11

Complications of hysterectomy

D A V I D J. H I L L MBBS, MRCS, LRCP, FRACOG, FRCOG

Consultant Gynaecologist
Endosurgery Unit, Mercy Hospital for Women, 126 Clarendon Street, East Melbourne, ~ctoria, 3002,
Australia

The complications of hysterectomy are discussed, generally speaking their definition is

poorly standardized and direct comparisons are extremely difficult. Furthermore, there is
uncertainty as to what is meant by laparoscopic hysterectomy. The complications are
discussed as post-operative fever, haemorrhage, injury to adjacent organs, other compli-
cations and life-threatening events. The incidence of post-operative infection and haemor-
rhage is least with the laparoscopic approach, but injury to surrounding organs is probably
greater. In 1982, the Collaborative Review of Sterilization study data suggested an average
woman of reproductive age with no pre-existing medical condition, no previous abdominal
surgery, and who received prophylactic antibiotics, was best served by vaginal hyster-
ectomy without colpororrhaphy rather than an abdominal procedure. This does not seem
to have changed. The incidence of abdominal hysterectomy may be reduced by adding
laparoscopy to vaginal hysterectomy to deal with adhesive disease, endometriosis or
adnexal disease. Laparoscopic hysterectomy is feasible and safe but the indications for this
approach have not yet been established.

Key words: hysterectomy; complications; abdominal; vaginal; laparoscopic.

There have been two sizeable problems in writing this chapter. First, there
is no universally accepted standard of morbidity or definition of major or
serious complications regarding hysterectomy. The calls for some
standardization seem to h a v e been ignored. As stated by Dicker et at (1982)
each complication should h a v e the following characteristics:
1. It should be as objective as possible to minimize the differences in
diagnosis and practice.
2. It should be uniformly documented in, and easily abstracted from, the
hospital records.
3. It should be clinically reasonable and acceptable.
The list should be as short as possible but be inclusive enough to identify
most w o m e n with an adverse operative sequelae and should be applicable
to any institution where hysterectomies are performed.
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182 D . J . HILL

Most publications contain information which is not defined and therefore

a direct comparison may not be possible.
There are reports of total morbidity of a procedure; some authors include
all complications and others only what they would consider as serious or
major. There seems little point in publishing or quoting a total morbidity
rate as the literature shows, for example with laparoscopically assisted
hysterectomy, that the rate varies from 2,8 to 95% (O'Callaghan, personal
communication). This data cannot be used to compare surgical skills,
hospital safety or technique efficiency.
The second problem is with the definition of laparoscopic hysterectomy;
vaginal and abdominal hysterectomy allude to the route through which the
procedure is performed but this obviously cannot apply to the laparoscope.
There has been a suggested classification for the various laparoscopic
hysterectomies (Garry, 1994; Pelosi and Pelosi, 1994), but the laparo-
scopic ligation of the uterine arteries is the sine qua non for laparoscopic
hysterectomy.
A laparoscopically-assisted vaginal hysterectomy is commonly
mistakenly spoken about as though it includes all of the subclassifications
that Reich has denoted (Reich, 1994). However, the technique is what it
says--a vaginal hysterectomy plus a laparoscopic component to undertake
any number of other surgical procedures to facilitate the main intention
which is to remove the uterus and cure the patient's problem. This may
include adnexectomy, lysis of adhesions, and removal of endometriosis.
Up to June, 1995, the outcome of only 4,502 cases of laparoscopic
hysterectomies have been published (Deprest et al, 1995). In only 76.1%
of these was the uterine artery ligated laparoscopically. Where compli-
cations have been discussed there is no definition of that complication and
certainly no indication as to whether it occurred with what we are strictly
assuming is a laparoscopic hysterectomy. Thus, with such small numbers
to call upon for comparison, we can only generally view the overall
complications of hysterectomy to possibly see a trend rather than make
definite statements.
The data on complications of laparoscopic hysterectomy come from
retrospective reviews of single or groups of surgeons with a particular
interest or expertise in laparoscopic surgery, and this may underestimate or
not accurately reflect the problem.
A laparoscopic hysterectomy promises small surgical scars to replace the
large scar of laparotomy, less post-operative pain, shorter hospital stay, and
shorter recovery period. If a complication occurs which requires a
laparotomy incision to remedy it, it is much less well tolerated. Precise pre-
operative counselling is required to pre-empt a possible increase in medico-
legal activity.
In hospital corridors there is quiet rejoicing or disgust amongst one's
surgical colleagues when they hear of a laparoscopic hysterectomy
problem. Most hysterectomies are still performed abdominally in Australia,
the UK and the USA (Selwood and Wood, 1978; Gran and Asine, 1984;
Easterday et al, 1983).
Most critics do not allow for the very real learning curve of operative
COMPLICATIONS OF HYSTERECTOMY 183

