312 Obstetrics and Gynecology Board Review •••
❍ What is the advantage of closing the peritoneum after vaginal hysterectomy?
Peritoneal closure extraperitonealizes the pedicle stumps. Thus, postoperative bleeding is more likely to present
vaginally and be recognized earlier than if it occurs intraperitoneally. Also, peritoneal closure can incorporate
ligation of an enterocele sac.
❍ How should the vaginal vault be supported after vaginal hysterectomy?
The uterosacral ligaments are used to support the vaginal vault. Often a modified McCall culdoplasty is performed.
With uterine prolapse, the uterosacral ligaments may be attenuated, and need to be shortened in order to provide
adequate support.
❍ How should the vaginal cuff be closed after vaginal hysterectomy?
Longitudinally as it lengthens the vagina.
❍ Do the ovaries continue to function normally after hysterectomy?
Yes. In almost all women undergoing hysterectomy prior to the natural menopause, the ovaries continue to
produce normal levels of hormones in a cyclic fashion until the natural age of menopause.
❍ In women 40 to 64 years of age undergoing hysterectomy, how many undergo elective oophorectomy?
50% to 66%.
❍ What does the term “incidental” oophorectomy indicate?
Incidental oophorectomy refers to removal of the ovaries at the time of surgery performed for another indication,
occurring by chance or without consequence. This is in contrast to prophylactic oophorectomy, when removal of
the ovaries is performed for future benefit.
❍ When is a prophylactic BSO justified with a hysterectomy?
Patient request, family history of ovarian cancer (only 5–10% genetic), and prevention of ovarian cancer
(1.4% lifetime risks).
❍ What are downfalls of doing a prophylactic BSO with hysterectomy?
Need for hormone replacement, possible re-operation for future de-novo ovarian cancer (0.1% risk of ovarian
cancer after hysterectomy) increased risk of death from CAD and all nonovarian cancers, and osteoporosis.
❍ If premenopausal, what are the risk of prophylactic BSO at the time of hysterectomy?
Increase risk of cognitive dysfunction (anxiety/depression, dementia, and Parkinson disease).
❍ In women undergoing prophylactic oophorectomy at the time of vaginal hysterectomy, in what percentage
of patients can the ovaries be removed successfully?
65% to 97%. Laparoscopic assistance can be used to facilitate the removal of the majority of the remainder.
❍ How often does ovarian cancer occur in hysterectomy patients with retained ovaries?
Approximately 0.1% of these women develop ovarian cancer. This represents a relative risk of about 0.6 as compared
with women who have not had a hysterectomy. Stated another way, of those women who develop ovarian cancer,
between 4% and 14% have had an antecedent hysterectomy during which the ovaries were not removed.