Total versus Supravaginal Hysterectomy

0 PERATIONS on the uterus for benign conditions constitute a Iarge percentage of the major operative procedures on any gynecoIogic service. The type of operation to be performed in any given case depends not onIy on the pathoIogic condition, the patient’s age, her marita1 state, the state of her genera1 heaIth and to some extent her wishes in the matter, but aIso on the experience of the surgeon and the resuIts he has obtained with various types of operations in simiIar cases. In some cases more or Iess satisfactory resuIts wiI1 be obtained with a variety of different operative procedures, but following some of these there may be the probability of future troubIe which wiI1 require a second operation or frequent treatments. In my experience, in many cases in which troubIe foIIows operation a cancer phobia deveIops to a greater or lesser degree. Many of them do not return to the origina surgeon because they think he does not understand their case. One of the most controversia1 points among gynecoIogists is whether to do a tota abdomina1 hysterectomy or a supravagina1 amputation in the majority of cases in which it is advisabIe to remove at least part of the uterine body. In a11 discussions on this subject it is freeIy admitted, even by ardent supporters of the more radica1 procedure, that statistics from the country as a whoIe wiI1 show a detiniteIy higher mortaIity and morbidity when this operation is performed. This does not mean, however, that the operation is at fauIt, but simpIy that it is being attempted by some surgeons who are not familiar with the various steps of a diffrcult operation. I am satisfied that when total abdomina1 hysterectomy is done by competent surgeons in a Iarge series of cases, the end results are better, the morbidity is Iess and the mortality no greater than when a subtotal abdomina1 hysterectomy is done in a similar series of cases by the same experienced surgeons. For the occasional operator or for any surgeon who has not taken special pains to become thoroughIy famiIar with the technique of a tota abdomina1 hysterectomy, my advice wouId be to continue doing the subtota1 operation in a Iarge majority of his cases even at the risk of leaving an infected cervix, which might require treatment or remova at a Iater date. A negIected infected cervix is a definite predisposing cause to compIications; the most frequent of these is thrombophIebitis and the gravest are puImonary emboli or the Iater deveIopment of cancer. I do not agree with those who say that the only advantage of tota abdomina1 hysterectomy over subtota1 operation is the protection against the later development of cancer. If this were the case, I wouId not fee1 justified in advising the tota operation as often as I do. Just what added danger there is of maIignant disease deveIoping in a cervica1 stump over the norma incidence of cancer of the cervix in a Iike number of cases is hard to determine. It is known, however, that cervicitis is a very common sequeIa to subtotal abdomina1 hysterectomy and that chronic irritation from infection is a definite predisposing cause of cancer. Statistics are very unreIiabIe in such cases and vary a great dea1 in different countries and among different surgeons in any one country. The weight of statistical evidence, however, is that cancer occurs in probabIy not more than I or 2 per cent of cases in which a subtota hysterectomy has been performed for benign conditions. Henriksen, in 940 255 Am J Surg 1940 V-48