Red Flags
- Suspected gynaecological malignancy on pre-operative work-up — refer to gynae-oncology before surgery; staging and surgical approach differ[1]
- Massive intra-operative haemorrhage — major obstetric haemorrhage protocol; uterine artery ligation, internal iliac ligation, or radiology-guided embolisation[1]
- Postoperative fever, abdominal distension, or sepsis — investigate vault haematoma, ureteric injury, bowel injury, pulmonary embolism[1]
- Suspected ureteric injury (oliguria, flank pain, urinoma) — urology and imaging same-day; early repair improves outcomes[1]
First-line treatment
Interventions
- Indication-driven surgery[1]Confirmed indication: leiomyoma not amenable to medical or conservative therapy, AUB refractory to medical management, adenomyosis, endometriosis with completed family, prolapse, gynae malignancy. Avoid for asymptomatic fibroids
- Route selection — vaginal preferred when feasible[1]Vaginal > laparoscopic > abdominal in benign hysterectomy where uterine size and access allow. ACOG/AAGL hierarchy: vaginal first-line for benign disease; laparoscopic second; abdominal reserved for indications (very large uterus, malignancy requiring staging, dense adhesions)
- Concurrent salpingectomy[1]Routine bilateral salpingectomy at hysterectomy for benign disease — reduces ovarian cancer risk; preserve ovaries unless oncological indication or perimenopause discussion
- Enhanced recovery pathway (ERAS)[1]Carbohydrate loading, regional anaesthesia or short-acting agents, opioid-sparing analgesia, early ambulation, early oral intake, early catheter removal — reduces hospital stay
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Antibiotic prophylaxis[1] | Cephalosporin ± metronidazole | Cefazolin 2 g IV (3 g if BMI ≥35) within 60 min of skin incision; add metronidazole 500 mg IV for vaginal hysterectomy | — | Single pre-operative dose; redose after 4 h or major blood loss; reduces surgical site infection by 50% |
| VTE prophylaxis[1] | Low-molecular-weight heparin | Enoxaparin 40 mg SC daily (or weight-adjusted) starting 12 h post-op for 7–10 days; longer in malignancy or extended risk | — | Mechanical prophylaxis (intermittent compression) intra-op; combine with chemoprophylaxis except very low risk; cancer surgery extends to 4 weeks |
| Tranexamic acid[1] | Antifibrinolytic | 1 g IV at induction, may repeat at 4 h or 1 g IV during heavy bleeding | — | Reduces operative blood loss; especially useful in fibroid uterus or anticipated heavy bleeding |
Antibiotic prophylaxis[1]
Cephalosporin ± metronidazole
- Adult
- Cefazolin 2 g IV (3 g if BMI ≥35) within 60 min of skin incision; add metronidazole 500 mg IV for vaginal hysterectomy
- Paediatric
- —
Single pre-operative dose; redose after 4 h or major blood loss; reduces surgical site infection by 50%
VTE prophylaxis[1]
Low-molecular-weight heparin
- Adult
- Enoxaparin 40 mg SC daily (or weight-adjusted) starting 12 h post-op for 7–10 days; longer in malignancy or extended risk
- Paediatric
- —
Mechanical prophylaxis (intermittent compression) intra-op; combine with chemoprophylaxis except very low risk; cancer surgery extends to 4 weeks
Tranexamic acid[1]
Antifibrinolytic
- Adult
- 1 g IV at induction, may repeat at 4 h or 1 g IV during heavy bleeding
- Paediatric
- —
Reduces operative blood loss; especially useful in fibroid uterus or anticipated heavy bleeding
Safety-net
- Recovery typically 2 weeks (vaginal/laparoscopic) to 6 weeks (abdominal) — avoid heavy lifting and intercourse for 6 weeks regardless of route[1]
- Return same-day for fever, severe pain not relieved by analgesia, vomiting, heavy bleeding, painful or absent urination, or breathlessness[1]
- If you keep your ovaries, you remain at usual age-appropriate ovarian and breast cancer risk; if removed before menopause, discuss HRT with your clinician[1]
Referral criteria
- Suspected gynaecological malignancyGynae-oncology[1]
- Complex case (massive fibroids, severe endometriosis, prior multiple surgeries, suspected accreta in obstetric hysterectomy)Tertiary minimally invasive gynaecology centre[1]
- Postoperative complication (sepsis, fistula, bowel injury, ureteric injury, severe pain)Surgical team and relevant subspecialty same-day[1]
- Pre-operative work-up showing severe anaemia, cardiac, or respiratory diseaseAnaesthetic and relevant medical specialty pre-operative optimisation[1]
Clinical summary
Indications, route selection, and peri-operative care for benign and oncologic hysterectomy in adult women.