Hysterectomy · House

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]

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

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

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]

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]

Indications, route selection, and peri-operative care for benign and oncologic hysterectomy in adult women.

1.FOGSI-ICOG Good Clinical Practice Recommendations on Advances in Hysterectomy (2024); ACOG Committee Opinion 701; AAGL guidance on Route of Hysterectomy (2024)