laparoscopy. Jones (1995) demonstrated a 68% reduction in complications

in the second half of his review of 252 cases.
Many of the surgeons involved in laparoscopic surgery are middle-aged,
trained in classical techniques, and practise in isolation, and have to rapidly
embrace and develop a new form of surgery with new instrumentations, and
work from a video monitor with a two-dimensional view and subsequent
loss of depth of vision. The general operative field is reduced although
specific anatomy and pathology is magnified.
There are complications from the laparoscopic approach as well as
complications from the technique of hysterectomy as a result of creating a
pneumoperitoneum and the blind insertion of the first trocar (Semm, 1987).
These are visceral or vessel perforations leading to damage, haemorrhage
or gas embolism.
Intraoperative diagnosis and repair of an injury involves fewer
consequences, fewer serious complications and fewer medico-legal
activities, particularly when performed by laparoscopic surgery where
repair of bowel, bladder and ureter can be undertaken at the time of the
surgery and preferably laparoscopically.
Later complications with the laparoscopic approach are usually due to
secondary necrosis associated with diathermy bums. Electrosurgery is
relied upon to a degree that would surprise surgeons practised in vaginal
and abdominal hysterectomy.
For this discussion, only hysterectomies performed for benign disease
will be considered. No radical hysterectomies for malignancy, and no
caesarean hysterectomies complex are included. Subtotal hysterectomy is
not discussed.
As far as the definitions of the various complications are concerned,
great emphasis has been placed on the publications by Dicker et al (1982)
and Harris (1995).
This author draws upon his own experience and published data on
laparoscopic complications (Hill, 1994; Hill et al, 1994) and unpublished
data from the Mercy Hospital for Women, Melbourne reports (N. Beischer,
1978 to 1989) on abdominal (2,754 cases) and vaginal (474 cases)
hysterectomy.
In 1982, Dicker et al reported their findings of a Collaborative Review of
Sterilization (CREST). This was a prospective review of the complications
accompanying elective hysterectomy for benign disease in women of
reproductive age (15 to 44 years) between 1978 and 1981 by the vaginal
(568) and abdominal (1,285) routes. However, their results may be some-
what skewed by the fact that 74% of the cases had some other concurrent
gynaecological procedure, and prophylactic antibiotics were used in 82 and
32% of vaginal and abdominal hysterectomies respectively.
In 1995, Harris reported his review of all publications on vaginal and
abdominal hysterectomy since the CREST study.
In 1995, a meta-analysis of all published data on laparoscopic
hysterectomy was reported by Garry & Phillips (3,189 cases) and Deprest
et al (4,502 cases)
Complication categories to be discussed are listed in Table 1.
184 D.J. HILL
Table 1. Hysterectomy compli-
cation categories for discussion.
Post-operative fever
Haemorrhage
Injury to adjacent organs
Other complications
Life threatening events

POST-OPERATIVE FEVER

The term febrile morbidity is best avoided as there is confusion over the
definition. Hemsell (1991) reported finding 32 separate definitions of
febrile morbidity in the literature.
For the sake of clarity, the definition of post-operative fever should be a
temperature greater than 38°C on two occasions at least 4 hours apart and
more than 24 hours after surgery. Generally speaking, a lot of reported data
on post-operative fever is not defined.
The most common rates for post-operative fever from abdominal,
vaginal, and laparoscopic hysterectomy are shown in Table 2.

Table 2. Percentage rates of post-operative fever from three routes of hysterectomy.

Most common rates (%)
Hysterectomy route Abdominal Vaginal Laparoscopic
Unexplained fever 10-20 5-8 1.4
Operative site infection 13.8-42 7.8-20 4.3
Urinary tract infection 1.1-5 1.7-5 <1

