Abdominal Hysterectomy: Tips and Tricks for the Minimally Invasive Gynecologic Surgeon

INTRODUCTION: This is a step-by-step video demonstration of best practices during abdominal hysterectomy, utilizing two case examples. Though abdominal hysterectomy numbers are decreasing across the country in favor of minimally invasive hysterectomy, there is still benefit in learning and maintaining minimally invasive techniques in open surgery. OBJECTIVE: To provide gynecologic surgeons with best practices in completing open abdominal hysterectomy, utilizing minimally invasive thinking and techniques. METHODS: Setting: Academic Medical Center Patients or Participants: The case example highlights two patients: 1) A 40-year-old G1 with massively enlarged uterus and symptomatic fibroids, desiring definitive surgical management; and 2) A 52-year-old G3 with massively enlarged fibroid uterus and resultant left lower extremity venous thromboembolism. Interventions: Open abdominal hysterectomy was performed in two appropriate candidates, demonstrating six best practices: 1) Patient positioning is key. 2) Midline vertical incisions are useful for massive uteri. 3) Visualization of the anatomy is crucial. 4) Take what the anatomy gives you. 5) Slow down at the uterine vessels. 6) Staged colpotomy can be performed if needed. RESULTS: In the case examples provided, both patients underwent successful abdominal hysterectomies without complications. Both surgeries had estimated blood losses of 50 cc, and both patients were discharged on postoperative day 2 without needing blood transfusions. Surgical pathology yielded benign specimens, each weighing >2200 g. Both patients’ incisions healed well without dehiscence or infection. CONCLUSIONS: There is still an important time and place for gynecologic surgeons to perform open abdominal hysterectomy, as pathology necessitates. These best practices demonstrate that even with open surgery, gynecologic surgeons can approach it with minimally invasive thinking and techniques.