Manual of New Hysterectomy Techniques Liselotte Mettler
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History and Future of Hysterectomy1

Chris Sutton
 
INTRODUCTION
The historical date December 25th, 1809 should be indelibly engraved on the brain of every practising surgeon, because it was the first time that the human abdomen was deliberately opened in order to remove a diseased organ, in this case a massive ovarian cyst. The brave pioneering surgeon was Ephraim McDowell, (1771–1830) (Figure 1.1) a Scotsman who had trained in Edinburgh and the equally brave patient was Mrs. Jane Todd Crawford (Figure 1.2) a distant cousin of Abraham Lincoln. McDowell had visited her on the 13th of December, at her home in Greensburgh, Kentucky and found that the 47-year-old woman had such a massive tumour that it was making it difficult to breath and making her life a complete misery. They both agreed that an operation was the only solution and she rode to McDowell's home in Danville, some sixty miles away, with the massive ovarian tumour resting on the pommel of her saddle. In those days there was no anaesthesia, no antisepsis or antibiotics and the procedure was performed on McDowell's kitchen table, whilst Mrs. Crawford recited psalms to distract her attention from the operation.
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Figure 1.1: Ephraim McDowell (1771–1830). The father of abdominal surgery
In these litigious times surgeons are naturally apprehensive of the outcome of their work, but pity poor Ephraim McDowell who had to contend with the knowledge that several of his townsfolk were erecting a gallows for him, should the patient die at the hands of “the dreadful doctor”.
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Figure 1.2: Jane Todd Crawford (1762–1842). The first woman to have a laparotomy—Christmas Day 1809
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McDowell made a nine inch long paramedian incision, ligated the left tube and the ovarian pedicle close to the uterus, then emptied some gelatinous fluid from the tumour enabling him to deliver it through the incision. The tumour weighed 10.2 kilograms and he had to tilt the patient over to her side to spill out any blood from the peritoneal cavity and then replace the bowel and sew the pedicle to the lower end of the wound, which he closed with interrupted sutures. The entire operation took only twenty-five minutes and five days later Mrs. Crawford was up and about and was found to be making her own bed in McDowell's house. She rode home to Greensburgh some twenty days later in excellent health and apparently lived to a ripe old age.
Although this was the first successful major abdominal operation through the peritoneum, McDowell did not publish the event until some nine years later, after which he had performed several other ‘ovariotomies’. During his life-time he performed thirteen of these procedures in all and only one patient died. This was an extraordinary record for those times when sepsis and peritonitis exacted a frightening toll following laparotomy. Others tried to emulate him and a fellow student from Edinburgh, John Lizzars, made his first attempt some fourteen years later but the patient succumbed and he then made three more successful attempts in 1825. In spite of these successes, it was Charles Clay (1801–1893) (Figure 1.3) who was the first to introduce the word ‘ovariotomy’ and this was a strange choice for the title of this operation, in an age when surgeons were usually reared in the classics and were often pedantic but usually aetimologically correct (Morton, 1965).
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Figure 1.3: Charles Clay. Performed the first abdominal hysterectomy on 17th November 1843
Charles Clay was regarded as the greatest ovariotomist in Europe. He performed his first operation on the 13th September, 1842, when, in the presence of several of his medical friends, he operated at the patient's house at 75 Heyrod Street, in Ancoats, Manchester. The tumour he removed weighed 17lbs. 5oz and the operation took forty minutes. The patient, who only had brandy and milk for analgesia, made a satisfactory recovery. In his lifetime, Clay performed 395 ovariotomies with a mortality of only 25 and although he accepted the need for anaesthesia following its introduction by Morton in Boston in 1846, he nevertheless felt that it rather interfered with his good results, because he clearly was of the opinion that the patients who had the fortitude to undergo surgery without it were imbued with a greater will to survive.
 