Unexplained fever
The biggest single subgroup of post-operative fever is that which is
unexplained. Garibaldi et al (1985) defined this as unexplained fever, post-
operatively, with no clinical evidence of infection.
Hemsell et al (1983) stated that 37% of their patients who had an
abdominal hysterectomy had a post-operative fever of unknown cause and
did not require treatment; their hospitalization was not prolonged and the
hospital costs were not increased. However, Duff (1982) found that 62% of
his abdominal hysterectomy group had an identical problem and that
antibiotics did help.
The CREST study (Dicker et al, 1982) reported that 16.8% of patients
who had an abdominal hysterectomy and 7.2% of those who had a vaginal
hysterectomy had an unexplained fever. In each case these accounted for
approximately half of all those with post-operative fever.
Harris (1995) considered all reports on abdominal hysterectomy since
the CREST study ended in August, 1981, and concluded that the most
common rate of unexplained fever with abdominal hysterectomy was 10 to
20%. He also found that the most common instance of unexplained fever
with vaginal hysterectomy was only 5 to 8%. He thought the reason for this
COMPLICATIONS OF HYSTERECTOMY 185

discrepancy might be that there were different patient populations, that the
definition of temperature elevation was different, that the use of prophyl-
actic antibiotics varied, and that the diagnosis of urinary tract infection or
pelvic cellulitis instead of unexplained fever varied widely in the literature.
Laparoscopic hysterectomy carries with it a 1.4% (Garry and Phillips,
1995) risk of unexplained fever which accounts for approximately one third
of all patients with post-operative fever.
Nowadays, with as rapid a discharge from hospital as possible, most
surgeons would treat their patients who had an unexplained fever
aggressively and indeed it would pose an ethical dilemma not to do so.

Operative site infection

Operative site infection includes pelvic infection/cellulitis, abdominal
wound infection, vaginal cuff abscess, pelvic abscess, and most infected
haematoma.
Vaginal cuff infection is difficult to diagnose. It is so subjective and
generally depends on the presence of a purulent discharge, a fever, and
vaginal cuff induration; the fever may not be so high as to include it by
definition as a case of post-operative fever.
The abdominal hysterectomy operative site infection ratio is commonly
reported as being between 14 and 42%; the CREST study reported 9.4%.
There is general consensus that antibiotics do reduce abdominal
hysterectomy wound infections (Holman et al, 1978; Houang, 1991; Polk
et al, 1980), but there is still some controversy as to whether antibiotics
reduce pelvic infection.
The incidence of operative site infection with vaginal hysterectomy is
less than that of abdominal hysterectomy. All studies show an incidence of
7.8 to 42% with the most common being between 8 and 20%; the CREST
study showed an incidence of 3.5%.
The overall efficacy of antibiotics with vaginal hysterectomy is accepted
(Polk et al, 1980; Duff, 1982).
The CREST study suggested from its data that an average woman of
reproductive age with no pre-existing medical condition and no previous
abdominal surgery who had a vaginal hysterectomy without colporrhaphy
and was treated with prophylactic antibiotics, had an overall incidence of
infection of only 15.8%. This compared with a similar group of patients
having an abdominal hysterectomy in which the infection rate was 46.7%.
However, the incidence of operative site infection with laparoscopic
hysterectomy may be as low as 2% (Garry and Phillips, 1995).
Prophylactic antibiotics have been used commonly with all hyster-
ectomies since Reich first reported the laparoscopic approach to
hysterectomy in 1989. As the final route of exit of the uterus is through the
vagina, one would expect the incidence of infection of the operative site to
be that of the vaginal hysterectomy group. The lower incidence is probably
due to the copious irrigation which occurs to ensure haemostasis. It would
be interesting to see whether the incidence of operative site infection
decreased in patients having vaginal or abdominal hysterectomy if
186 D.J. HILL

irrigation was similarly used. After all, irrigation of the pelvis is by no

means a new idea and was used in the pre-antibiotic era as a means of
diluting the pool of possible sepsis, if not altogether eradicating it.

Remote infection
Remote infection is a poor term but useful for categorizing causes of fever
which are not in the operative site and not unexplained.
Urinary tract infection would obviously be the most common with the
overall risk with abdominal and vaginal hysterectomy between 1 and 5%
(Harris, 1995) respectively. If an indwelling catheter is not used and the
patients receive prophylactic antibiotics, there is a definite decrease in the
incidence of urinary tract infection.
The incidence of urinary tract infection with laparoscopic hysterectomy is
less than 1% (Garry and Phillips, 1995). Indwelling catheters are probably
used less frequently, but if so, far less than 24 hours is usual.
The 0.4% incidence of pneumonia reported in the CREST study has not
changed substantially, despite earlier mobilization, physiotherapy and
prophylactic antibiotics in 'at risk' groups.
Following Dicker et al's report (1982), the American College of
Obstetricians and Gynecologists expressed an opinion supporting the use of
prophylactic antibiotics as a means of reducing what they called 'febrile
morbidity' (ACOG Committee Opinion, 1991). Which drug to use, at what
dose and for what duration, is beyond the scope of this work.
The overall consensus is that there is less risk of post-operative fever
with a vaginal hysterectomy rather than abdominal hysterectomy and much
less risk again with laparoscopic hysterectomy.

