Anatomical Complications of Hysterectomy: A review

Rebecca C. Ramdhan1,2, Marios Loukas, R. Shane Tubbs1,2

1
Department of Anatomical Sciences, St. George’s University, Grenada, West Indies
2
Seattle Science Foundation, Seattle, WA, USA

shanet@seattlesciencefoundation.org

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process which may lead to
differences between this version and the Version of Record. Please cite this article as an
‘Accepted Article’, doi: 10.1002/ca.22962

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Abstract
Introduction: Hysterectomy is the most commonly performed gynecological procedure in the
United States with three possible surgical approaches; vaginal, abdominal and laparoscopic. As
with any surgical procedure, various anatomical complications can arise. These include injuries
to anatomical structures such as the urinary bladder, ureter, intestines, rectum, anus and a
multitude of nervous structures. Other complications include sexual dysfunction, vaginal cuff
dehiscence and urinary incontinence.
Materials and Methods: Using standard search engines, the anatomical complications of
hysterectomies are reviewed.

Conclusions: Surgeons who perform hysterectomies or are involved with post-operative

hysterectomy patients should be familiar with the possible complications of this common
procedure and the steps that can be taken to help reduce the risk of those complications.
Clinicians should also inform their patients of the potential complications as they can affect
lifestyle and comfort.

Key words: hysterectomy, complication, laparoscopic, abdominal, transvaginal, surgery,

women, female, anatomy, pelvic

Introduction
Hysterectomy is a very common procedure in which the uterus is surgically removed. It is
estimated that 33% of women in the United States have had a hysterectomy by the age of 60. It is
also the most common gynecological procedure in the United States, with more than 600,000
procedures performed annually (Clarke-Pearson and Geller, 2013).

Indications for hysterectomy

Most hysterectomies are performed for benign indications (Clarke-Pearson and Geller, 2013).

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Three surgical approaches can be taken to a hysterectomy - abdominal, vaginal and laparoscopic
- depending on factors such as the patient’s age, uterine volume and mobility, body mass index,
history of abdominal surgery and nulliparity (Terzi et al., 2016). In general, a hysterectomy can
be indicated for a multitude of reasons. One study involving 282 patients reported that the most
common indication was myoma uteri with or without abnormal uterine bleeding, followed by
endometrial, post-menopausal bleeding, pelvic masses, pelvic pain and uterine prolapse (Terzi et
al., 2016). In terms of surgical approaches, Jacoby et al. (2009) reported that uterine leiomyoma
was the leading cause for abdominal hysterectomy in 2005, whereas prolapse accounted for most
vaginal hysterectomy cases and abnormal bleeding accounted for more than half of laparoscopic
hysterectomies. Race can also play a role in the indications for hysterectomy. Wu et al. (2003)
reported that for Caucasian women, uterine leiomyoma was the leading indication (33%),
followed by menstrual disorders 21%) and then prolapse (16%). In African American women,
uterine leiomyoma was also the top indication (70%) followed by menstrual disorders (12%) and
then endometriosis (6%). Lastly, for Hispanic women, the top indication was again leiomyoma
(46%), followed by prolapse (46%) and menstrual disorders (14%). For all three races,
abdominal hysterectomy was the most common surgical approach.

Complications of Hysterectomy
According to Clarke-Pearson and Geller (2013) there are many complications of a hysterectomy
ranging from infectious (vaginal cuff cellulitis, infected abscesses and hematomas, wound
infections, urinary tract infections, respiratory infections and febrile morbidity) to anatomical
(gastrointestinal injuries, genitourinary injuries, neuropathies and vaginal cuff dehiscence) to
pathological (cancer and venous thromboembolism). DeNardis et al. (2008) reported that some
complications can be classified as perioperative (less than seven days after surgery) or delayed
(1-6 weeks after surgery). Perioperative complications include fever, ileus, pulmonary embolism,
Clostridium difficile colitis and postoperative hemorrhage, whereas some delayed complications
include wound infections, seroma, hematoma, lymphocele, bowel injuries and vaginal cuff
separation. There can also be an increased risk of pelvic organ prolapse, pelvic organ fistula
disease, and urinary incontinence (Altman et al., 2016). This review will focus on the anatomical
complications of a hysterectomy.

