**Abstract**

Hysterectomy is a major operation and is as old as time. This chapter touches briefly on the history of this procedure, its present aspects and general advice for these women who may need a hysterectomy, and finally the direction of new developments about it.

**Keywords:** hysterectomy, vaginal hysterectomy, abdominal hysterectomy, laparoscopic hysterectomy, robotic hysterectomy

### **1. Introduction**

Hysterectomy is the surgical removal of the uterus and, in some circumstances, the ovaries, cervix, fallopian tubes and supporting tissues. It ranks, just behind cesarean section, as the second most common surgery among women, and is the most common non-pregnancy-related major surgery performed on women worldwide.

Hysterectomy is a major surgical procedure that has risks and benefits, and may be classified as abdominal and vaginal according to the route of access. The abdominal route may be through conventional laparotomy, laparoscopy or robotic surgery, or vaginal hysterectomy through the superior part of the vagina. Occasionally both routes are used in combination.

#### **2. Indications**

The indications for hysterectomy include benign conditions such as dysfunctional uterine bleeding, uterine fibroids, endometriosis, adenomyosis and genital prolapse. In addition, it is indicated in cases of gynecological malignancies 0f the uterus, ovaries and cervix, and for future malignancy risk-reducing indications, such as cases of BRCA 1 or 2 mutations or Lynch syndrome [1, 2].

#### **3. History**

The origin of hysterectomy is obscure, but the first operation was vaginal hysterectomy that reputedly was performed by Soranus of Ephesus in the Greek city of Ephesus around 160 AD for the extirpation of an inverted uterus that had become gangrenous [3].

Historically, time passed with no clear record of advancement until the beginning of the 19th century. Lauvariol of France is credited for performing the first

vaginal hysterectomy, followed by Baudelocque, who artificially prolapsed and then cut away the uterus and its appendages [3].

It was at the beginning of the 19th century too, in 1809, that the world's first abdominal surgery was performed on a kitchen table. The operator was Ephraim McDowell from Danville, Kentucky. He removed an ovarian cyst that weighed 10.2 k. The patient survived [3].

Early procedures were performed without anesthesia, with some milk, brandy and prayers for some comfort, but the performance of medical procedures that caused intolerable pain to patients was technically unfeasible until anesthesia became part of the surgery. It enabled patients to undergo an operation safely without experiencing severe distress and intolerable pain.

By 1831, ether, nitrous oxide and chloroform had been discovered, albeit not applied medically yet. The first use of anesthesia in surgery was by Crawford Long of Georgia who, in 1842, used nitrous oxide on a very limited number of minor surgical cases. A few years later anesthesia was considered and implemented as a major breakthrough [3].

Of interest is the fact that dentistry was the first profession to use anesthesia, A Connecticut dentist, Horace Wells, in 1844, tested nitrous oxide by having his own tooth removed whilst under the influence of the gas. Wells' dental student, William Morton introduced ether to dental procedures in 1846, and is regarded as the world's first anesthetist, after the name 'anesthesia' was suggested by Oliver Holmes [3].

James Simpson of Edinburgh employed anesthesia in childbirth. This was condemned by the Calvinist Church as being against its beliefs. Because of its odor and long induction period, Simpson abandoned ether in favor of chloroform, which was favored in Europe until its hepatic toxicity became clear. Of interest is the fact that John Snow used it for Queen Victoria's delivery of Princess Charlotte with no apparent ill effects [4].

With the new developments in medicine, in general, anesthesia and surgery in particular, continued their advancements and refinements. The lower transverse abdominal incision along the pubic hairline was introduced by Johannes Pfannenstiel of Breslau in the 1920s. Harry Reich performed the first laparoscopic hysterectomy in Kingston, Pennsylvania in 1988 [5, 6].