CHARLES CLAY AND THE FIRST ABDOMINAL HYSTERECTOMY IN THE WORLD
Charles Clay was born at Bredbury, near Stockport in 1801. He was reared in Manchester and brought up by his uncle. His school career was broken and on the whole unsatisfactory. He spent his early medical career apprenticed to Kinder-Wood, who was on the staff of St. Mary's Hospital, in Manchester, England.
Clay studied at the Manchester Royal Infirmary and later spent some time in Edinburgh before settling down to a busy surgical practice in Ashton-under-Lyne, ten miles to the east of Manchester. After sixteen years there, during which time he gained a reputation for his surgical work, he moved to the centre of the thriving Victorian city of Manchester where, in 1839, he established his practice. His consulting rooms in Piccadilly, Manchester, are on the first floor and that is where the world's first hysterectomy was performed over what is now a golf and sports shop. In a contemporary illustration we see him at the peak of his surgical career, complete with top hat, looking profoundly confident. He was in fact a contemporary of my great grandfather, who had established a large Chartered Surveyors and Auctioneers business in Spring Gardens, half a mile to the west.
All of Clay's first five ovariotomies survived, but in his fifth case he was not so lucky. He had confidently diagnosed a large ovarian tumour, but on making his 3massive incision the patient coughed and extruded a huge uterine fibroid, which he was unable to replace. He therefore had no choice but to continue with a subtotal hysterectomy and this took place on the 17th November, 1843. A few days later, on 21st November, 1843, A.M. Heath, also of Manchester, also opened the abdomen suspecting a large ovarian tumour and found a massive fibroid and in both cases the women died soon afterwards from massive haemorrhage.
The following year, Charles Clay found himself in a similar situation and again proceeded to perform a subtotal hysterectomy, having placed a ligature of Indian hemp round the supravaginal cervix. On this occasion the patient survived the operation but, sadly, died on the fifteenth postoperative day, having fallen out of bed. This was sad, not only for the patient, but for Charles Clay's claim to having performed the first successful hysterectomy, because she had in fact survived the critical immediate postoperative period and had not succumbed to sepsis, which was the usual mode of death, and it was not for a further twenty years that he was able to claim the first successful hysterectomy in Europe (vide infra).
Reading the contemporary accounts of this patient's postoperative course, it is difficult to determine the exact mode of death. Some accounts suggest that she had a secondary bleed and died of haemorrhage after falling out of bed and it is not inconceivable that his ligature included both ureters and the poor woman possibly fell out of bed due to uraemic coma. It is, however, firmly routed in Mancunian folklore that she was dropped inadvertently on the floor by a pair of incompetent porters whilst the nurses were changing the bed linen. If this were true, the death was entirely unrelated to the operation and if this accident had not occurred, Clay could have claimed to have performed the first successful hysterectomy in the world.
 
ELLIS BURNHAM PERFORMS THE WORLD'S FIRST SUCCESSFUL ABDOMINAL HYSTERECTOMY
Ellis Burnham, of the United States of America, performed the first hysterectomy with a patient surviving. (Graham 1951; Benrubi 1988). This was performed in the town of Lowell, Massachusetts in 1853 and again the diagnosis was incorrect and Burnham thought he was operating on a massive ovarian cyst. On this occasion when the abdomen was opened the patient vomited and, as with Clay's case, extruded a large fibroid uterus. Burnham tied off both uterine arteries and carried out a sub-total hysterectomy and the patient survived. This was an amazing achievement and he performed fifteen further hysterectomies during his subsequent career which spanned thirteen years, but sadly only three survived, the rest dying from peritonitis, sepsis, haemorrhage and, somewhat surprisingly, exhaustion.
The early record of the first abdominal hysterectomies reads like a disaster saga from 1843 to 1853 when Burnham produced the first survivor, but even then the diagnosis was wrong. Later that year, in September, Kimball (also from Massachusetts) carried out the first deliberate hysterectomy for a fibroid tumour, with the patient surviving the operation (Kimball, 1855; Benrubi 1988). The patient made a full and complete recovery, but 8 months later the protruding ligatures were still causing inconvenience. In the early years of hysterectomy the ligatures were brought through the lower part of the incision and the ligature was left long in order to encourage the drainage of ‘laudable pus’, which was the custom of the day when the main vessel in an amputated limb was tied with a long ligature. In favourable circumstances the ligature became detached some weeks after the procedure, but it is obvious now that it was a contributing factor to the sepsis that usually brought about the demise of these patients. It is difficult to understand why gynaecologists adopted this technique and possibly it was the second case of John Lizzars of Edinburgh who, less than a month after his first successful ovariotomy, excised another cyst and on this occasion he employed a short ligature and allowed it to drop into the wound and the patient died. Whether this small series of two cases persuaded a whole generation of surgeons to employ the long ligature is difficult to say, but this extraordinary practice retarded the progress and development of gynaecological surgery for almost half a century.
 