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Genitourinary tract injuries
An injury to the genitourinary tract, which comprises the urinary bladder and/or ureters, has an
occurrence rate of approximately 1–2% for all major gynecological surgeries. Among these
injuries, 75% occur during hysterectomy, which leads to an average of 5,000 injuries annually in
the United States (Walters and Karram, 2007; Clarke-Pearson and Geller, 2013).

When the surgical routes used are compared, one randomized trial that involved more than 1,300
hysterectomies reported a bladder injury rate of 1% for the abdominal route, 2.1% for
laparoscopic route, and 1.2% for the vaginal route (Johnson et al., 2006). Other trials reported
ranges from 0.3% to 1.2% for abdominal, 0.2% to 8.3% for laparoscopic, and 0.7% to 4% for
vaginal hysterectomies (Nieboer et al., 2009). From these studies it was concluded that there was
a greater risk of urinary bladder and ureter injury during laparoscopic hysterectomy than during
abdominal or vaginal hysterectomy (Clarke-Pearson and Geller, 2013).

The urinary bladder is often injured when the prevesical plane is dissected, especially during
formation of a bladder flap during abdominal or laparoscopic hysterectomy, or during anterior
colpotomy at the time of vaginal hysterectomy. These injuries tend to be noticed at the time of
surgery except for serosal injuries that do not create a full-thickness defect in the bladder wall,
which can lead to delayed cystotomy and vesicovaginal fistula formation during the
postoperative period. Factors that increase the risk of cystotomy during hysterectomy include
cesarean delivery, endometriosis, pelvic adhesive disease, and cancer (Smith et al., 1999).

Ureteral injuries tend to be less frequent than bladder injuries, but possibly because their
incidence is grossly underestimated. Studies demonstrate that about 66% of ureteral injuries go
unrecognized at the time of surgery (Gilmour et al., 1999; Clarke-Pearson and Geller, 2013).
Reports indicate that the incidence of ureteral injury is estimated as low as 0.05–0.5% for
gynecological surgery, the laparoscopic route having the highest rate and the vaginal route the
lowest (Gilmour et al., 2006; Carley et al., 2002). Injuries tend to transpire during dissection
along the pelvic sidewall, especially when dissecting along the infundibular-pelvic ligament.
Less common sites of injury include the lower uterine segment during ligation of the uterine
vessels and the base of the bladder during ligation of the cardinal and uterosacral ligaments.
Several factors predispose the patient to ureteral injury and these include former pelvic surgeries,
hemorrhage, endometriosis, cancer and compromised exposure secondary to large pelvic masses

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(leiomyomas) or obesity (Clarke-Pearson and Geller, 2013).

Prevention of genitourinary tract injury

It is vital to identify the bladder and ureters accurately during dissection to preclude injury to
these structures during a hysterectomy. Clarke-Pearson and Geller (2013) recommend insertion
of a Foley catheter at the start of the case, and confirming drainage will reduce the rate of
bladder injury regardless of the surgical route taken. An alternative method is identification of
the Foley bulb or retrograde filling of the bladder to define the boundaries of the bladder during
dissection. This identification can also be accomplished by placing a blunt metal probe into the
bladder through the urethra to delineate its borders (Clarke-Pearson and Geller, 2013).

The clinician should pay attention to the bladder’s location and enter the peritoneal cavity
adequately cephalic to it, irrespective of whether the mode of entry is through an abdominal
incision or through a laparoscopic trocar. The bladder flap should be mobilized before either
ligating the uterine artery or cervical amputation. This avoids unintentional incorporation of the
bladder tissue into the incisions. Dissections should be sharp to recognize the anatomical planes
better, especially if the clinician encounters scarring from previous pelvic surgeries. With vaginal
hysterectomy, sharp dissection upon entry into the anterior peritoneum is necessary and
important to mobilize the urinary bladder base and lower the risk of injury. A retractor should
subsequently be placed in this vesicovaginal plane to elevate the urinary bladder away from
further dissection (Clarke-Pearson and Geller, 2013).