HAEMORRHAGE

Haemorrhage is reported both intraoperatively and post-operatively, early

or late. Early post-operative haemorrhage, may be due to a slipped ligature
or inadequately closed vessel, and a late haemorrhage is associated with
infection. Unfortunately, reports of such haemorrhages do not clarify this.
The comparative rates for haemorrhage associated with hysterectomy are
shown in Table 3. According to Harris (1995) the criteria for the definition
of haemorrhage should include one or more of the following:

Table 3. Percentage rates of haemorrhage from three routes of hysterectomy.

Abdominal Vaginal Laparoscopic
All reports Most common All reports Most common All reports
Hysterectomy route (%) (%) (%) (%) (%)
Intmoperative 0.2-3.7 1-2 0.5-3.5 1-3 ?
Post-operative 0,2-2.3 1-2 0.4-5.7 1-5 0.8
Transfusion 2.2-7.5 2-12 0.7-13 2-8 1.2
? = insufficient data,
C O M P L I C A T I O N S OF H Y S T E R E C T O M Y 187

1. A b l o o d loss greater than 1000ml (Boos et al, 1972).

2. A blood transfusion given during the operation (Easterday et al, 1983).
3. A haemoglobin drop greater than 3 to 5 g (Pratt and Dalkeku, 1990).
4. A blood loss at vaginal hysterectomy requiring conversion to
abdominal hysterectomy (Reiter et al, 1992).

To further confuse the definition, post-operative bleeding can be defined as

an event which required intervention and may occur hours, days or weeks
after the initial surgery. If the bleeding requires vaginal packing, vaginal
suturing, a laparotomy, or radiological techniques to occlude vessels, it
should be considered a significant post-operative haemorrhage. If the
bleeding required antibiotic treatment with or without rehospitalization, it
should not be considered a haemorrhage.
At least 30% of patients said to have a post-operative haemorrhage
present after discharge from hospital (Naylor, 1984), or at the earliest 48
hours after surgery, as occurred in 80% of patients in the series of Gitsch et
al (1991).
There may well be a problem in reporting patients who had a laparo-
scopic hysterectomy and post-operative haemorrhage, as geographically
they may not be in the same State, where the operation occurred.
Although we have defined haemorrhage as a blood loss greater than
t000 ml and/or a blood loss at vaginal hysterectomy requiring conversion
to abdominal hysterectomy, these are subjective definitions. Different
surgeons will react in different ways to blood loss. Reporting such
information further depends on how rigorous the initial storage of infor-
mation is, its subsequent retrieval, and whether the retriever discounted
some of the claims of complication.
To confuse the situation further, some authors only use the need for
blood transfusion to define those who have 'significant haemorrhage'. It is
fair to assume that prior to the 1980s and AIDS, blood transfusion was used
more liberally. Since that time there have also been the added problems of
hepatitis B and C viral infection. There is good evidence to show that until
the haemoglobin falls below 7 g, there is little need for blood transfusion.
If one looks at all series of hysterectomies that have been reported in the
past 10 years, the overall transfusion rate for hysterectonay is 3.4%, a
significantly low rate (Gambone et al, 1990; Browne and Frazer, 1991;
Reiter et al, 1992; Dwyer and Stirrat, 1993); these authors reported a rate
of 0.7 to 6%. In the CREST series, vaginal hysterectomy carried a 2.6%
risk that further treatment would be required for bleeding whereas in the
abdominal hysterectomy cases, there was only a 1.6% risk that further treat-
ment would be required.
The original gold standard from the CREST study showed an incidence
of transfusion of 15.4 and 8.3% for abdominal and vaginal hysterectomy
respectively. But since then, as already discussed, the incidence of trans-
fusion has fallen and, in all reported literature, the incidence would now be
between 2.2 and 7.5% and 0.7 and 13% respectively. The most common
incidence would be from 2 to 12% for abdominal hysterectomy and 2 to 8%
for vaginal hysterectomy. This increased incidence of bleeding with vaginal
188 D.J. HILL

hysterectomy is supported by a number of other retrospective studies

(Amirikira and Evans, 1979; Chryssikopoulous and Loghis, 1986).
The incidence of haemorrhage associated with laparoscopic hyster-
ectomy now averages as low as 1.2% (Garry and Phillips, 1995). The
reintervention for haemorrhage according to Deprest et al (1995) was 0.8%.
Thus we are probably looking at an incidence of 1% for the problem of
haemorrhage associated with laparoscopic hysterectomy. I think that this is
most likely related to the close inspection of the pedicles on completion of
the hysterectomy from the magnified view, irrigation and even reduced gas
pressure. There is also a lesser likelihood of secondary haemorrhage
associated with infection as we know the overall incidence of infection is
considerably reduced.

