediate resection is essential. Because thermal
injury with monopolar electrosurgery involves the
conductance of energy beyond the site of effect,
careful inspection of the site of injury is necessary to
ensure that healthy margins are repaired. An injury
related to bipolar electrosurgery will not have the
same thermal spread, but care should be taken to
examine the tissue carefully for signs of damage.
Small isolated sites of electrosurgery damage may be
managed with closure of the defect with a 2-0 absorb-
able suture in a transverse fashion to avoid narrowing
of the lumen. Larger injuries will necessitate segmen-
tal resection and reanastomosis.
Immediate or delayed injury to the bowel that has
led to direct mechanical trauma or vascular disruption
VOL. 121, NO. 3, MARCH 2013 Clarke-Pearson and Geller
with necrosis will require local excision with reanas-
tomosis. Rarely is a diverting colostomy or ileostomy
necessary in the face of a colonic injury. Indications
for diverting colostomy would include extensive
trauma resulting in compromised blood supply,
extensive infection, or a history of radiation to the
injured area. Small areas of denudement of the serosa
may be managed by oversewing the serosa, again in
a transverse fashion to avoid narrowing of the lumen.
Surgical principles, such as gentle handling of
tissue with moist laparotomy sponges, use of appro-
priate surgical instruments, and assuring adequate
blood supply, can help ensure a successful repair. In
addition, as with repair of a GU tract injury, a tension-
free repair is critical.
The value of nasogastric suction has been debated,
and many surgeons no longer use one in the post-
operative period. We prefer postoperative bowel rest
until bowel sounds have returned. At that point, diet
can be advanced to liquids. Regular food can be given
once flatus has returned.
BLEEDING COMPLICATIONS
OF HYSTERECTOMY
Bleeding complications associated with hysterectomy
are related to several variables, including the type of
hysterectomy performed. Based on the results of
randomized trials comparing two or more routes of
hysterectomy, the median range of estimated blood
loss for abdominal hysterectomy is 238–660.5 mL, for
laparoscopic hysterectomy is 156–568 mL, and for
vaginal hysterectomy is 215–287 mL.3 When compar-
ing estimated blood loss based on route of hysterec-
tomy, a Cochrane review showed that laparoscopic
hysterectomy had a significantly lower estimated
blood loss than abdominal (OR 245.26, CI 272 to
217) and vaginal hysterectomy had a significantly
lower estimated blood loss than laparoscopic hyster-
ectomy (OR 9.72, CI 250 to 269).
Other blood loss parameters, including transfu-
sion, decline in hemoglobin, hematoma, and vascular
injury, also were correlated with surgical route in
some cases. For example, transfusion was more likely
after laparoscopic compared with vaginal hysterec-
tomy (OR 2.07, CI 1.12–3.81), with no difference
between laparoscopic and abdominal or vaginal and
abdominal hysterectomy. Change in hemoglobin was
less for laparoscopic than abdominal hysterectomy
(OR 20.55, CI 20.082 to 20.28). The incidences
of pelvic hematoma and vascular injuries were not
significantly different between the three routes of
hysterectomy.
Complications of Hysterectomy 665
Prevention
There are many variables that contribute to increased
bleeding complications, including obesity, poor visual
exposure (attributable to endometriosis, adhesions,
large masses), distorted anatomy, uterine fibroids, skill
of the surgeon, volume of the surgeon’s practice, sur-
gical volume of the hospital, pharmacologic venous
thromboembolism prophylaxis, concurrent use of aspi-
rin and other antiplatelet drugs, and over-the-counter
preparations (including, but not limited to, garlic, gin-
ger, ginko, and St. John’s wort).55
Few data exist that prospectively describe the
most common sites of intraoperative bleeding at the
time of hysterectomy. The pelvis has a rich blood
supply arising predominately from the external and
internal iliac arteries. Other arterial supply comes
from the inferior mesenteric artery (supplying the
sigmoid colon) and the ovarian arteries. The venous
drainage from the pelvis is even more complex, with
a network of collateral veins that drain through the
external iliac, internal iliac, inferior mesenteric, and
ovarian veins. It is likely that the majority of significant
intraoperative bleeding comes from injury to these
pelvic veins.