As with the urinary bladder, identification principles help to prevent injury to the ureters. The
ureters pass over the bifurcation of the common iliac vessels before coursing below the uterine
artery and passing anterior and lateral to the cervix. It is important to pinpoint the ureter on the
medial aspect of the broad ligament when operating in the pelvis. Using a retroperitoneal
approach by opening the pararectal space can help to identify the ureter in this region. If
hemorrhage obscures the surgical field, it is vital to apply pressure rather than clamping and
ligating. There is no evidence that preoperative ureteral stenting decreases the rate of ureteral
injury during hysterectomy, but intraoperative stenting in cases in which the ureters cannot
otherwise be identified can help (Clarke-Pearson and Geller, 2013).

Vaginal cuff dehiscence

Vaginal cuff dehiscence is a rare but serious postoperative complication that is unique to

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hysterectomies. It usually occurs several weeks to months after the hysterectomy but can have a
delayed presentation of up to several years (Clarke-Pearson and Geller, 2013). It typically
presents with postcoital bleeding, vaginal spotting or watery vaginal discharge. Symptoms
indicative of pelvic pressure or a bulge can occur if there has been bowel evisceration (Iaco et
al., 2006).

In a systematic review, Uccella et al. (2011) reported that there was a 0.3% vaginal cuff
dehiscence rate. This incidence is similar to a 10-year cumulative data collection, which suggests
an incidence of 0.24%, gradually increasing to approximately 0.39% as more recent years are
studied (Clarke-Pearson and Geller, 2013). The authors also reported that this complication is
more frequent after total laparoscopic hysterectomy (1.35%) than after laparoscopic assisted
vaginal hysterectomy (0.28%), total abdominal hysterectomy (0.15%) or total vaginal route
(0.08%). In terms of risk prevention, Uccella et al. (2011) reported that trans-vaginal
colporrhaphy after a total laparoscopic hysterectomy led to a three-fold reduction in risk of
dehiscence compared to the laparoscopic route. Shortly after, a multi-institutional analysis by
Uccella et al. (2012) revealed that transvaginal suturing reduces the risk of vaginal dehiscence
after total laparoscopic hysterectomy. This was supported by Dall’Asta et al. (2008), who also
recommended the vaginal route for vaginal cuff closure. Clarke-Pearson and Geller (2013)
reported a meta-analysis that also contrasted vaginal, laparoscopic and robotic cuff closure and
discovered that the vaginal closure entailed the lowest occurrence of vaginal cuff dehiscence
(0.18%) compared to laparoscopic (0.64%) and robotic (1.64%).

The most frequent risk factor associated with vaginal cuff dehiscence is direct trauma from
sexual intercourse (Clarke-Pearson and Geller, 2013). Other factors that contribute to this
complication are maneuvers that increase abdominal pressure (chronic cough, constipation,
obesity and straining), smoking, diabetes, anemia, immunosuppression, malnutrition,
corticosteroids, prior vaginoplasty and pelvic surgeries and menopause.

If this complication arises, it can be managed conservatively with pelvic rest for small or partial
dehiscences. Surgical intervention is indicated for larger or complete dehiscences and should be
performed vaginally if achievable. The bowels should also be examined thoroughly once there is
suspicion of evisceration. Broad-spectrum antibiotics are recommended in all cases as all
dehiscences expose the peritoneal cavity to vaginal flora (Clarke-Pearson and Geller, 2013).

