Supracervical Versus Total Hysterectomy

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Abstract
Manchester, England was the site of the world's first hysterectomy, performed by Charles Clay in November 1843.1 Under-taken to remove a large myomatous uterus, the operation was successful (the uterus was removed), but the patient died on the 15th postoperative day. Approximately 10 years later, Walter Burnham performed the first truly "successful" hysterectomy (the patient survived) in Massachusetts. Unfortunately, 3 of his next 15 patients did not fare so well. These early procedures were always subtotal hysterectomies. Animal gut or hemp was used to strangulate the cervix after the uterus had been amputated and removed. The cervical stump was exteriorized until tissue distal to the hemp "circlage" sloughed, allowing the remainder of the cervix to retract back into the abdomen. Dr. Richardson introduced total abdominal hysterectomy (TAH) in 1929.2 He advocated total hysterectomy (removal of the uterus and cervix) to prevent the subsequent development of cervical carcinoma. At the time, cervical screening was unknown, and the incidence of cervical carcinoma was reported to be 0.4%. Despite Dr. Richardson's recommendations, subtotal hysterectomy remained the preferred surgical technique until the late 1940s. In those pre-antibiotic days, removal of the cervix predisposed the patient to development of peritonitis, which was most often fatal. Left in place, the cervix provided an effective barrier against contamination of the peritoneal cavity by microorganisms indigenous to the vagina. Because of this, 95% of all hysterectomies performed before 1950 were supracervical. This scenario changed dramatically with the discovery of penicillin and other antibiotics in the 1950s. The newly discovered ability to treat infection, coupled with an increasing availability of blood transfusion, resulted in a dramatic increase in the use of Dr. Richardson's technique of total hysterectomy. Once again, concern focused on the subsequent development of carcinoma in the retained cervical stump. At approximately the same time (1950s), the Paponiculou smear became widely used as an effective method of screening for cervical disease.3 As a result, early detection and treatment of cervical disease dramatically decreased death rates from cervical cancer. Gynecologists' preference for total hysterectomy, however, was well entrenched and remained unchanged. Total hysterectomy (vaginal or abdominal) remained the unquestioned "standard of care" until Kirt Semm reported the first laparoscopic supracervical hysterectomy in 1991.4 Dr. Semm's version was christened the Classic Abdominal Semm Hysterectomy or "CASH" (an unfortunate acronym). It involved coring out the entire transformation zone and endocervical canal, followed by laparoscopic ligation of vascular pedicles. The uterus was morcellated and removed through laparoscopic incision sites. By this method, Dr. Semm attempted to duplicate abdominal hysterectomy without a vaginal incision or removal of the cervix. Although CASH did not achieve widespread acceptance, it did rekindle the debate over supracervical versus total hysterectomy. While developing new laparoscopic techniques for supracervical hysterectomy, other gynecologic surgeons began to explore the issue. New arguments favoring supracervical hysterectomy began to surface, and the discussion has raged on.