Understanding and identifying the vascular anat-
omy of the pelvis and its relationship to other organs
(ureter, bladder, rectum) are central to preventing
hemorrhagic complications. This is even more impor-
tant when the anatomy and anatomic land marks are
distorted by other pathology (Fig. 1). Being familiar
with the retroperitoneal anatomy also helps protect
vital structures and vessels in the course of a difficult
dissection. Taking advantage of surgical planes that
are avascular is key to preventing vascular injury
and in controlling bleeding. These spaces include par-
arectal space, paravesical space, rectovaginal septum
or space, cervico-vesicle plane, and retropubic space
(space of Retzius).
Identification
In the course of performing a hysterectomy (by
whatever technique or route), the primary vascular
supply to the uterus must be controlled. Basically, this
involves controlling the ovarian and uterine blood
supply. Loss of control of these vascular pedicles often
results in obvious bleeding, which usually can be
managed by clamping and ligating the pedicle. When
clamping bleeding vessels, especially the ovarian and
uterine vessels, care must be taken to identify the
ureter as well as other vessels on the pelvic side wall.
Suture ligature, hemostatic clips, and bipolar and
monopolar electrosurgery are all reasonable means
to obtain hemostasis—once vessels have been identified
666 Clarke-Pearson and Geller Complications of Hysterectomy
—depending on the situation and skills of the surgeon.
Additional bleeding may arise either when the bladder
is dissected from the cervix and upper vagina or when
the vagina is incised in performing the colpotomy to
remove the uterus (also occurring at the initiation of
a vaginal hysterectomy).
More serious bleeding occurs from injury to the
plexus of pelvic veins, which are not easily isolated or
dissected. The best means to manage bleeding from a
venous plexus is direct pressure with a laparotomy
pack or sponge to immediately control the bleeding site.
Management
The surgeon then must assess the extent of the vascular
injury and develop a plan of management, which
includes the following: obtaining better exposure by
extending the incision, placing a different retractor, and
adjusting lighting (including considering the use of
a headlamp); obtaining additional assistance and addi-
tional suction; assuring that the patient is stable and
that the anesthesia team has adequate blood products
available (additional intravenous lines for rapid blood
product infusion may be necessary); and securing
necessary supplies that may be used to obtain hemo-
stasis (suture, clips, and hemostatic agents).
Once these steps have been taken, the area of
bleeding is slowly exposed to ascertain the site and
extent of the vascular injury. In many cases, direct
pressure on a small venous bleeding point may
coagulate on its own. If the bleeding site can be
identified and isolated, it may be clamped and suture-
ligated or clipped. Use of hemostatic agents contain-
ing thrombin or coagulation products that come in
solid, liquid, or powder form, combined with pres-
sure, may be necessary to control diffuse bleeding
from a venous plexus.
During significant bleeding, attention must be
paid to the patient’s overall status and the surgeon
must be certain that adequate blood products (includ-
ing clotting factors) are being replaced. In most instan-
ces, pressure on the bleeding site will stop bleeding
and allow time to replace blood and blood products.
The error we have seen too often is not recognizing
that the patient has become depleted of clotting fac-
tors in the course of trying to achieve hemostasis,
resulting in additional diffuse bleeding from other
sites. A general rule is to replace clotting factors
(fresh-frozen plasma, cryoprecipitate, platelets) for
every 4 units of packed red blood cells administered,56
although newer trauma data recommend a 1:1 ratio
for massive blood loss.57 For more difficult bleeding,
ligation of the anterior division of the internal iliac
arteries has been successful in decreasing the arterial
OBSTETRICS & GYNECOLOGY
pressure in the pelvis, resulting in decreased blood
flow and a better chance to identify and control the
bleeding site.
Ultimately, if bleeding cannot be controlled,
a pressure pack should be placed firmly in the pelvis
and the patient should be taken to the intensive care
unit. Maximal hemodynamic support and replace-
ment of blood products are the immediate goal of
advanced hemorrhage, with consideration of interven-
tional radiology assessment for arterial embolization.
Once stable, after 48–72 hours, the patient should be
returned to the operating room to remove the pack
and make further surgical attempts at hemostasis. We
have been pleasantly surprised to find that many times
the packing results in hemostasis.
NERVE INJURY ASSOCIATED
WITH HYSTERECTOMY
Neuropathy after hysterectomy is a rare but signifi-
cant event. A review of the literature reveals a rate of
0.2–2% after major pelvic surgery.58,59 For benign hys-
terectomy, the rate is likely near the lower end of this
range, because more nerve injuries are associated with
radical pelvic cancer surgery. The following discus-
sion addresses the major neuropathies that can occur
during hysterectomy. Principles of prevention, identi-
fication, and management are addressed specifically
for the more common neuropathies associated with
hysterectomy. Less common neuropathies are listed
in Table 1.