UNINTENDED MAJOR SURGICAL PROCEDURE

An unintended major surgical procedure includes unplanned re-operation

and the unplanned removal or repair of an organ. The CREST study first
popularized this category and other authors have subsequently begun to
measure the rates of unintended major procedures (Clarke-Pearson et al,
1987; Chan et al, 1993).
However, although this seems a good idea, one has to look carefully at
the published data to see when, why and how bladder, bowel and ureteric
damage have occurred, whether there has been successful primary repair or
a subsequent repair for fistula, or indeed if an initial injury was noted or
repair failed. Table 4 shows the rates of injury to adjacent organs with each
type of hysterectomy.
The CREST study reported that an unintended major surgical procedure
occurred in 5.1 and 1.7% of patients undergoing vaginal and abdominal
hysterectomy respectively. This may well be under reported for the
abdominal procedure when viscus repair is undertaken under the same
anaesthetic, and not recorded as a complication but as a necessary
manoeuvre and does not add to the patient's hospitalization. Those authors
who have bothered to clarify this category, reported that an unintended
major surgical procedure accompanies a hysterectomy per se in 4 to 5% of
cases (Gambone et al, 1990; Browne and Frazer, 1991; Chan et al, 1993).
The laparotomy risk from laparoscopic hysterectomy is 3.5% (Garry and
Phillips, 1995). This may be due to technical difficulties as well as bleeding

Table 4. Percentage rates of unintended major surgical procedures

during hysterectomy.
Abdominal Vaginal Laparoscopic
Hysterectomy route All reports rates (%)
Bladder 1-2 0.5-1.5 1.1
Bowel 0.1-0.5 0.1-0.8 0.5
Ureter 0.1-0.5 0.05-0.1 0.3
Vesicovaginal fistula 0.1-0.2 0.1-0.2 1.6
COMPLICATIONS OF HYSTERECTOMY 189

or trauma to the bladder, bowel, or ureter. This obviously does not include
those cases where the injury is recognized and repaired laparoscopically at
the initial anaesthetic.

Bowel injury
All reported rates of bowel injury are between 0.1 and 1%, with most series
showing a slightly higher incidence of bowel injury with abdominal
hysterectomy. This probably reflects the surgeon's preference for electing
not to operate vaginally for gross adhesive disease or endometriosis. The
CREST study reported a bowel injury incidence of 0.3 and 0.4% for
abdominal and vaginal hysterectomy respectively.
The incidence of bowel injury during laparoscopic hysterectomy is
reported as 0.5% (Garry and Phillips, 1995). This high incidence with a
laparoscopic technique may be partly due to the inherent risk of the laparo-
scopic approach, with viscus damage due to the Veress needle or trocar
insertions. The reported bowel injury rate with laparoscopy per se is 0.2%
(Chamberlain and Brown, 1978; Petersen et al, 1988).

Bladder injury
The overall injury to the bladder is about 1 to 2%, but is probably rising
with the increased rate of caesarean section delivery and the trend towards
more difficult vaginal hysterectomy.
In the 1970s, the bladder injury rate was approximately 0.3% (Amirikira
and Evans, 1979). In the 1980s Gambone et al (1990), reported a 2.3%
incidence of bladder injury, but two thirds of his patients had had caesarean
surgery; Browne and Frazer (1990) quoted a 1.4% incidence.
Mattingley et al (1985) reported that abdominal hysterectomy carried a
higher risk of bladder damage than vaginal hysterectomy, but these figures
were reversed by Kovak (1986) in his series containing a number of
difficult vaginal procedures.
With laparoscopic hysterectomy, bladder lacerations during the
operation occurred in 1% of patients (Garry and Phillips, 1995), and there
was a high incidence in those who had had a caesarean section (Hill, 1994).
It is also possible that laceration occurs during the vaginal component of
the procedure or during closure and is therefore not directly caused by the
laparoscopic approach (Hill et al, 1994).
The vesicovaginal fistula rate is reported as 0.1 to 0.2% following
abdominal and vaginal hysterectomy and 0.3% following the laparoscopic
procedure. This may be due to a poorer repair technique if performed
laparoscopically or to non-recognition of the injury. Routine cystoscopy on
completion of the hysterectomy is highly recommended.

