A hysterectomy is the surgical removal of the uterus and is one of the most common gynecological procedures performed worldwide. It may be carried out for conditions such as uterine fibroids, abnormal uterine bleeding, endometriosis, adenomyosis, pelvic inflammatory disease, prolapse, or certain gynecological cancers. Depending on the indication and surgical expertise, hysterectomy may be performed via abdominal, vaginal, laparoscopic, or robotic-assisted approaches. Regardless of the method chosen, understanding the basic surgical steps is crucial for safe and effective outcomes.

Preoperative Preparation

Before surgery, the patient undergoes:

Clinical assessment including pelvic examination and imaging to confirm the diagnosis.

Blood investigations for hemoglobin, coagulation, and overall fitness.

Informed consent with explanation of the risks, benefits, and possible need for removal of ovaries or fallopian tubes.

Bowel and bladder preparation, depending on the route of surgery.

Antibiotic prophylaxis to reduce infection risk.

Anesthesia planning, as most hysterectomies are performed under general or regional anesthesia.

Patient Positioning and Incision

In abdominal hysterectomy, the patient is placed in a supine position and a Pfannenstiel (bikini line) incision or midline vertical incision is made.

For laparoscopic or robotic hysterectomy, the patient is placed in a lithotomy position with Trendelenburg tilt, and trocars are inserted after creating pneumoperitoneum.

In vaginal hysterectomy, no abdominal incision is made; access is through the vagina.

Exposure and Access

The abdominal cavity is entered carefully to expose the uterus.

The surgeon identifies key structures: uterus, fallopian tubes, ovaries, bladder, ureters, and pelvic vessels.

Retraction or laparoscopic visualization is used for optimal exposure.

Division of Supporting Ligaments

The uterus is held with clamps or graspers, and the following ligaments are divided systematically:

Round Ligaments – These are divided and ligated on both sides to begin mobilization.

Broad Ligament – The peritoneum is incised to expose the underlying structures.

Fallopian Tubes and Ovarian Ligaments (or Infundibulopelvic Ligament if ovaries are removed) – These are clamped, cut, and ligated. Care is taken to avoid injury to the ureters, which run close to these structures.

Mobilization of the Bladder

The vesicouterine peritoneum is opened, and the bladder is dissected downwards, away from the cervix and uterus.

This step is critical to prevent accidental bladder injury, especially in patients with prior cesarean deliveries or adhesions.

Control of Uterine Vessels

The uterine arteries and veins are identified at the level of the cervix.

They are carefully clamped, cut, and ligated.

The surgeon ensures the ureters are not in close proximity before applying clamps.

Separation at the Vaginal Cuff (for total hysterectomy)

The cardinal and uterosacral ligaments are divided and secured.

The cervix and uterus are separated from the vagina by cutting around the vaginal cuff.

In subtotal hysterectomy, the cervix is left intact, and the separation is higher.

Removal of the Uterus

The uterus is detached and removed through the abdominal incision (open surgery), through the vagina (vaginal hysterectomy), or by morcellation/colpotomy (laparoscopic and robotic surgery).

If adnexectomy (removal of fallopian tubes and ovaries) is planned, it is completed before extraction.

Closure of the Vaginal Cuff

The vaginal cuff is sutured using absorbable sutures.

In laparoscopic and robotic approaches, intracorporeal suturing is performed.

Proper closure prevents bleeding and reduces the risk of cuff dehiscence.

Hemostasis and Inspection

The surgical field is inspected thoroughly for bleeding points.

Hemostasis is achieved with sutures, clips, or cautery.

The ureters and bladder are checked to ensure no injury has occurred.

Closure of the Incision

For abdominal hysterectomy, the fascia and skin are closed in layers.

In minimally invasive methods, trocars are removed, and port sites are sutured.

A drain may be placed if indicated.

Postoperative Care

Pain management with analgesics.

Monitoring for complications such as bleeding, infection, urinary retention, or deep vein thrombosis.

Early ambulation to prevent clots and promote bowel function.

Diet progression from liquids to solids as tolerated.

Discharge planning with advice on wound care, activity restriction, and follow-up.

Conclusion

The basic steps of hysterectomy follow a logical sequence: exposure, division of supporting ligaments, mobilization of the bladder, control of blood vessels, removal of the uterus, and closure. While the surgical approach may differ—abdominal, vaginal, laparoscopic, or robotic—the underlying principles remain the same: safety, hemostasis, and preservation of surrounding structures. Mastery of these steps ensures smooth execution of one of the most important gynecological procedures, ultimately improving patient outcomes and quality of life.