Femoral
The most common neuropathy associated with pelvic
surgery involves the femoral nerve.58,60 Arising from
the L2 to L4 nerve roots, the femoral nerve travels
beneath the psoas muscle, emerging at its lateral bor-
der, across the iliacus muscle, passing through the
inguinal canal, and running down the anterior thigh.
The femoral nerve supplies both motor and sensory
function to the pelvis and lower extremities. It directly
innervates several muscles, such as the psoas, iliacus,
sartorius, pectineus, and quadriceps (vastus medialis,
intermedius and lateralis, and rectus femoris). It also
provides sensation to the anterior thigh. In addition,
the saphenous nerve is a branch of the femoral nerve
originating distal to the inguinal ligament that inner-
vates the anterior patella, anteromedial aspect of the
lower leg, and medial aspect of the foot. The most
common sites of femoral nerve injury are the anterior
surface of the psoas muscle and the inguinal canal.
Femoral nerve injury along the psoas muscle usually
is attributable to direct compression of the femoral
nerve from the blades of a self-retaining retractor
VOL. 121, NO. 3, MARCH 2013 Clarke-Pearson and Geller
(Fig. 2). This risk is increased with a thin body habitus,
long retractor blades, and prolonged operative time.61
Prolonged compression of the nerve by retractors
results in ischemic injury as well as “stretch” injury.
It would be extremely unusual for the femoral nerve
to be transected at the time of hysterectomy. The
other major type of femoral nerve injury is an indirect
stretch injury as the nerve passes through the inguinal
canal. Most commonly, this occurs with hyperflexion,
external rotation, or hyperflexion and external rota-
tion of the hip in the dorsal lithotomy position (Fig. 3).
Other factors that increase the risk of nerve injury
include diabetes mellitus, gout, uremia, alcoholism,
and malnutrition, all of which decrease vasculariza-
tion and the ability of the nerve to withstand insult.
Symptoms of a femoral nerve injury are usually
apparent within the first 72 hours after surgery.
Sensory symptoms can include numbness and para-
sthesia over the anterior thigh that may extend down
the anteromedial aspect of the leg and medial aspect
of the foot. There also may be dull pain in the inguinal
region. This is more likely with a direct compression
injury at that site. Motor deficits include weakness in
any or all of the muscle complexes that the femoral
nerve supplies. The classic finding is quadriceps
weakness, wherein the patient cannot straighten the
leg at the knee. This often becomes apparent when the
patient attempts to walk. Examination also will reveal
a weakened patellar reflex. This deficit can be quan-
tified not only by comparing quadriceps strength in
the unaffected side but also by comparing with
ipsilateral adductor strength, because the adductor
muscles are innervated by the obturator nerve and
should not be affected by a femoral nerve injury.
Careful neurologic examination usually is suffi-
cient to establish femoral nerve injury, but confirma-
tion can be accomplished with nerve conduction
studies and needle electromyography. However, these
electrodiagnostic tests should not be performed for at
least 2 weeks after the injury is sustained. In the first
7–11 days after nerve injury, the motor and sensory
axons can remain excitable and electrical stimulation
may demonstrate normal or only slightly reduced
responses, which can mask a more significant injury.62
Treatment of a femoral neuropathy includes phys-
ical therapy directed at range of motion and muscle
strengthening. Electrical stimulation also may be useful.
For symptomatic relief of pain and inflammation,
nonsteroidal anti-inflammatory drugs and acetamino-
phen are useful. Anticonvulsant medications such as
carbamazepine, phenytoin, and gabapentin may help
alleviate neuropathic pain. Use of a knee brace and a
cane may be helpful in the initial rehabilitation process.
