**Abstract**

Surgical site infections (SSIs) are associated with increased morbidity, mortality, and healthcare costs. SSIs are defined as an infection that occurs after surgery in the part of the body where the surgery took place. Approximately 1–4% of hysterectomies are complicated by SSIs, with higher rates reported for abdominal hysterectomy. Over the past decade, there has been an increasing number of minimally invasive hysterectomies, in conjunction with a decrease in abdominal hysterectomies. The reasons behind this trend are multifactorial but are mainly rooted in the well-documented advantages of minimally invasive surgery. Multiple studies have demonstrated a marked decrease in morbidity and mortality with minimally invasive surgeries. Specifically, evidence supports lower rates of SSIs after laparoscopic hysterectomy when compared to abdominal hysterectomy. In fact, the American College of Obstetricians and Gynecologist recommends minimally invasive approaches to hysterectomy whenever feasible. This chapter will review the current literature on surgical site infection (SSI) after hysterectomy for benign indications.

**Keywords:** infection, hysterectomy

### **1. Introduction**

Hysterectomy is one of the most commonly performed surgeries in the United States. In fact, Merrill et al. reported a 45% lifetime risk of hysterectomy [1] with an overall rate of 5.4 per 1000 women per year. The majority of hysterectomies are performed for benign gynecologic conditions—that is, the presence of fibroids. Other indications include abnormal uterine bleeding, uterovaginal prolapse, and pelvic pain. Hysterectomy can be performed via multiple routes—abdominally, laparoscopically (including robotic approach), or vaginally. Vaginal and laparoscopic procedures are considered minimally invasive surgical approaches based on the ability to avoid a large abdominal incision. These routes of hysterectomy are associated with shortened hospitalization and postoperative recovery when compared to the abdominal approach. As a result, analysis of U.S. surgical data demonstrates evolving practice patterns with an increase in minimally invasive hysterectomies and a decrease in abdominal hysterectomies [2, 3].

The Centers for Disease Control and Prevention defines surgical site infection (SSI) as an infection that occurs after surgery near the surgical site within 30 days following surgery or 90 days where an implant is involved. They can range from superficial infections involving skin, or more serious infections involving tissues underneath the skin, organs, or implanted materials. As such, SSI is classified as superficial, deep, or organ/space. The CDC monitors SSI via the National Healthcare Safety Network with reported SSI rates of 1.7% and 0.9% after abdominal and vaginal hysterectomy respectively [4].

In a retrospective cohort study of 23,366 patients undergoing laparoscopic and abdominal hysterectomy between the years 2005 and 2011, 783 (3%) developed a surgical site infection. The majority of these were wound infections with approximately ¼ of cases being infections of the organ space which represents 0.7% of the entire cohort [5]. A more recent large cohort study examining patients between the years 2012 and 2015 demonstrated a 2% incidence of postoperative infection after hysterectomy [6]. When stratified between abdominal versus minimally invasive approaches, the incidence of SSI in the abdominal hysterectomy group exceeded 1%, while the incidences in the other groups were 0.2–0.3% [7–9].

It is well known that postoperative infections are associated with increased patient morbidity and mortality, and may result in additional costs, extended hospital stays, and prolonged antibiotic use. On average, patients who had an SSI following hysterectomy incur twice the cost of care of their counterparts who did not have an SSI. In a study examining the clinical and economic burden of surgical site infection following hysterectomy, the highest cost owing to SSI (\$19,203; 95% CI 17,260–21,365) was for abdominal hysterectomy. In addition, those who had SSI had a mean length of stay (LOS) that was between three and fivefold the LOS of those who did not have an SSI irrespective of surgical approach [10]. SSI following index surgery is also associated with a significantly greater percentage of hospital readmissions. Surgical site infections after hysterectomy have serious implications on patient care and healthcare as a whole. This chapter will review the current literature on surgical site infection (SSI) after hysterectomy for benign indications and address various methods of prevention and treatment.

### **2. Route of hysterectomy**

There are a variety of factors that influence the route of hysterectomy including informed patient preference, accessibility of the uterus, extent of extrauterine disease, size and shape of the vagina and uterus, concurrent procedures, available hospital technology and support, the nature of the case**—**whether it is emergent or scheduled, and surgeon training and experience. The American College of Obstetricians and Gynecologists (ACOG) recommends vaginal hysterectomy as the approach of choice whenever feasible [11].

Evidence supports that the vaginal approach is associated with better outcomes when compared with other approaches to hysterectomy. A Cochrane review analyzing 47 randomized control trials with a total of 5,102 women determined that vaginal hysterectomy resulted in quicker return to normal activity when compared to abdominal hysterectomy. There was no difference in satisfaction, quality of life, and surgical complications. Similarly, laparoscopic hysterectomy also resulted in more rapid recovery, fewer febrile episodes, and lower incidence of SSI when compared to the abdominal approach [12]. In this systematic review, there were no advantages of laparoscopic over vaginal hysterectomy. In addition, the laparoscopic approach was associated with longer operating times and increased rates of urinary tract injuries [13]. As a result, a vaginal approach continues to be the preferred route of hysterectomy.

When it is not feasible to perform a vaginal hysterectomy, a surgeon must choose between a laparoscopic or an open abdominal approach. A Cochrane review demonstrated faster return to normal activity, shorter hospital stay, fewer infections, and improved quality of life in patients undergoing laparoscopic versus abdominal hysterectomy. However, operating times were longer with higher rates of lower urinary tract (bladder and ureter) injuries in the laparoscopy group [13].

#### *Surgical Site Infection after Hysterectomy DOI: http://dx.doi.org/10.5772/intechopen.101492*

When stratified by the type of hysterectomy**—**total laparoscopic hysterectomy (TLH), laparoscopic-assisted vaginal hysterectomy (LAVH), and laparoscopic supracervical hysterectomy (LSCH)**—**a comparison of the 30-day incidence of deep or organ-space and superficial incisional SSIs in 46,755 women demonstrated a decreased risk of deep or organ-space SSI in the LSCH group compared to the other subtypes [14]. The overall rate of 30-day deep or organ-space SSI was 1.8%. There were no differences in superficial SSI in all groups; however, the rate of deep or organ-space SSI was lower in women who underwent LSCH (0.6%) compared with TLH (1.0%) and LAVH (1.1%).

When stratified into various forms of laparoscopic hysterectomy including robotic hysterectomy, laparoscopic-assisted vaginal hysterectomy, and single-port hysterectomy, the authors concluded that more research was needed to determine if there is in fact, a benefit over conventional laparoscopic approaches. The largest study available on single port laparoscopy in gynecology was a retrospective study from Cleveland Clinic reviewing a total of 908 cases. The authors concluded that single port access was safe and feasible in gynecologic surgery inclusive of both malignant and premalignant conditions with a low rate of adverse outcomes. Perhaps the most prevalent adverse outcome is an increased risk of incisional hernia with a rate of 5.5% [15, 16]. Well-designed studies that compare outcomes of alternative hysterectomy routes (robotic, laparoscopic assisted vaginal, and single-port) are needed to determine if patients may benefit from these other approaches.

Although minimally invasive routes to hysterectomy remain the preferred approach, open abdominal hysterectomy is still an important surgical option for some patients. Open abdominal hysterectomy may become necessary in a variety of clinical scenarios including failure of to maintain a minimally invasive approach.