Ureter injury
In a group of relatively uncomplicated hysterectomies a rate of 0.1 to 0.5%
is commonly reported for ureter injuries. These diagnosed equally during
190 D.J. HILL

the intraoperative and post-operative periods (Bright and Peters, 1977;

Daly and Higgins, 1988).
The incidence of ureter injury is less common with vaginal than with
abdominal hysterectomy. This may be due to the inherent technique of the
vaginal hysterectomy (Kudo et al, 1990) and/or to the fact that the surgeon
may choose the abdominal route for more difficult hysterectomies where there
is severe adhesive disease, endometriosis or complicated adnexal surgery.
Harris (1995) reported rates for ureter injury in abdominal hysterectomy
from 0.1 to 1.7 and in vaginal hysterectomy from 0 to 0.1%.
It might be suggested that there is a higher ureteric injury rate with
laparoscopic hysterectomy, however Garry and Phillips (1995) reported
only eight ureteric injuries out of 3189 laparoscopic hysterectomies, which
is a rate of 0.3%. Reports in the literature vary from 0 (Hill et al, 1994) to
4.8% (Calandra, 1995). ff the laparoscopic approach is truly replacing the
abdominal procedure for the more difficult surgical cases, we would expect
a higher incidence of ureteric damage.
The ureter is stable in its anatomical site at the point where the uterine
artery crosses it, which is 1.5-2 cm lateral to the edge of the cervix. The
ureter has been involved in a number of injuries during laparoscopic
hysterectomies, particularly when the uterine artery is being divided with
disposable stapling devices. This has been attributed to the width of the six
rows of staple which are 1.2 cm wide so that their placement across the
vessel may clamp the ureter. Hunter and McCartney (1993) have, in fact,
described bilateral ureteric transection by this method.
A number of surgical strategies have been suggested to overcome the
difficulty of knowing where the ureter is positioned during laparoscopic
hysterectomy, as there is no lateral flexion as in the abdominal approach nor
the dissection and lateral placement of the ureters and bladder as in the
vaginal approach. The probability is that there is an inadequate perception
of the anatomy at laparoscopy with a possibly more careless approach.
Various strategies have been suggested to overcome this problem
including dissecting the ureters from the pelvic sidewall (Liu and Reich,
1994), use of eliminated ureteric stents (Phipps et al, 1993), standard
ureteric stents (Hill, 1994), or avoiding the use of the stapler gun altogether
(Woodland, 1992). Bipolar diathermy of the uterine artery is not necessarily
safer (Nezhat et al, 1995) and suturing techniques are for the expert only.
For some surgeons, cystoscopy has become a standard procedure at the
conclusion of a laparoscopic hysterectomy (Hill, 1994). What is clear is
that care must be taken to identify the ureters before dividing the uterine
arteries during a laparoscopic hysterectomy.
I suspect a greater number of ureteric injuries have occurred and have
simply not been reported.

OTHER COMPLICATIONS

A group of less common or less serious complications (Table 5) was

popularized by the CREST study and again by Hams (1995).
COMPLICATIONS OF HYSTERECTOMY 191

Table 5, Percentage rates of other complications from three routes of hysterectomy.

Hysterectomy route Abdominal (%) Vaginal (%) Laparoscopic (%)
Urinary retention 4.8 8 0.3
Paralytic ileus 2.2 0.2 0.2
Wound dehiscence 0.3-0.7 - 0.3
Neuropathy ? ? ?
Fallopian tube prolapse ~ ? ?
Laparoscopic injury to vessels - - 0.4
Laparoscopic wound problem - - 0.9
Atelectasis 6 1 ?
? = insufficient data.

Urinary retention
Urinary retention seems to be more of a problem with vaginal hyster-
ectomy, particularly if a colporrhaphy is also performed; this occurred in
24% of cases in the CREST study. If no colporrhaphy was performed,
urinary retention was a problem in only 8%, and urinary retention
associated with abdominal hysterectomy occurred in 4.8% of the CREST
study. Only 0.3% of those having a laparoscopic hysterectomy (Garry and
Philips, 1995) experienced urinary retention.

