A hysterectomy is a surgery to remove a person’s uterus.1 After a hysterectomy is performed, the patient will no longer have menstrual periods and cannot become pregnant.1 Given the invasiveness and permanence of the surgery, it is highly unlikely that a clinician would perform a hysterectomy for a nonmedical reason.2 Despite the fact that many conditions solved by hysterectomy could be handled with other medical treatments, hysterectomies are very common;3 one in three women in the United States has had one by age 60.4 Because of the widespread nature of hysterectomy, it is the anesthesia provider’s job to be knowledgeable about the uses and types of hysterectomy, associated complications and research in anesthesia for hysterectomy.
Hysterectomy can serve as a treatment for many conditions and has several forms. A patient may undergo a hysterectomy for a variety of reasons, including uterine fibroids that cause pain, bleeding or other problems; uterine prolapse, which is a sliding of the uterus into the vaginal canal; cancer of the uterus, cervix or ovaries; endometriosis, in which uterine tissue grows in other places of the body; abnormal vaginal bleeding; adenomyosis, or a thickening of the uterus; or chronic pelvic pain.5 Depending on the patient’s condition, a clinician may choose to remove all or only part of the uterus.5 There are five types of hysterectomy: subtotal or partial hysterectomy, in which the uterus is removed but the cervix is left in place; total hysterectomy, in which the uterus and cervix are removed; hysterectomy and bilateral salpingo-oophorectomy, in which the uterus, fallopian tubes and ovaries are removed; hysterectomy with prophylactic bilateral salpingectomy, in which the uterus and fallopian tubes are removed; and radical hysterectomy, in which the uterus, fallopian tubes, ovaries, upper part of the vagina, pelvic ligaments and lymph nodes are removed.6 For different types of surgery, the clinician may consider a traditional abdominal hysterectomy or a minimally invasive procedure, which entails vaginal incision or laparoscopy (i.e., a small incision in the abdomen).5 According to a study by Varol et al., the overall complication rate for women undergoing abdominal hysterectomy was 44 percent, as compared to 27.3 percent for vaginal hysterectomy.7 Possible complications associated with hysterectomy include damage to the urethra, bladder, bowel or vagina; bleeding and blood clots; infection; and ovary failure.8 Long-term side effects of hysterectomy include bone loss, increased risk of stroke or heart attack, urinary issues, early onset menopause, vaginal dryness and a decreased libido.2 Also, it prevents the possibility of future pregnancy, which can have various psychological effects on a patient. Hysterectomy is a complex procedure involving many types, surgical techniques, complications and long-term side effects.
The various surgeries for hysterectomy are accompanied by several alternatives for anesthetic techniques. For example, at Morosan and Popham’s institution in Australia, laparoscopic hysterectomies are performed using premedication with intravenous midazolam followed by fentanyl, propofol and atracurium or rocuronium.9 Intraoperative and postoperative analgesia include morphine, paracetamol and intravenous parecoxib.9 However, several other studies mention the use of either general or local anesthetics. In Chestnut et al.’s study on obstetric hysterectomy, which is performed at the time of Cesarean section or immediately following vaginal delivery,10 all patients received epidural anesthesia.11 Meanwhile, Moawad et al. describe a patient who underwent total laparoscopic hysterectomy under regional anesthesia.12 In cases of failed epidural injection, such as Bajwa et al.’s vaginal hysterectomy patient with a fused lumbar spine, the paramedian approach (as opposed to the traditional midline approach) can be used to achieve local anesthesia.13 Wodlin et al. found that in patients undergoing abdominal hysterectomy, spinal anesthesia with intrathecal morphine was more effective than general anesthesia in reducing postoperative pain, discomfort, opioid use and recovery time.14,15 Intrathecal anesthesia was also less costly for the hospital.15 Sprung et al. found that vaginal hysterectomy patients also showed lower pain after intrathecal versus general anesthesia, though there was no effect of anesthesia modality on length of hospitalization or patients’ postoperative functional status.16 Anesthesia providers may need to consider the patient’s reason for surgery and contraindications before selecting the optimal anesthetic drug or modality.