THE INTRODUCTION OF ANAESTHESIA
Kimball's patient was also the first to be lucky enough to reap the benefits of the introduction of anaesthesia, in this case chloroform. In these early days, surgery made very slow progress, because of the severe limitation of effective pain relief during operations, as well as devastating postoperative infections. Before the discovery of anaesthesia, surgeons had to rely on opiates, plants containing hyoscyamus and mandragora and, of course, alcohol was known to make patients oblivious enough to pain to permit surgical procedures to be undertaken.
In 1772, Joseph Priestly discovered nitrous oxide gas and later this was used as a party piece, because it induced amusement and euphoria and became known as “laughing gas”. Humphrey Davey (1778–1829), the 4inventor of the miner's safety lamp, noted a reduced sensitivity to pain in these “revellers” and suggested that it might be useful during surgery, but unfortunately no one followed up his suggestion. By 1831, all three basic anaesthetic agents–ether, nitrous oxide gas and chloroform–had been discovered, but no medical applications of their pain relieving properties had been made. Probably the first historical use of anaesthesia in surgery was Dr. Crawford W. Long (1815–78) of Georgia who, in 1842 applied his social experiences with laughing gas to perform three minor surgical procedures. He did not realise the significance of what he had done and made no effort to publicise his discovery until several years later when anaesthesia had been hailed as a major breakthrough. Oddly enough, it was the dentists who were the first to utilise anaesthesia, presumably because of the extreme sensitivity of the teeth and gums. Dr. Horace Wells (1815–48), a Connecticut dentist, learnt of the peculiar properties of nitrous oxide in 1844 and tested them by having one of his own teeth removed whilst under the influence of the gas. Delighted with the results, he administered it to several patients and then demonstrated it at Harvard, but unfortunately the patient cried out in agony and Wells was booed and hissed out of the room. It therefore fell to his colleague and dental student, William T.G. Morton (1819–68) to demonstrate before the same medical class of Dr. John C. Warren the effectiveness of sulphuric ether in inducing dental anaesthesia. Morton gave the first successful public demonstration of surgical anaesthesia on October 16th 1846 at the Massachusetts General Hospital on what has become known as “Ether Day” (Figure 1.4). Morton is universally regarded as the world's first anaesthetist and he turned up twenty minutes late for the operation, thereby setting a precedent that anaesthetists have adhered to even in present times.
Although ether became immediately extremely popular, Oliver Wendel Holmes was the first to supply the name “anaesthesia” because the Boston medical community were at a loss to describe the condition induced by this new agent. James Simpson of Edinburgh abandoned it in favour of chloroform, because of its disagreeable odour, irritating properties and long induction period. During the next century, chloroform continued to be the agent of choice in Europe until its unmanageable toxicity and delayed damage to the liver became appreciated. Simpson employed anaesthesia in childbirth and was vehemently opposed and condemned by the Calvinist Church fathers' in Edinburgh, because it was contrary to the biblical admonition that a woman must bring forth her child in pain. Luckily the fact that John Snow (1813–58) used it for Queen Victoria's delivery of Princess Charlotte, went a long way to make it acceptable and it is indeed fortunate that she did not herself suffer the liver damage that was frequently associated with its use.
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Figure 1.4: Ether Day. William Morton administers the first anaesthetic on 16th October, 1846
Charles Clay, when he presented his results to the Obstetrical Society of London in March 1863 described one hundred and eight operations for ovarian tumours with thirty-four postoperative deaths. He was inclined to lay the blame for the worsening results on the advent of general anaesthesia. He said: “I am not certain if chloroform has really added to the success of ovarian operations. The first fourteen of my cases were undertaken before it was discovered and of these fourteen, nine recovered. But though I willingly admit the almost impossibility of obtaining the consent of females to submit to so formidable operation without the aid of this valuable agent - …. if it could be accomplished, I would infinitely prefer to operate without it, as the patient would bring to bare on her case a nerve and determination which would assist beyond all value the after treatment”.
In spite of his reservations there was no doubt that the invention of anaesthesia went a long way to make surgery more acceptable. Nowadays one can only wonder at the horrendous suffering that these women had to endure when they were split from sternum to symphysis pubis by a cold surgical knife, having little to comfort 5them but some milk and brandy or, in the case of Jane Todd Crawford, the comfort of reciting the psalms.
 