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Urinary incontinence
In the past, urinary incontinence was associated with hysterectomies (Bohlin et al., 2017; Milsom
et al., 1993). Some studies report that the vaginal approach to hysterectomy has been linked with
the stress subtype of urinary incontinence (Altman et al., 2007). Interestingly, reports also
indicate that hysterectomy can cause remission of urinary incontinence, and therefore adds to the
difficulty of informing patients about the potential risks of urinary incontinence with this
operation (Duru et al., 2012). Three major factors that increase the risk of urinary incontinence
after the surgery are age, obstetric trauma and obesity (Gyhagen et al., 2013). Bohlin et al.
(2017) found that the highest rate of de novo urinary incontinence was documented in patients
with a body mass index ≥ 30, patients with a prior vaginal delivery, and those with a lower
uterine weight. On the other hand, remission of incontinence was more frequent in patients with
a large uterus, probably because the bladder is decompressed when the uterus is removed. A
heavy uterus also lowers the ventral vaginal wall and pubocervical ligaments, which affects
urethral support; accordingly, the supportive tissue returns to its proper position when the uterus
is removed, which reinforces the mechanisms of continence. In women with obstetrical trauma
(vaginal deliveries), the supportive tissue cannot revert to its anatomical position. This leads to a
weakened pelvic floor, and if coupled with higher intrabdominal pressure as in obesity, it makes
the patient prone to urinary incontinence when the uterus is removed.

Sexual dysfunction

Many women who undergo hysterectomy express concern that their sexual life will be negatively
affected after the procedure (Dennerstein et al., 1977). The extent to which patients truly
experience sexual dysfunction is debatable and controversial as the experimental data and
hypotheses do not truly match the clinical evidence. Maas et al. (2003) explained some of the
hypotheses and their explanations for the expected disturbances in sexual function. These include
physical factors and hormonal changes and are explained below.

Dyspareunia
A total hysterectomy involves the removal of the uterine corpus and the cervix. Absence of the
cervix can lead to a shorter vaginal vault, which in turn can result in severe dyspareunia and
altered sensation during sexual intercourse (Fidan et al., 2017). Scar tissue that forms in the

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vaginal vault can also contribute to dyspareunia (Kilkku et al., 1983).

Anorgasmia
The uterus and cervix are both vital to the physiology of orgasm, which is thought to be a
neurological genital reflex. Smooth muscle contraction in the fallopian tubes, uterus and
paraurethral glands of Skene are brought about by a biphasic motor response. Soon after, the
striated muscles within the pelvic floor, perineum and anal sphincter contract. It is believed that
orgasm is experienced when contractions of the internal genitalia (uterus, cervix and vagina)
send a sensory stimulus that reaches the brain and is consciously recognized. Removing the
uterus and cervix could interfere with this chain of events resulting in the inability to achieve
orgasm (Maas et al., 2003)

Vaginal dryness
Pelvic autonomic nerves innervate the vasculature in the vaginal wall, which is needed for the
neurally controlled lubrication response. These pelvic nerves are at risk for iatrogenic injury
during a total hysterectomy, which results in decreased lubrication and disrupted vaginal
vasocongestion during sexual arousal (Maas et al., 2003). Radical hysterectomy performed for
cervical cancer has been associated with a higher chance of nerve injury than hysterectomies for
benign indications (Butler-Manuel et al., 2000). With radical hysterectomies, the uterus and
cervix are removed along with its lateral anterior and posterior ligaments. These ligaments are
anatomical pathways for the pelvic autonomic nerves and as a result of their removal the nerves
tend to be disrupted. This explains why a radical hysterectomy for cancer is more likely to entail
sexual dysfunction than hysterectomies performed for benign conditions (Maas et al., 2003).
This was supported by Bergmark et al. (1999), who reported that women with cervical cancer
who underwent radical hysterectomy reported a lack of lubrication and genital swelling during
sexual arousal, resulting in significant distress.

Hormonal changes
Postmenopausal women experience physiological ovarian failure as their hormonal levels,
particularly estrogen and androgen, decrease significantly. Lower estrogen levels contribute to
sexual dysfunction as they reduce vaginal lubrication and result in dyspareunia, while inadequate
androgen levels decrease libido and sexual arousability (Apperloo et al., 2003). This is why
postmenopausal women who undergo hysterectomy with bilateral oophorectomy have no