Hysterectomy is a common procedure that is used to treat a variety of medical conditions. Hysterectomies have numerous forms and can be approached with many surgical techniques. Anesthesia for hysterectomy can be general or local, and the type selected may depend on the patient’s condition and the anesthesia provider’s recommendation. Future research should investigate the best anesthetic drugs and induction procedures based on hysterectomy type and surgical technique.
1. Temkin SM, Kho K. Hysterectomy. A–Z Health Topics April 1, 2019; https://www.womenshealth.gov/a-z-topics/hysterectomy.
2. National Women’s Health Network. At what age do doctors allow women in the USA to have a hysterectomy? At What Age Can I Get A Hysterectomy October 13, 2016; https://www.nwhn.org/age-can-get-hysterectomy/.
3. Cornforth T. Hysterectomy in the United States. Verywell Health. Web: About, Inc. (Dotdash); November 26, 2019.
4. National Center for Chronic Disease Prevention and Health Promotion. Hysterectomy. Women’s Reproductive Health February 17, 2017; https://www.cdc.gov/reproductivehealth/womensrh/index.htm#Hysterectomy.
5. Johnson TC. Hysterectomy. WebMD Medical Reference February 14, 2019; https://www.webmd.com/women/guide/hysterectomy.
6. Department of Health & Human Services. Hysterectomy. Better Health Channel 2020; https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/hysterectomy.
7. Varol N, Healey M, Tang P, Sheehan P, Maher P, Hill D. Ten-year review of hysterectomy morbidity and mortality: Can we change direction? The Australian & New Zealand Journal of Obstetrics & Gynaecology. 2001;41(3):295–302.
8. National Health Service. Complications: Hysterectomy. Health A to Z February 1, 2019; https://www.nhs.uk/conditions/hysterectomy/risks/.
9. Morosan M, Popham P. Anaesthesia for gynaecological oncological surgery. Continuing Education in Anaesthesia Critical Care & Pain. 2013;14(2):63–68.
10. Chawla J, Arora D, Paul M, Ajmani SN. Emergency Obstetric Hysterectomy: A Retrospective Study from a Teaching Hospital in North India over Eight Years. Oman Medical Journal. 2015;30(3):181–186.
11. Chestnut DH, Dewan DM, Redick LF, Caton D, Spielman FJ. Anesthetic management for obstetric hysterectomy: A multi-institutional study. Anesthesiology. 1989;70(4):607–610.
12. Moawad NS, Santamaria Flores E, Le-Wendling L, Sumner MT, Enneking FK. Total Laparoscopic Hysterectomy Under Regional Anesthesia. Obstetrics and Gynecology. 2018;131(6):1008–1010.
13. Bajwa SJS, Bajwa SK, Kaur J, Singh BA, Prasad S. Anaesthetic management of a vaginal hysterectomy case with an unanticipated failure of epidural injection due to fused lumbar spine. International Journal of Applied & Basic Medical Research. 2011;1(1):57–59.
14. Wodlin N, Nilsson L, Årestedt K, Kjlhede P. Mode of anesthesia and postoperative symptoms following abdominal hysterectomy in a fast-track setting. Acta Obstetricia et Gynecologica Scandinavica. 2011;90(4):369–379.
15. Wodlin NB, Nilsson L, Carlsson P, Kjølhede P. Cost-effectiveness of general anesthesia vs spinal anesthesia in fast-track abdominal benign hysterectomy. American Journal of Obstetrics and Gynecology. 2011;205(4):326.e321–326.e327.
16. Sprung J, Sanders MS, Warner ME, et al. Pain relief and functional status after vaginal hysterectomy: Intrathecal versus general anesthesia. Canadian Journal of Anesthesia. 2006;53(7):690.