Complications of Hysterectomy 667
Table 1. Less Common Nerve Injuries Associated With Hysterectomy

Nerve Origin Site of Injury Deficit Seen

Genitofemoral L1-L2 Compression with retractor Loss of sensation or parathesias

on anterior surface of over mons, labia majora, and
psoas muscle femoral triangle
Lateral femoral L2-L3 Compression with retractor Loss of sensation over
cutaneous on anterior surface of anterolateral thigh
iliacus muscle
Obturator L2-L4 Pelvic sidewall dissection Loss of adduction of the hip; loss
of sensation over medial thigh
Saphenous Posterior division of Compression of medial Loss of sensation over anteromedial
femoral nerve once aspect of knee in dorsal lower leg and foot
it passes beneath the lithotomy position
inguinal ligament
Sciatic L4-S3 Stretching in sciatic notch Gluteal pain radiating down posterior thigh
with hyperflexion of hips into popliteal
in dorsolithotomy position fossa, loss of hamstring
muscle function
Tibial L4-S2, sciatic nerve Compression of popliteal fossa Inability to dorsiflex foot or extend
divides into peroneal in dorsal lithotomy position toes; loss of sensation over plantar surface
and tibial branches of foot
Pudendal S2-S4 Compression at ischial spine Loss of sensation of vulva and perineum
with hemorrhage
Upper brachial C5-C7 Exaggerated lateral flexion Erb palsy, medial rotation and
plexus of the neck (example: extension of the arm
shoulder blocks)
Lower brachial C8-T1 Exaggerated abduction of Klumpke palsy, loss of intrinsic
plexus the arm (example: more than muscles of the hand
90-degree angle on arm (“claw hand”)
boards)
Ulnar C8-T1 Compression at medial Loss of sensation of fourth and
epicondyle fifth digits

Prognosis depends on the severity of the injury.
As the nerve bundles go through degeneration and
subsequent regeneration, mild neuropathies may
resolve within days to weeks, whereas more severe
cases may take months to possibly years. It is important
for the patient to understand that recovery may be
prolonged to prevent early feelings of fear and
frustration. Spontaneous resolution of most femoral
neuropathies is the rule rather than the exception.
Prevention of a femoral nerve injury is accom-
plished by good surgical technique. Care should be
taken with the placement of any self-retaining retrac-
tor. Examination of placement of the retractor blades
should be performed and periodically checked during
the case to ensure that they are not directly lying on
the psoas muscle. For some retractors, such as an
O’Conner-O’Sullivan retractor, the lateral blades may
be elevated off of the psoas muscle by placing towels
between the retractor and the abdominal wall. For
other retractors, elevation of the retaining ring off
of the abdominal wall and selection of appropriately
sized retractor blades (such as with a Bookwalter
retractor) is the surgeon’s responsibility. For patients
placed in the lithotomy position, a careful examination
of the legs should confirm that the hips are not
hyperflexed or overly externally rotated, no matter
what type of surgical stirrups are used.63 A general rule
is to line up the long axis of the lower extremity with
the umbilicus and the contralateral shoulder to ensure
the correct angle of external rotation of the hip. One
can assess for hyperflexion by palpating the popliteal
pulses. If the angle of flexion is great enough to com-
press the femoral artery in the inguinal canal, it is likely
causing compression of the nerve as well.
Iliohypogastric and Ilioinguinal Nerves
The iliohypogastric and ilioinguinal nerves also are at
risk for injury during hysterectomy, albeit less com-
monly than the femoral nerve.58 These nerves emerge
from the T12 to L1 and L1 to L2 regions, respectively,
and course through the muscles of the anterior abdom-
inal wall. Specifically, the iliohypogastric penetrates the
fascia of the internal oblique and the ilioinguinal pen-
etrates the fascia of the transverses abdominus. The

668 Clarke-Pearson and Geller Complications of Hysterectomy OBSTETRICS & GYNECOLOGY

Fig. 2. Femoral nerve injury with abdominal retractor
placement. Illustration by John Yanson. 1. Retractor blades
compressing the psoas muscle may also compress the
femoral nerve. 2. The femoral nerve can be compressed
beneath the inguinal ligament with hyperflexion of the hip.
Clarke-Pearson. Complications of Hysterectomy. Obstet Gynecol
2013.
iliohypogastric and ilioinguinal nerves provide sensory
supply to the medial thigh as well as the labia majora,
labia minora, and mons. They do not contribute any
component of motor function within the pelvis.