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changes in their hormonal levels as they have already experienced physiological ovarian failure.
In contrast, premenopausal women who undergo this procedure have significant decreases in
their estrogen and androgen levels, which tip them over into a ‘postmenopausal hormonal state’.
Interestingly, it is expected that premenopausal women who undergo hysterectomy with
conservation of the ovaries should not go into ovarian failure, but some believe that it can still
accelerate ovarian failure and increase postmenopausal symptoms including vaginal dryness
(Maas et al., 2003). A reasonable rationalization is that the blood supply to the ovaries can be
compromised during a hysterectomy. The ovarian arteries travel to their destination from the
pelvic sidewall, and are not present in the surgical field during a hysterectomy. However, after
the ovarian arteries reach the ovaries, they continue along the fallopian tubes to supply the upper
part of the uterus. In a hysterectomy without oophorectomy, the fallopian tubes are ligated as an
essential surgical step, which will therefore inevitably ligate the continuation of these ovarian
arteries. This ligation will interfere with the blood flow dynamics in the artery and impair the
ovarian microcirculation (Maas et al., 2003). This was supported by Cattanach (1985), who
reported reduced estrogen production in more than half of women after ligation of the fallopian
tubes.

Clinical studies regarding sexual dysfunction

There are extensive scientific and experimental data addressing the belief that hysterectomy
changes the physiology of the sexual response to some extent, but it is uncertain whether these
changes are substantial enough to be clinically significant. According to Lonnée-Hoffmann and
Pinas (2014), current evidence suggests that hysterectomy for benign disease could actually have
favorable effects on sexual function and general wellbeing, and approximately only 10-20% of
women experience impaired sexual function including dyspareunia and altered orgasmic
experience.

Laumann et al. (1999) explains that the quality of a woman’s sex life prior to and after
hysterectomy is likely to be influenced by factors such as age, race, mental problems,
relationship problems and socioeconomic conditions. Lonnée-Hoffmann and Pinas (2014)
reported that preexisting psychiatric morbidity, for example depression and unsatisfactory sexual
function, is strongly associated with postoperative sexual dysfunction. This was supported by
Maas et al. (2003), where prehysterectomy depression was associated with dyspareunia, vaginal

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dryness, low libido, and anorgasmia after hysterectomy.

Kilkku et al. (1983) interviewed two groups of patients; one had undergone total abdominal
hysterectomy with bilateral oophorectomy and the other had undergone subtotal hysterectomy
with bilateral oophorectomy. He compared coital frequency, dyspareunia, libido, and frequency
of orgasm. Both groups demonstrated equal though slight reduction in coital frequency.
Nevertheless, dyspareunia decreased from 30.8% preoperatively to 15.6% postoperatively in
women in the total hysterectomy group, whereas the decrease in the subtotal group was greater
(28.6% to 6.3%). There were no momentous differences in libido, but the frequency of orgasm
was significantly reduced one year after surgery in the total hysterectomy group, though it
remained unchanged in the subtotal group.

According to Virtanen et al. (1993), a prospective study on 102 women undergoing hysterectomy
demonstrated no differences in orgasmic function before and after the operation. Twenty-one
percent reported "decreased orgasm" both preoperatively and one-year postoperatively.
However, dyspareunia decreased from 40% preoperatively to 9% one year after the procedure.
Rhodes et al. (1999) reported that among the women who were still sexually active
posthysterectomy, 9.4% developed vaginal dryness, 2.3% developed anorgasmia, 5.2%
developed a low libido, and 2% developed dyspareunia that was still present after 24 months.

Interestingly, in an article by Farrell and Kieser (2000), there was either an enhancement or no
change in sexual function in women after hysterectomy. The percentage of women with
unchanged or enhanced libido ranged between 60 and 100%, and the percentage of women with
decreased libido ranged from 0 to 40%. For orgasm, these figures were 75-92% unchanged or
enhanced, and 8-25% decreased. These studies led investigators to deduce that quality of life
improved for most women who had hysterectomies and that hysterectomy did not adversely
affect sexuality. Similar conclusions were drawn in a more recent comparable review by Katz
(2002).