THOMAS KEITH AND THE DAWN OF THE NEW ERA
Charles Clay used the long ligature throughout his career and Lawson Tate, from Birmingham, who was the first surgeon to successfully operate on an ectopic pregnancy, believed that had he cut the ligature short and completely closed the wound, the mortality rate would probably have fallen to 6 or 8%. Interestingly enough, results such as this were achieved by Isaac Baker Brown, who cauterised the ligated ovarian pedicle, dropped it and closed the abdominal wound on 40 occasions with only 4 deaths. This man came from London's greatest teaching hospital, St. Mary's Hospital in Paddington - and sadly went the way of so many in our profession in the past and even in present times. He somehow went off at a tangent and in 1865 published a paper on “The cureability of some forms of insanity, epilepsy and hysteria by clitoridectomy”. Unfortunately, he also advertised the success of this procedure and as a result he fell from grace and was expelled from the Obstetrical Society of London and died in obscurity. Because of this, his technique of ovariotomy failed to be adopted and it fell to Thomas Keith, an apprentice of James Young Simpson, to rediscover this manoeuvre.
Thomas Keith was probably the greatest analytical surgeon in our speciality during the late nineteenth century. He was a wild looking man, born in the Manse of St. Cyrus, near Montrose in the Scottish Borders and was a lifelong sufferer from cysteine stones for which he required many operations which probably accounts for his rather startling appearance (Figure 1.5). His brother George was present at Simpson's first chloroform experiment–as was Matthews Duncan of placenta fame– and one can only hope that Thomas availed himself of chloroform when he underwent his repeated lithotomies.
Thomas Keith performed his first ovariotomy in September 1862, but his initial mortality was high. This was around the time when Lister was preaching his principles of antiseptic surgery, but Keith found that the carbolic spray did not help to reduce his operative mortality. Keith therefore turned his attention to the method of wound closure and abandoned the long ligature and the exteriorised clamp that Spencer Wells had popularised (Figure 1.6) and instead cauterised the pedicle and dropped it into the peritoneal cavity, which he then drained. He was also a vigorous opponent of the technique of blood-letting and produced the best results obtained so far-156 cases with only 6 deaths (3.8% mortality). His hysterectomy results were no less impressive and by the time he left Edinburgh to emigrate south to London he had recorded 33 cases with only 3 deaths. Spencer Wells, (Figure 1.7) a Society dilettante who considered himself the greatest gynaecological surgeon in Europe at that time and drove from hospital to hospital in London in his “brougham and silver grey four” produced results that were appalling and out of 40 hysterectomies performed for fibroids, there were 29 deaths–a mortality rate of 73%! Lawson Tate, (Figure 1.8) a rather aggressive character who loathed Spencer Wells, found that using the carbolic spray he still had a 38% mortality with his first 50 ovariotomies. He then realised that it was not the spray that had given Keith his excellent results–and indeed there is no evidence that Keith ever used the carbolic spray–but it was the intraperitoneal method of dealing with the pedicle.
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Figure 1.5: Thomas Keith. Dispensed with the long ligature and made hysterectomy a safer operation
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Figure 1.6: Spencer Wells. Clamp to exteriorise the cervix
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Figure 1.7: Spencer Wells (1818–1895). Seen here at the Garden party of Baroness Burdett-Couts
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Figure 1.8: Lawson Tait (1845–1899). A successful Birmingham surgeon who loathed Spencer Wells
He immediately adopted this technique, abandoned the carbolic spray and lost only 2 of his next 73 patients. He also learned from both Lister and Keith the value of cleanliness and this was unusual in those days, because none of the surgeons wore gloves and very few even deigned to wash their hands before operating. The early hysterectomies were extremely sociable affairs and it was considered good form to bring along ones friends, both medical and non-medical, to witness these momentous surgical events. Figure 1.9 shows the famous French gynaecologist, Pean operating in much the same way as Pavarotti might sing to a social soirée.
Lawson Tate summed up the end of this rather dark era in gynaecological surgery with the following words “the ovarian tumour was the battlefield whereupon the first abdominal engagements were fought. Whereas ovariotomy undoubtedly opened the gateway to abdominal surgery, Spencer Wells by his outmoded technique and resultant mortality of 25% undoubtedly held back progress, because no one would submit women to such fearful risk unless life were already threatened. Dr. Thomas Keith ended this dark period by showing us how to operate on the abdomen without fear and with little risk”.
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Figure 1.9: Jules Pean (1830–1898). A famous French Surgeon
 
CHARLES CLAY AND THE FIRST SUCCESSFUL HYSTERECTOMY IN EUROPE
Although Charles Clay took great pride in his experience with ovariotomy, in his important presentation to the Obstetrical Society of London, almost as an aside, he mentioned a successful case of the entire removal of the uterus and its appendages (Clay, 1863). This was the first successful hysterectomy in Europe and it is important to emphasise this, because many reference books give priority to Koeberle of Strasbourg who performed his operation on the 2nd April, 1863. Charles Clay performed his first successful hysterectomy with oophorectomy and salpingectomy on the 3rd January, 1863, three months before Koeberle, and described it in his presentation to the Obstetrical Society of London on the 3rd March, 1863. He therefore had the priority by three months and indeed had very bad luck in not being able to make this claim 719 years earlier when the patient fell out of bed on the fifteenth postoperative day. Clay's operation was well authenticated by three doctors from Preston, Sheffield and Manchester and immediately after the operation Professor J.Y. Simpson of Edinburgh arrived unexpectedly. He was greatly interested in the case and took the specimen back to Edinburgh from whence, sometime later, he returned a description and a sketch, ending his letter with “your case may turn out as a precedent for operative interference in some exceptional cases of large fibroids of the uterus and I congratulate you most sincerely on the happy recovery of your patient”.
Koerberle of Strasbourg used a slightly different technique when he performed his operation on 2nd April, 1863. The operation was planned and the diagnosis of fibroids was correct, but to obtain haemostasis he used a device called the serre-noeud (Figure 1.10) whereby wires were twisted around each half of the cervix, which was then exteriorised through the abdominal wound until eventually it sloughed off and fell internally and the clamp could be removed.
Unfortunately, recovery was by no means the commonest outcome and the mortality from the abdominal approach to hysterectomy was reported as exceeding 70%, even as late as 1880.
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Figure 1.10: The serre-noeud. Used by Eugene Koeberle from Strasbourg who Performed the second successful abdominal hysterectomy in Europe
 