In an abdominal hysterectomy, the most common
site of injury of these nerves is at the level of the
anterior abdominal wall, where they may be transected
with a wide Pfannenstiel incision or simply by exces-
sive lateral stretching of the underlying layers of the
fascia. In general, a Pfannenstiel incision is 10–15 cm in
length. The risk of nerve injury is greatly increased if
the incision is extended beyond the lateral borders of
the rectus muscles. Stretch injury can occur from place-
ment of a self-retaining retractor in an already-widened
incision. During laparoscopic hysterectomy, the iliohy-
pogastric and ilioinguinal nerves may be injured with
laterally placed trocars. A good rule of thumb is to
place these trocars at least two fingerbreadths medial
to the anterior superior iliac spines. It is important to
note that injury also can occur with entrapment or
scarring related to closure of facial incisions.
Symptoms of injury usually include sharp, burn-
ing pain in the area of sensory distribution. This pain
may radiate into the perineum. Signs of injury usually
occur within hours to days of the insult.
Peroneal Nerve
The peroneal nerve originates from the L4 to S2
region of the lumbosacral roots, emerging from the
division of the sciatic nerve within the popliteal fossa.
Peroneal nerve injury during hysterectomy is rare.58
VOL. 121, NO. 3, MARCH 2013 Clarke-Pearson and Geller
Fig. 3. Femoral nerve injury in lithotomy position. Illus-
tration by John Yanson. 1. The tibial nerve can be com-
pressed in the popliteal fossa with hyperflexion of the knee.
2. The peroneal nerve can be compressed at the lateral
fibular head if the leg is allowed to rest against the stirrup.
3. The sciatic nerve can be compressed in the sciatic notch
with hyperflexion of the hip. 4. The femoral nerve can be
compressed at the inguinal ligament with hyperflexion of
the hip. 5. The nerves of the brachial plexus can be
stretched with either exaggerated lateral flexion of the neck
or abduction of the arm more than 90 degrees or com-
pressed with shoulder blocks. 6. The ulnar nerve can be
compressed against the medial epicondyle, which is more
likely when the arms are tucked at the patient’s sides
Clarke-Pearson. Complications of Hysterectomy. Obstet Gynecol
2013.
At the level of the fibular head, the common peroneal
nerve divides into the superficial and deep peroneal
branches. The superficial branch is more prone to
injury because it wraps around the lateral aspect of
the fibular head and is only protected by a layer of
subcutaneous tissue. The superficial peroneal nerve
has both motor and sensory function. It supplies the
peroneus longus and the peroneus brevis muscles of
the lower leg. It also provides sensory input to the
anterior and lateral aspects of the lower leg and
the dorsum of the foot, excluding the skin between
the great and second toes.
Peroneal nerve of injury can occur during hys-
terectomy when the patient is placed in the dorsal
lithotomy position using stirrups. Pressure from the
stirrup on the lateral edge of the fibular head is the
cause of this compression injury. The classic finding
with peroneal nerve injury is “foot drop.” This is often
apparent the first time a patient attempts to ambulate
after surgery. Sensory deficits also can be apparent
along the sensory distribution of this nerve.
Neuropathies associated with hysterectomy are
uncommon but can be debilitating if they do occur.
Most neuropathies can be prevented by careful
Complications of Hysterectomy 669
attention to positioning on the operating table and
good surgical technique. A thorough understanding of
the pathophysiology of injury, identification of dys-
function, and timely initiation of treatment are essen-
tial to optimize outcome and to minimize patient
anxiety when dealing with such an injury. Fortunately,
most injuries are transient and will recover spontane-
ously, although this may take several weeks to
months. Diligent counseling of patients not only after
an injury but also in the preoperative period is
essential.
VAGINAL CUFF DEHISCENCE
Vaginal cuff dehiscence is a postoperative complica-
tion unique to hysterectomy. Although it is a rare
complication, it can lead to serious morbidity. The
estimated incidence of vaginal cuff dehiscence is
0.24% based on 10-year cumulative data, but it is
slightly higher (0.39%) when assessing more recent
years.64 Total laparoscopic hysterectomy has the high-
est rate of vaginal cuff dehiscence (1.35%) compared
with laparoscopic-assisted vaginal hysterectomy
(0.28%; OR 4.9, CI 1.1–21.5), total abdominal hyster-
ectomy (0.15%; OR 9.1, CI 4.1–20.3), and total vag-
inal hysterectomy (0.08%; OR 17.2, CI 3.5–75.9).65
One estimate of cuff dehiscence after robotic total
hysterectomy based on 510 patients was 4.1%.65 How-
ever, there was no comparison with other routes. A
meta-analysis comparing vaginal, laparoscopic, and
robotic cuff closure found that vaginal closure has
the lowest incidence (0.18%), followed by laparo-
scopic (0.64%; OR 3.57, CI 1.54–8.33), and robotic
(1.64%; OR 9.09, CI 3.86–25.0).66 The increased risk
seen with the laparoscopic-assisted routes is thought to
be attributable to the unique use of monopolar elec-
trosurgery to perform colpotomy with these modali-
ties and possible differences in closure methods and
techniques.
