Based on the finding that many serous carcinomas arise in the fallopian tube rather than in the ovary, it was proposed that bilateral salpingectomy with ovarian conservation should be performed in patients with these high penetrance germline mutations while awaiting more definitive surgical intervention (30,31). One could consider this in women at average risk for these tumors when they undergo hysterectomy for benign disease. It is unknown whether this would substantially decrease the risk of developing these malignancies.
Although salpingo-oophorectomy can be accomplished by laparoscopy or laparotomy in virtually 100% of cases, the success rate for vaginal hysterectomy ranges from 65% to 95% for experienced vaginal surgeons (32,33).
Appendectomy Appendectomy may be performed concurrently with hysterectomy to prevent appendicitis and to remove disease that may be present. The former use is of limited value because the peak incidence of appendicitis is between 20 and 40 years of age, whereas the peak age for hysterectomy is 10 to 20 years later (34). There is no increase in morbidity associated with appendectomy performed at the time of hysterectomy (35). Incidental appendectomies in all abdominal hysterectomies could reduce the morbidity of appendicitis at a later time (35).
Appendectomy is performed with vaginal hysterectomy without additional intraoperative or postoperative morbidity (36).
Cholecystectomy Gallbladder disease is about four times more common in women than men, and its highest incidence occurs between 50 and 70 years of age, when hysterectomy is most often performed. Women may require both procedures. A combined procedure does not appear to result in increased febrile morbidity or length of hospital stay (37).
Abdominoplasty Abdominoplasty performed at the time of hysterectomy is associated with a shorter hospital stay, a shorter operating time, and a lower intraoperative blood loss than when the two operations are performed separately (38,39). Liposuction can be performed safely at the time of vaginal hysterectomy (40).
Choice of Surgical Access: Vaginal, Abdominal, or Laparoscopic Hysterectomy
From 2000 to 2004, approximately 68% of all hysterectomies were performed abdominally and 32% were performed vaginally. One-third of the vaginal cases were performed with the assistance of the laparoscope (laparoscopically assisted vaginal hysterectomy) (1). There are no specific criteria that can be used to determine the route of hysterectomy. The route chosen should be based on the individual patient, but vaginal access is preferred. An alternative access is preferred if there is a narrow pubic arch (less than 90 degrees), and a narrow vagina (narrower than two fingerbreadths, especially at the apex), or if the there is an undescended immobile uterus. The presence of an adnexal mass, cul-de-sac disease, pelvic adhesions, or the assessment of chronic pain may require the addition of laparoscopy for assessment. A previous cesarean section or nulliparity does not contraindicate a vaginal approach (41).