Ileus or obstruction
Paralytic ileus, not surprisingly, was more common in abdominal
hysterectomy and the CREST study reported an incidence of 2.2%. This
was 0.2% with vaginal hysterectomy. It is uncertain from the reported
information how often ileus is a primary diagnosis and how often it is
secondary to other factors such as pelvic infection and haemorrhage.
There are no such figures for complications with laparoscopic
hysterectomy, although Garry and Phillips (1995) reports small bowel
obstruction not requiring any surgical intervention in 0.2% of patients.
Small bowel obstruction associated with hysterectomy other than in
laparoscopic cases is in the range of 0.1 to 1% (Amirikira and Evans, 1979;
Chryssikopoulous and Loghis, 1986; Kovak, 1986; Gambone et al, 1990).

Abdominal wall injury

The laparoscopic approach for hysterectomy carries with it an inherent risk
of vessel injury from the Veress needle or trocars. The likelihood of a major
vessel injury has been variously reported as being between 0.3 and 6.4 per
thousand. The overall literature risk is 1:1000 cases (Loffer and Pent, 1975;
Mintz, 1977; Chamberlain and Brown, 1978; Frenkel et al, 1981; Phillips
et al, 1984). In laparoscopic meta-analysis the incidence was 0.4% (Garry
and Phillips, 1995).
Hill et al (1994) reported that five of their 220 cases had anterior
abdominal wall blood vessel injury, three requiring post-operative blood
transfusion.
192 D . J . HILL

Significant haematoma and/or breakdown was encountered in 0.7% of

the Mercy Hospital abdominal hysterectomy group (unpublished data).
Laparoscopic wound problems such as bruising, cellulitis and infection,
occurred in 0.9% of cases (Garry and Phillips, 1995) with haematoma
occurring in an additional 0.3 to 0.7% mostly with midline incisions (Jones
et al, 1988; Gallup et al, 1990). The risk of laparotomy haematoma is 0.3%.
A laparoscopic hernia problem most often occurs with trocar entries of
10mm or more umbilically or laterally, and the fascial level of these
wounds should be sutured.

Neuropathy
Neuropathy is a complication which is probably grossly under reported but
is of relevance now because patients are in the lithotomy position for longer
with laparoscopic hysterectomy or more complex vaginal procedures.
Gombar et al (1992) reported transient femoral neuropathy in four patients
after vaginal hysterectomy. Schwartz (1993) reported transient lateral
peroneal and femoral neuropathy associated with laparoscopic surgery in
general. To avoid these complications, there should be an avoidance of
extremes of hip flexion, abduction and external rotation, and patients with
a history of back, hip or leg problems are probably best placed in the
lithotomy position they will be in during their procedure prior to
anaesthesia.
Kvist-Poulsen and Boret, 1982 reported that transient femoral nerve
injury occurred in abdominal hysterectomy owing to the blades of the
retractor.

Fallopian tube prolapse

Fallopian tube prolapse seems to be an uncommon complication, almost
exclusively occurring in those patients who have had a vaginal
hysterectomy; it is not mentioned in many reports. It may be related to the
fact that some surgeons do not routinely close the vaginal cuff. This
complication may occur months or years after hysterectomy with an
average presentation of 10 months after surgery (Wetchler and Hurt,
1986).

LIFE THREATENING EVENTS

The incidence of life threatening events and indeed death is listed in

Table 6.
In 1975, Kakkar et al established the value of low-dose subcutaneous
heparin in preventing fatal emboli in general surgery patients. The evidence
that low-dose heparin significantly reduces the incidence of thrombo-
embolic disease in benign gynaecological procedures is mixed. Although
intermittent pneumatic compression devices for the calf have been shown to
reduce the incidence of thromboembolism in oncological patients, there is
COMPLICATIONS OF HYSTERECTOMY i93
Table 6. Percentage of life threatening events from three routes of hysterectomy.
Vaginal Abdominal Laparoscopic
Hysterectomy route (%) (%) (%)
Pulmonary embolus-pulmonary infarct 0 0.2 0.2
Myocardial infarction, cardiac-ptflmonary arrest 0 0.1
Anaphylactic reaction 0 0.1
Disseminated intravascular coagulation 0 0.1
Death 0.2 0.1 0.03

