Table 1 Surgical techniques for hysterectomy with relative indications and contraindications

Vaginal hysterectomy (VH)

Genital prolapse (50–65% of cases)

Hypermenorrhoea/dysfunctional uterine bleeding

Symptomatic (bleeding) uterine leiomyomas

Microinvasive cervical carcinoma

History of caesarean section (CS) or other pelvic surgery

No previous vaginal delivery

Large uterus (≥12–14-week gestation size)

Coexistent extrauterine pelvic pathology (e.g. adhesions, endometriosis)

Need for oophorectomy

Invasive tumours

Laparoscopically assisted VH (LAVH)

Dysfunctional uterine bleeding or symptomatic uterine leiomyomas in patients with contraindicated or difficult VH (e.g. due to previous CS or adhesions)

Patients with chronic pelvic inflammatory disease (PID) requiring hysterectomy

Patients with endometriosis requiring hysterectomy

Obesity

Very large uterus

Potentially malignant adnexal mass

Risk of laparotomic conversion (e.g. severe post-surgical adhesions, endometriosis requiring bowel resection and/or involving rectovaginal septum)

Total laparoscopic hysterectomy (TLH)

Same as LAVH + endometrial and cervical tumours

Abdominal hysterectomy (AH)

Malignant genital tumours

Potentially malignant adnexal mass

Uterine leiomyomas not amenable to VH and laparoscopy (e.g. very large uterus, severe adhesions)

Endometriosis and PID not amenable to laparoscopy (e.g. due to rectovaginal septum involvement, need for bowel resection)

Secondary post-partum haemorrhage (exceptional)

Benign uterine disease (e.g. dysfunctional uterine bleeding or symptomatic uterine leiomyomas) amenable to VH or laparoscopy