EARLY VAGINAL HYSTERECTOMIES
The origins of vaginal hysterectomy are lost in the mists of antiquity, but the first was reputedly performed by Soranus in the Greek city of Ephesus in AD 120, although there is an even more vague reference to the procedure having been performed 50 years before the birth of Christ by Themison of Athens (Lameras 1975). According to the medical historian Richard Leonardo, the procedure performed by Soranus was the removal of an inverted uterus that had become gangrenous (Leonardo 1944). The ureters and often the bladder, were invariably part of these early surgical excisions and the patients invariably died. Nevertheless, in the writings of the eleventh century Arabic physician, Alsaharavius, he clearly states that if the uterus had prolapsed externally and could not be reinserted, then he advised his pupils that it should be surgically excised (Benrubi 1988) and it is unlikely that he would have advocated this practice if death was the invariable result of their intervention. In fact there are several reports of patients surviving vaginal hysterectomy in the middle ages, and these are referred to in medical writings in the sixteenth and seventeenth centuries. The first authenticated case was reported by Berengarius da Carpi who lived in Bologna in AD 1507 and was reputed to have performed a partial vaginal hysterectomy. Schenck of Grabenberg reported 26 cases during the early part of the seventeenth century and the operation was also performed by Andreas da Crusce in 1560 and Valkaner of Nuremburg in 1675, when the patients appeared to have survived. Modern medical historians are somewhat sceptical about some of these early reports and, as usual, have largely ignored the contribution of the midwives of Europe who, from time to time, amputated prolapsed or inverted puerperal uteri. They have also overlooked an early example of self-help: the case of Faith Howard, a 46-year-old peasant woman who performed the operation on herself. This case was well documented and reported in 1670 by Percival Willoughby, an early man-midwife and lifelong friend of William Harvey, the discoverer of the circulation. Apparently, whilst she was carrying a heavy load of coal one day, Faith's uterus prolapsed completely and, frustrated by this frequent occurrence, she grabbed the offending organ, pulled as hard as possible and cut the whole lot off with a short knife. In his report, Willoughby states that “there was a mighty bleeding which eventually stopped” and Faith lived on for many years after this, “water passing from her insensible day and night”, obviously from a vesico-vaginal fistula.
 
THE FIRST ELECTIVE VAGINAL HYSTERECTOMIES
Baudelocque from France introduced the technique of artificially prolapsing and then, in favourable cases, of cutting away the uterus and appendages. He performed 23 such procedures during the 16 years following 1800, but gave Lauvariol the credit for having performed the first operation in France. This was well before the time of the first abdominal operation performed by Charles Clay in 1843.
Most of these procedures were performed on puerperal uteri and were undertaken on an emergency basis, but the first planned procedure was by Osiander 8of Gottingen in 1801. Wisely, he did not report the case until he had operated on his ninth patient. In 1810, Wrisberg, in a prize essay read before the Vienna Royal Academy of Medicine, advocated vaginal hysterectomy for cancer and two years later, Paletta performed the operation. He was not entirely certain, however, that he had extirpated the entire uterus.
 
CONRAD LANGENBECK, SURGEON-GENERAL TO THE HANNOVERIAN ARMY
Conrad Langenbeck, (Figure 1.11) who came from Gottingen, was a surgeon of such supreme swiftness that he once amputated a shoulder while a colleague, who had come to observe the procedure, turned his back for a moment to take a pinch of snuff. Langenbeck was Surgeon-General to the Hannoverian Army and also a Professor of Anatomy and Surgery and was certainly the most distinguished surgeon of his day. He had read Wrisberg's paper and also the report of Paletta and this encouraged him to perform the first deliberate planned vaginal hysterectomy for carcinoma in 1813. He did not however, report the operation until 1817 and because of the abuse that he was subjected to, he probably regretted ever doing it.
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Figure 1.11: Conrad Langenbeck. Surgeon-General of the Hannoverian Army performed the first vaginal hysterectomy for endometrial cancer in 1813
He had little precedent to follow, so he had to devise his own plan for the removal of the entire uterus. He performed a retroperitoneal dissection, taking great care not to enter the peritoneal cavity. Unfortunately, towards the end of the operation he encountered very heavy bleeding and called upon his assistant to help him. Unfortunately his assistant, a Surgeon Commander debilitated by gout, was unable to rise from his chair when called upon to render assistance. Langenbeck had no option but to grasp the bleeding artery with his left hand and with his right hand he passed a needle carrying a ligature through the tissues beyond the bleeding point. With no one to assist him, he had to tie the ligature by grasping one end between his teeth and secured the pedicle with a one handed slip knot tied with his right hand. Following the procedure he could detect no opening into the peritoneal cavity and the patient made a surprising and uneventful recovery. Sadly, after such a display of surgical virtuosity, none of his colleagues would believe the report of his operation when it was published four years later. The specimen had somehow been lost and never reached the pathology department and the assistant with gout died some two weeks later, so there was no one to testify that the procedure had in fact taken place. The patient herself was demented and thus an unreliable witness and died of senility some 26 years later and only then could he prove by post-mortem examination that he had performed the operation. During that 26 years he was ridiculed and subjected to the jibes of his colleagues and no one gave him credit at the time for this spectacular achievement.
 
