308 Obstetrics and Gynecology Board Review •••
❍ Which patients undergoing hysterectomy should receive perioperative antibiotic prophylaxis?
All patients undergoing hysterectomy should receive antibiotic prophylaxis. The target in administering antibiotic
prophylaxis is to have the antibiotic present in tissue prior to incision and then throughout the procedure.
The antibiotic chosen should have a spectrum broad enough to cover the typical organisms found during the
procedure—gram positive for skin and gram negative for abdominopelvic organisms.
❍ From a historical perspective, why are most abdominal hysterectomies total rather than supracervical and
how has this changed?
Before 1950, cervical carcinoma was the most common female genital cancer in the United States. Although
this is still true worldwide, the incidence of cervix cancer in the United States has fallen dramatically. Cervical
stump cancer is difficult to treat, and therefore carries a poor prognosis. Therefore, before widespread Pap smear
screening, it was felt that the cervix should almost always be removed. Recently there has been renewed interest in
supracervical hysterectomy because it is technically easier, and is associated with fewer surgical risks.
❍ What are contraindications for supracervical hysterectomy?
Recent or recurrent cervical dysplasia, endometrial hyperplasia, or a gynecologic neoplasm.
❍ What percentage of women experience postoperative cyclical vaginal bleeding after a supracervical
hysterectomy?
5% to 20%.
❍ What is the percentage of women who have a reoperation for trachelectomy after a supracervical
hysterectomy?
1% to 3%.
❍ What is the role of LAVH?
LAVH is associated with faster postoperative recovery and less pain than abdominal hysterectomy. However, LAVH
offers no advantages over simple vaginal hysterectomy when vaginal hysterectomy can be done. LAVH has its chief
utility in detecting and possibly correcting pelvic adhesive disease that would otherwise make vaginal hysterectomy
more technically difficult and potentially dangerous. A further use of laparoscopic assistance is the ligation of the
infundibulopelvic ligaments when they are technically difficult to reach via the vaginal approach.
❍ What are the disadvantages of laparoscopic hysterectomy?
Longer operating times and higher genitourinary injuries.
❍ What are the advantages of laparoscopic hysterectomy?
Shorter hospital stays, faster return to normal activity, lower EBL/smaller drop in hemoglobin, and fewer wound
infections.
❍ When using a self-retaining retractor in a transverse incision, one must be aware of what potential nerve
injury?
The lateral femoral cutaneous nerve.
❍ Which ligament is divided first in performing abdominal hysterectomy?
The round ligament. In cases where severe anatomic distortion or adhesions are found, the round ligament will
almost always be identifiable, and can be followed to the uterus.