Gastrointestinal tract injuries

The incidence of injury to the gastrointestinal tract after hysterectomy can range from 0.1% to
1%, with an average of 0.3% for abdominal and 0.2% for laparoscopic hysterectomies (Makinen
et al., 2001). The occurrence of bowel injury with vaginal hysterectomy ranges from 0.1% to

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1.0% (Nieboer et al., 2009; Lethaby et al., 2006). Bowel injuries during a hysterectomy can be
classified into three main types: thermal injury, direct mechanical injury, and indirect injury due
to interruption of blood supply (Clarke-Pearson and Geller, 2013).

Thermal injury
All routes of hysterectomy can cause thermal injury. This happens most frequently when current
is conducted from a monopolar instrument to the bowel during pelvic dissection in areas where
there is unclear visualization; for example, the deep pelvis, at the cuff, or in the cul-de-sac.
Thermal injuries to the bowel can go unrecognized at the time of surgery, especially during the
laparoscopic route. Careful and thorough inspection can reveal blanched spots on the bowel’s
serosal surface. If it goes unnoticed and is left unrepaired, the injury tends to have a delayed
course (Clarke-Pearson and Geller, 2013).

Direct mechanical injury

Direct mechanical injury can result from either sharp or blunt instruments and is most frequent
during adhesion removal, and to a lesser extent placement of laparoscopic equipment. If
intraabdominal adhesions are expected, a different entry method is a 2-mm to 5-mm incision at
the Palmer point, followed by insufflation, trocar, and camera placement at this site to survey the
lower abdomen. An “open” entry technique for the initial port can also be used but the data show
that it does not decrease the incidence of gastrointestinal injury although it reduces the risk of
vascular injury. Decompression of the stomach with a nasogastric or oralgastric tube can
decrease the injury risk when laparoscopic trochars are placed. Most of the time, mechanical
injury is likely to be recognized at the time of surgery either as an uncovering of the serosal
surface or a full-thickness defect in the bowel wall. However, smaller serosal defects can go
undetected and patients can develop postoperative complications such as bowel perforations.
This can be recognized by development of fever, leukocytosis, nausea, vomiting, and an acute
abdomen and is confirmed by an abdominal and pelvic CT with oral contrast (Clarke-Pearson
and Geller, 2013).

Vascular injury
Vascular injuries are a result of disruption of the blood supply through the mesentery to the
bowel. This injury is seldom encountered during a benign hysterectomy, but clinicians should
always be made aware and able to recognize it. Vascular injury to the bowel will normally have

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an indolent course and is therefore diagnosed later in the postoperative period (Clarke-Pearson
and Geller, 2013).

Rectal and anal injuries

Abdominal and vaginal hysterectomy is associated with an increased risk of mild rectal
incontinence symptoms. Patients with a reported history of obstetric sphincter injury are at
particular risk for posthysterectomy fecal incontinence (Muhleman et al., 2017). Greater age at
the time of surgery is also associated with a higher risk of anal incontinence.

Rectal injuries are relatively rare. In a study by Mathevet et al. (2001) there were 14 rectal
injuries (0.45%) amongst 3076 vaginal hysterectomies and two concomitant bladder and rectal
injuries (0.06%). In five of the cases, the rectal lacerations occurred during attempts to gain entry
into the pouch of Douglas, in which they occurred in the midline and were <2 cm in length. Two
of the lacerations were intraperitoneal.

A rare case report by Shin et al. (2016) discussed an unfortunate event in which a surgical
sponge was accidently left inside the patient’s body after a hysterectomy. The patient presented
later with vague lower abdominal pain, fever and rectal discharge about 15 months after the
procedure and a colonoscopy revealed the surgical sponge in the rectosigmoid colon, which
penetrated the sigmoid colon and rectum transmurally leaving an opening on both sides.

Common nerve injuries

Neuropathy secondary to hysterectomy is unusual. Reports indicate a 0.2–2.0% occurrence rate
after major pelvic surgery, benign hysterectomies accounting for the lower end of this range.
Most nerve injuries are associated with radical pelvic cancer surgery (Irvin et al., 2004; Cardosi
et al., 2002). The nerves that are commonly affected during a hysterectomy are the femoral,
iliohypogastric, ilioinguinal and common fibular nerves.