FURTHER DEVELOPMENTS IN TECHNIQUE AT THE END OF THE NINETEENTH CENTURY
The latter years of the last century witnessed further development and the technique for abdominal hysterectomy was refined and standardised by Freund. Czerny, following Conrad Langenbeck's original description, did the same for vaginal hysterectomy (Ricci 1945).
The first planned hysterectomy performed on a gravid uterus took place in 1876 by Porro from Milan (Speert, 1980).
Radical hysterectomy for cervical cancer was introduced by the German surgeon Schuchardt and was later refined and popularised by Ernst Wertheim, the famous Austrian surgeon from Vienna, after whom the operation is now somewhat unfairly named. The end of the nineteenth century and the early years of the twentieth century witnessed the introduction of specially modified instrumentation, anaesthesia and antisepsis and the mortality rate for vaginal hysterectomy dropped precipitously and by 1886 was approximately 15%; by 1890 it had reached 10% and by 1910 it was as low as 2.5%. 9Abdominal hysterectomy lagged far behind and at one time it was formally condemned by the Academy of Medicine of Paris, when they met in 1872. Even 8 years after that, T.G. Thomas reported on 365 collected cases which revealed a staggering mortality of 70%. It is extraordinary that given this high mortality, women allowed themselves to be subjected to this procedure and there was a time that it was advocated for hysteria and menstrual melancholia, the modern equivalent of which is the pre-menstrual syndrome.
In spite of these disastrous results, progress in abdominal hysterectomy was being made. Mikulicz abandoned the serre-noeud after using it for 15 years and instead placed triple ligatures on the broad ligaments and tied each one of them separately. In 1878, Freund introduced techniques for packing off the intestines, ligating the major blood vessels and covering the cervical stump with peritoneum, which, in the same year, had been practised independently by both Schroeder and Spencer Wells. In 1889, Lewis Stimpson had advocated the systematic ligation of the main ovarian and uterine vessels instead of tying off the entire broad ligament and three years later, Bare of Philadelphia, the father of the modern sub-total hysterectomy, tied the uterine vessels “outside of, but close to, the cervix”. He was also the first to advocate “care…to avoid the ureter”! This technique was further refined in 1896 by Howard Kelly, who described an immaculate technique for sub-total hysterectomy little different from that employed today. Thus, in the space of one decade, exterior fixation of the uterus by the serre-noeud or a cervical clamp, such as that designed by Spencer Wells, had been replaced by intraperitoneal treatment of the cervical stump, which itself was modified and became extraperitoneal again, by covering the stump with pelvic peritoneum.
These new techniques are reflected in the dramatic fall in mortality shown in the figures from the London teaching hospitals in 1896 and 1906, showing an impressive drop in mortality from 22 to 3.4%, allowing one of my distant relatives, John Bland Sutton to write in 1904: ‘The removal of the uterus is followed less frequently by unpleasant sequelae than any other major operation in surgery. Hysterectomy has a wonderful future, and this is a great thing to say of an operation which 40 years ago had no more reality than “Jack the Giant Killer”.’
 
THE DEVELOPMENT OF HYSTERECTOMY IN THE TWENTIETH CENTURY
Up until the end of the Second World War, the universal approach to hysterectomy was the sub-total procedure, with the reduced chance of pelvic infection and ureteric injury, but mainly in the pre-antibiotic era, to reduce the chance of ascending infection and peritonitis, which was almost invariably fatal. Once this problem had been eradicated by the development of antibiotics, hysterectomy almost invariably included removal of the cervix and the man who has pride of place for performing the first total hysterectomy was E.H. Richardson from the United States of America in 1929 (Richardson, 1929). His main concern in moving away from the traditional subtotal procedure, was to prevent the occurrence of stump carcinoma, yet even in the days before cervical screening was available, the actual incidence of neoplastic change in retained cervical stumps was only 0.4% in 6,600 cases in the United States of America (Cutler and Zolenger, 1949) and 0.1% in Finland (Kilkku, Gronroos and Rauramo, 1985). As Tom Lyons (1993) has pointed out, this is similar to the rate of vaginal cancer following total abdominal hysterectomy and yet no one has seriously recommended the removal of the vagina at hysterectomy as prophylaxis against this.
Apart from the change from sub-total to total hysterectomy during the twentieth century, the only change in the abdominal procedure was the almost universal adoption of the less disfiguring transverse scar introduced by Johannes Pfannenstiel from Breslau in 1900. Unfortunately this great surgeon died at the young age of 47, following a needle-stick injury in much the way as his Viennese colleague Semmelweiss, who taught the world the value of antisepsis in the prevention of puerperal fever, had done before him. Apart from the obvious cosmetic attraction of the transverse scar, it has a much higher tensile strength and was less prone to wound dehiscence and subsequent incisional hernia. Nevertheless it took many years to be universally accepted and my predecessor in Guildford was still employing large vertical incisions even in the 1980s.
Increased surgical skill and prowess from an apprenticeship type of training has ensured that the operation now is extremely safe with an incidence of ureteric injury of 0.2–0.5% and mortality of 0.12%. (Amirikiah, Evans, 1979; Daly and Higgins 1988).
The advent of prophylactic anticoagulants and antibiotics has further increased the safety of this procedure. The oft quoted figures of Dicker (1982) showing the superiority of vaginal hysterectomy with a morbidity of 24.5% compared with that of abdominal hysterectomy with a morbidity of 42.8%, are an eloquent testimony of the efficacy of prophylactic antibiotics, since those who had a vaginal hysterectomy had the benefit of these drugs, whereas those having an abdominal hysterectomy did not.10
Almost inevitably the increased safety of the operation led to an explosive increase in the number of hysterectomies performed, so that it is now the second most common operation undertaken in the United States of America with over 650,000 being performed annually at a cost of approximately three billion dollars. With the increasing safety the indications for the procedure have become more lax, to the extent that at the end of the last decade a Californian woman only had a fifty fifty chance of going to her grave still in possession of her uterus. Not only had the procedure become open to a certain amount of abuse, but technological advances, apart from endometrial ablation, had largely by-passed hysterectomy and during the mid part of this century, gynaecological surgery was in the doldrums.
 