Risk Factors and Prevention
Several risk factors have been postulated for the risk of
cuff dehiscence, with direct trauma from sexual inter-
course being most common.67 Other risk factors
include repetitive Valsalva maneuver (chronic cough,
constipation, obesity, straining), smoking, malnutrition,
anemia, diabetes, immunosuppression, menopausal
status, previous pelvic surgery, previous vaginoplasty,
and corticosteroid use.68 Because the rate of dehiscence
is so low, it is difficult to truly understand how these
risk factors contribute to the overall incidence. As
a result, there is little information regarding practice
recommendations to prevent cuff dehiscence. Some
hypothesize that “cold” incision of the vagina may be
670 Clarke-Pearson and Geller Complications of Hysterectomy
preferable to electrosurgery. When electrosurgery is
used, techniques that reduce thermal spread should
be used, including lower voltage, reduced tissue con-
tact, using a cutting (compared with coagulation) cur-
rent, and using other energy devices such as
a harmonic scalpel. There is no evidence that primary
closure of the cuff is preferable to secondary granula-
tion in terms of preventing a dehiscence.67 There is no
evidence that a two-layer closure is superior to a single-
layer or open cuff.69 One study reported decreased
dehiscence with use of a barbed suture during laparo-
scopic and robotic cuff closure.70 A retrospective anal-
ysis reported decreased dehiscence with transvaginal
suturing for total laparoscopic hysterectomy.71 Good
surgical technique can help to decrease the risk of
dehiscence, including minimal use of electrosurgery
for hemostasis, end-to-end tissue approximation with
incorporation of the all vaginal layers, 1-cm suture mar-
gins, and maintaining hemostasis.
Presentation
Vaginal cuff dehiscence usually occurs in the first
several weeks to months after surgery but can be
delayed up to several years (especially in postmeno-
pausal women). Median time to dehiscence has been
reported from 1.5 to 3.5 months.67,70 In one study,
median time to dehiscence was delayed up to 6.5
months in the vaginal hysterectomy group compared
with 2.5 months for all other routes.64 Vaginal cuff
dehiscence often presents with postcoital bleeding,
other vaginal spotting, or watery vaginal discharge.64,67
If bowel evisceration has occurred, patients often have
symptoms of pelvic pressure or a bulge. Any patient
suspected of having a cuff dehiscence requires a vaginal
examination with visual inspection and manual palpa-
tion to determine cuff integrity. An abdominal exami-
nation also should be performed to rule out an acute
abdomen from peritonitis, bowel injury, or obstruction.
If there is suspicion for occult bowel injury, CT imag-
ing should be considered.
Management
Vaginal cuff dehiscence can be managed either conser-
vatively or surgically. All dehiscences lead to exposure
of the peritoneal cavity to vaginal flora and should be
managed with broad-spectrum antibiotics. Small or
partial dehiscences can be managed expectantly with
pelvic rest. Larger or complete dehiscences usually
require surgical closure. This should be accomplished
vaginally when possible. If bowel evisceration has
occurred, the bowel must be thoroughly inspected for
injury. Although vaginal cuff dehiscence is rare, it can
lead to serious morbidity. Prevention, early recognition,
OBSTETRICS & GYNECOLOGY
and proper management can help to avoid life-threat-
ening consequences.
CONCLUSION
As one of the most common procedures performed in
the United States, hysterectomy has a large effect on
women undergoing this procedure and on their
families, employers, and caregivers. We have pre-
sented a review of the most common complications
associated with hysterectomy and recommendations
for prevention and management of these complica-
tions. As surgeons and health providers, our goal is to
provide optimal care while exposing our patients
to minimal risk. We can accomplish this by not only
recognizing the potential surgical complications of
hysterectomy but also using good surgical technique
to avoid these complications and performing timely
diagnosis and treatment of any complications.
Although we cannot avoid all surgical complications,
we can strive to minimize the risks for women
undergoing hysterectomy.
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