I read with interest Dr. Andrew Menzin’s article, “Hysterectomy: total versus supracervical surgery” [March]. It has been my practice for some time to conserve the cervix whenever possible. However, my concern has not been for the preservation of sexual function. Rather, I believe the supracervical approach is safer for the patient and—from a legal perspective—the gynecologist. The majority of lawsuits related to hysterectomy arise from alleged damage to the bladder or ureters. These risks are minimized, if not eliminated, when the cervix is conserved. Additionally, the risk of hemorrhage is greatly reduced in a supracervical procedure.
My own technique is to clamp and divide the uterine arteries after creating a small bladder flap. I then take a single pedicle from the cardinal ligaments bilaterally. Using a transverse V-shaped incision, I separate the fundus from the cervix at the level of the internal os. Finally, I easily approximate the stump edges after coagulating the endocervical canal with electrocautery.
Douglas Heritage, MD
DR. Menzin responds:
I appreciate Dr. Heritage’s thoughts on the potential benefits of the supracervical hysterectomy. Several points regarding the procedure should be emphasized.
First, in his technique, the ureter is still at risk, as the uterine artery pedicle is one of the most common sites of ureteral injury during a hysterectomy.
Second, care should be taken to ensure removal of the upper cervix—as described both in the article and Dr. Heritage’s letter—to avoid the presence of residual endometrial tissue at the cervical stump.
Lastly, preoperative counseling should include a thorough review of the risks and benefits along with a discussion of therapeutic alternatives.