THE DEVELOPMENT OF LAPAROSCOPIC SURGERY
Laparoscopy was introduced into continental Europe in the 1940s with the pioneering surgery of Hans Frangenheim from Konstanz and Raoul Palmer from Paris. It was largely ignored in the United Kingdom and North America until Patrick Steptoe, working in a small district hospital in Oldham, Lancashire, published the first book in the English language (Steptoe, 1967) which allowed wide dissemination of this new technique in the English speaking world.
Laparoscopy became an enormously important diagnostic tool in gynaecology and even allowed the performance of relatively minor procedures, such as female sterilisation, ventrosuspension and puncture or fenestration of ovarian cysts. In the early years it was necessary to operate directly down the laparoscope in an intensely uncomfortable position, which certainly contributed to my own prolapsed intervertebral disc and I suspect many of my colleagues also developed occupational injury to their backs. The catalyst needed to catapult this new surgical approach from fantasy to reality was the development of small silicone chip cameras, enabling the entire operating team to take part in the surgery by way of a television monitor and the development of superior optics by the invention of the rod lens system and external cold light source, both of which were developed by Professor Harold Hopkins, FRS, from Reading University in the United Kingdom.
Gradually gynaecological surgery became more sophisticated and much of the inspiration for this was the pioneering work of Professor Kurt Semm from Kiel University in Germany and his successor Professor Lilo Mettler and Professor Maurice Bruhat and his gifted team from Clermont-Ferrand in France. The stage was now set for minimally invasive surgery to become a reality, and for a long time gynaecologists struggled with primitive surgical equipment and relied on advances in laser technology and electro-surgical devices to achieve cutting and coagulation.
Our general surgical colleagues took an astonishingly long time to wake up from their slumbers before realising that the procedure par excellence suited for endoscopic surgery was the removal of the gall bladder. Even then, it took a gynaecologist (Philippe Mouret) from Lyon, France, to show them how it was done. The realisation of the enormous financial profits to be made from endoscopic surgery finally spurred the instrument manufacturers to produce a new generation of surgical equipment, so that finally we had scissors that actually cut and devices that could quickly and effectively secure vascular pedicles with clips, sutures or linear arrays of titanium staples.
In a remarkably short space of time, enthusiasts from all over the world had adopted these techniques so that, at the time of writing, at least 80% of gynaecological operations which heretofore required major surgery with a large painful scar, could be operated on under endoscopic vision with several small access ports for the surgical instruments, resulting in a shorter hospital stay and a rapid return to domestic life and work.
 