Femoral nerve
The femoral nerve is the nerve most commonly injured during pelvic surgery (Irvin et al., 2004;
Alsever et al., 1996). The injury frequently occurs at the anterior surface of the psoas muscle or
the inguinal canal. It can be due to compression of the nerve from the retractor blades on the
anterior psoas muscle, and the risk is greater in patients with a thin body habitus and with the use

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of longer retractor blades and prolonged operative times (Kvist-Poulsen and Borel, 1982).
Persistent compression of the nerve can lead to ischemic injury and a ‘stretch’ injury. The
femoral nerve can also be indirectly stretched as it passes through the inguinal canal. This effect
is heightened by hyperflexion, external rotation, or both of the hip in the dorsal lithotomy
position (Clarke-Pearson and Geller, 2013). Some conditions that further heighten the risk of
nerve injury include diabetes mellitus, gout, uremia, malnutrition and alcoholism, as they all
decrease vascularization and the ability of the nerve to endure and tolerate insult (Clarke-Pearson
and Geller, 2013).

Patients who suffer a femoral nerve injury during hysterectomy can undergo physical therapy
that focuses on range of movement and muscle strength. Symptomatic relief involves using non-
steroidal anti-inflammatory medications whereas neuropathic pain can be targeted with
anticonvulsants such as carbamazepine, phenytoin and gabapentin (Clarke-Pearson and Geller,
2013).

Iliohypogastric and ilioinguinal nerves

The iliohypogastric and ilioinguinal nerves are also at risk for injury during a hysterectomy. This
frequently occurs at the anterior abdominal wall in an abdominal hysterectomy, where the nerves
can be transected with a wide Pfannensteil incision that extends beyond the lateral borders of the
rectus muscles. A stretch injury can also occur with extreme lateral stretching of the fascial
layers, or from placing a self-retaining retractor in an already widened incision. With
laparoscopic hysterectomies, the nerves can be injured with trocars that are positioned laterally,
but this can be avoided by remembering to place them at least two fingerbreadths medial to the
anterior superior iliac spine (Clarke-Pearson and Geller, 2013).

Common fibular nerve

Common fibular nerve injury during a hysterectomy is rare but clinicians should still be aware of
its potential risk when the patient is placed in the dorsal lithotomy position using stirrups. The
common fibular nerve wraps around the lateral aspect of the neck of the fibular and is protected
only by a layer of subcutaneous tissue and is therefore prone to compression injury from the
pressure of the stirrup (Clarke-Pearson and Geller, 2013).

Other less common nerve injuries

Less common nerve injuries include those to the genitofemoral nerve, which can be compressed

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with the retractor on the anterior psoas major muscle, causing patients to experience parathesias
over the mons pubis, labia majora and femoral triangle. The lateral femoral cutaneous nerve can
be compressed with the retractor on the anterior region of the iliacus muscle, which can cause
parathesias over the anterolateral thigh. The obturator nerve can be injured during pelvic sidewall
dissection leading to weak adduction of the hip and parathesias of the medial thigh. The
saphenous nerve can be injured from compression of medial aspect of the knee in the dorsal
lithotomy position; the patient will lose sensation over the anteromedial leg and medial foot. The
sciatic nerve can be injured through stretching in the greater sciatic foramen with hyperflexion of
the hips in the dorsolithiotomy position; patients experience gluteal pain radiating down the
posterior thigh into the popliteal fossa as well as loss of leg function. The tibial nerve can be
compressed in the popliteal fossa in the dorsal lithotomy position, which results in the loss of
plantarflexion of the foot as well as parathesias over the plantar surface of the foot. The pudendal
nerve can be compressed at the ischial spine if there is hemorrhage and the patient can lose
sensation of the perineum and potentially weakness of the external urethral and anal sphincters
(Clarke-Pearson and Geller, 2013; Plochocki et al., 2016).

Conclusions

Clinicians who perform hysterectomies or are involved with post-operative hysterectomy

patients should be familiar with the possible complications and the steps that can be taken to help
reduce these risks.

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