no large series confirming this benefit in those with benign gynaecological

disease. The CREST study showed that in a low risk group of patients, the
overall incidence was 0.3%. However, if the pre-operative risks are higher,
such as in age, malignancy, history of previous deep venous thrombosis,
lower extremity oedema, varicose veins, obesity, increased anaesthetic time,
increased blood loss and intraoperative transfusion and malignancy, the risk
rises to 2% (Chryssikopoulous and Loghis, 1986).
There are factors which increase the complication rate following
hysterectomy such as age, underlying medical disease, obesity, and
malignancy.
It may be difficult to separate age from underlying medical disease
(Anderson et al, 1993). Boyd and Groome (1993) studied abdominal
hysterectomy for benign disease and reported that age unaccompanied by
medical disease was not a risk factor. However, a history of cardiac or
pulmonary disease was a reliable predictor of post-operative morbidity
resulting in rates of 68 and 52% respectively. Schneider and Benito (1988)
studied surgery on women over 75 and found that there was a higher
incidence of urinary tract infection, wound dehiscence and thromboembolic
disease in this age group.
Obesity, defined as a 20% increase over the ideal body weight for a given
patient, carries with it an increased risk of blood loss, operative site
infection, unexplained fever, wound dehiscence, and thromboembolic
disease (Morrow et al, 1977; Pitkin, 1977; Kovak, 1986).
When all hysterectomy procedures are considered, death occurs in one of
1000. This is a sobering statistic and well to be remembered when con-
sidering alternative treatments for benign conditions.

SUMMARY

We may look at the complications of hysterectomy to direct practising

gynaecologists to the approach best for the patient be it abdominal, vaginal
or laparoscopic. It seems that gynaecologists have looked at the compli-
cations of hysterectomy and chosen the route that suits them best. Seventy
to 80% of hysterectomies in the USA, the UK and Australia are performed
through an abdominal incision; it may possibly be easier, but it is not
necessarily safer. This, however, may be due to the fact that only
hysterectomies which are thought to be simple, preferably associated with
some prolapse, are performed vaginaUy and the rest abdominally.
194 D.J. HILL

Should we relearn how to do vaginal hysterectomies which are not so

simple or should we adopt the totally new concept of the laparoscopic
hysterectomy? It is probable that we should do both. We should operate
through the vagina with better lighting such as headlamps and we should
feel more secure if there is bleeding, as we can laparoscope the patient,
irrigate the pelvis and isolate the bleeding vessel. We could learn new
techniques to reduce uterine size. We could reduce the perceived contra-
indications to vaginal hysterectomy by adding prior laparoscopy. However,
if you add laparoscopy to every vaginal hysterectomy you may lose or
diminish several of the advantages of the vaginal approach, particularly the
decreased operative and anaesthetic time; the costs and risks also increase.
We could look for predictors of difficulty performing a vaginal
hysterectomy and only laparoscope them (Kovak et al, 1990). Predictors of
pelvic adhesive disease, for example may be a previous treatment of pelvic
inflammatory disease, previously documented endometriosis, previous
pelvic or abdominal surgery, previously documented pelvic adhesions,
history of chronic pelvic pain, cervical, uterine or adnexal tenderness, and
a pelvic mass, or decreased uterine mobility. Unfortunately, almost 50% of
these patients would have no adhesive disease and 30% of those with
adhesions have no predictor (Stovall et al, 1989).
It would seem from this essay that there may be increased risk of bowel
or urinary tract damage from the laparoscopic approach, but if more difficult
surgery is being performed in this way rather than through the abdominal
approach, one would expect this to happen. However, this cannot, of course,
be used to condone the complications that then may occur.
There seems little doubt that the incidence of infection and haemorrhage
are reduced quite markedly with the laparoscopic approach. If this is due to
irrigation, then perhaps this technique should be used with the other routes
of hysterectomy.
The bottom line is that there are insufficient reports in the literature
regarding laparoscopic hysterectomy. The criteria for this type of operation
have not been established, with only 4000 cases or so reported in the world
literature since it was first described by Reich et al (1989).
In very small series, Redwine (1995), Harris and Olive (1994) and Boike
et al (1993) have compared abdominal, vaginal and laparoscopic
hysterectomies. There is no evidence that laparoscopic hysterectomy has an
unacceptably high complication rate. It is clearly feasible to perform and
can be safely accomplished. Large prospective randomized trials must be
done before the advantages, disadvantages and complications of this
technology can seriously be elucidated.
In 1982, the CREST study data suggested that for an average woman of
reproductive age with no pre-existing medical condition and no previous
abdominal surgery, a vaginal hysterectomy was preferred to the abdominal
approach; this does not seem to have changed.
I think it is important that there should not be widespread acceptance of
laparoscopic hysterectomy and it should remain in the hands of those
committed to laparoscopic surgery per se to evaluate its place. Meanwhile,
the patient is best served by her gynaecologist performing hysterectomy in
COMPLICATIONS OF HYSTERECTOMY 195

the way he or she feels most confident. Perhaps the patient should take
more care in choosing that gynaecologist.

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