LAPAROSCOPIC HYSTERECTOMY
Harry Reich performed the first laparoscopic hysterectomy in the world in 1989, in the William Nesbitt Memorial Hospital in Kingston, Pennsylvania, USA. He published his article the following year (Reich, De Caprio and McGlynn, 1989). Subsequently he demonstrated this technique in all the continents of the world where the performance was met with varying degrees of amazement and scepticism. Critics claimed that it took too long and would not be suitable for busy operating schedules in most countries and was a luxury peculiarly suited to the cosseted U.S. health system, where the average gynaecologist only performs one or two procedures a week (Sutton, 1994).
The reason that he took so long was that he performed the entire procedure laparoscopically, including dissecting out part of the ureter and individually ligating and tying off the uterine artery and vein with extracorporeal sutures. He also performed the colpotomy incision laparoscopically and repaired it via the laparoscope. Other surgeons found this too time consuming and soon the procedure of laparoscopic assisted vaginal 11hysterectomy became established, where the upper pedicles were ligated, electro-coagulated or stapled laparoscopically whilst the remaining part of the operation was performed as a routine vaginal hysterectomy. Unfortunately this led to a certain amount of abuse, because this procedure was designed to replace an abdominal, not a vaginal hysterectomy, and yet many cases were performed which clearly could have been completed entirely by the vaginal approach. Equally, it soon became evident that none of the laparoscopic part of the operation did anything to make the vaginal approach any easier and since there is no descent until the uterosacral and cardinal ligaments are transected, most surgeons found that with the limited access involved–otherwise they would have been done vaginally–the procedure became a very difficult vaginal hysterectomy. Cynics pointed out that this was in fact a complicated way of performing a vaginal hysterectomy, but it certainly had the advantage of honing vaginal surgical skills and allowed dissection of bowel adhesions laparoscopically, as well as the treatment of endometriosis and the easier removal of ovaries. It also had the advantage that the internal wound could be inspected at the completion of the procedure and any residual bleeding vessels could be sealed by bipolar diathermy ensuring that at the end of the procedure the field was absolutely dry. This did not however, prevent secondary haemorrhages occurring a few days later and the lack of bleeding at the end of the procedure did not necessarily prevent subsequent haematoma formation.
These various criticisms led some laparoscopic surgeons to develop a purer approach to the operation and reverted to supracervical hysterectomy with removal of the transformation zone, either by coring it out with a serrated edge reamer (Semm, 1993; Ewen and Sutton 1994) or by simply removing the transformation zone with an electrosurgical loop from below (Donnez, 1993) or coagulating it with the Nd:YAG artificial sapphire contact probe laparoscopically (Lyons, 1993). The first laparoscopic hysterectomy in Europe was performed by the Classic Intrafascial SEMM Hysterectomy (CISH) technique by Professor Kurt Semm on a Saturday afternoon on September 7th 1991 in Kiel and this technique has been employed by his successor Professor Liselotte Mettler since then with good results. Employing these techniques, the possibility of cervical carcinoma should theoretically be reduced to zero, although all authors recommended annual cervical cytological surveillance, but it also allowed a purer laparoscopic approach, because it could avoid a vaginal incision and the fundus and adnexae could be removed by an electric morcellator. Additionally it had the advantage of avoiding any surgery in the danger zone around the ureter, was less likely to be associated with infection and abscess formation, maintained the integrity of the pelvic floor and was less prone to post hysterectomy urinary dysfunction, since there was little bladder dissection and, arguably, did not interfere with a patients sexual arousal and orgasm (Kilkku, 1983).
Although this procedure enjoyed a good safety record and could be performed relatively quickly, the patients being discharged on the second or third postoperative day and return to full activity in three weeks (Ewen and Sutton, 1994), we have found a disconcerting number of patients who had persistent pain and bleeding and eventually had to have the cervical stump removed. A clinical audit in our hospital (Haddad, 1995) found that this was only in patients whose indication for hysterectomy was endometriosis and if this group were excluded, then it was a very satisfactory operation. Other authors (Schwarz 1993) have had a similar experience and we have found that since endometriosis is the main indication for hysterectomy in our department, its role has become somewhat limited.
 
THE FUTURE
Considering the length of time that Homo Sapiens has inhabited this planet, the history of hysterectomy is a short one and we have undoubtedly come a long way in a relatively small span of years. Our pioneering forefathers had to contend with a horrendous mortality rate and very high morbidity, but with technological advances made during this century, particularly with regard to antisepsis and antibiotic prophylaxis of infection, together with safe anaesthesia, intravenous fluids and blood transfusion, the procedure is now very safe with a mortality rate of approximately 12 per 10,000 (Bachman, 1990) and is increasingly performed to improve quality of life, rather that to save life.
It is always difficult to predict the future, but almost certainly alternatives to hysterectomy will continue to evolve and, as with general surgery, many operations will be replaced by medical treatment. A clearer understanding of the aetiology of endometriosis creating a basis for rational treatment would considerably decrease the number of procedures performed for that ill understood condition. The widespread introduction of cervical screening has reduced the incidence of cervical cancer in the western world and, in the future more effective screening for endometrial cancer could allow medical treatment in selected patients, although ovarian cancer will probably still require surgical treatment.12
Endometrial ablation with electro-resection or the neodymium YAG laser has been successful in the treatment of menorrhagia, although some scoffers have suggested that the initial one year 87% success rate, which is widely reported, (O'Connor and Magos 1997) drops rapidly away and merely delays the need for hysterectomy for a period of time. This has not been the experience in our department (Pooley 1998) and we have found that even at the end of five and six years 75% of the patients are still satisfied with the treatment and this has avoided a large number of hysterectomies. This figure reflects the results of multiple surgeons in training and if one only includes the results of a single surgeon in the private sector the 6-year long-term success rate rises to 83%.
Second generation methods of endometrial ablation that are already being developed, such as thermal balloons, hydrothermal, impedence-controlled and cryoablation techniques as well as new microwave systems will be expected to give much more uniform destruction of the endometrium in most cases (Sutton, 2006).
Refinements in the treatment of fibroids by interruption of their blood supply by cervical occlusive devices or uterine artery embolisation first described by Ravina in Paris (Ravina 1998) have dramatically reduced the number of hysterectomies performed for this condition and our radiological colleagues have performed over 1200 of these procedures with an impressive safety record and in recent years have achieved many successful pregnancies with similar outcomes to age matched controls (Walker WJ 2006).
In the future it may well be that hysterectomy will only be performed for malignant conditions and with the inclusion of para-aortic and pelvic lymphadenectomy this will be more efficiently undertaken by laparoscopic procedures in some instances assisted by increasingly sophisticated robots.
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