What is the difference between a total hysterectomy and an extrafascial (also known as simple) hysterectomy?

Difference Between Total Hysterectomy and Extrafascial Hysterectomy

A total hysterectomy and an extrafascial (simple) hysterectomy are the same procedure, both referring to the complete removal of the uterus and cervix while preserving the surrounding tissue planes. 1

Defining Characteristics

• Total/extrafascial hysterectomy involves removal of the uterine corpus and cervix without removing parametrial tissue, preserving the fascial planes surrounding the uterus 1
• The procedure removes the uterus with the outer wall while preserving the surrounding fascia and ligaments 2
• This is in contrast to radical hysterectomy, which removes additional parametrial tissue and a portion of the upper vagina 1

Surgical Technique

• In total/extrafascial hysterectomy, the surgeon cuts parametrial tissue along the circumference of the cervix in three sequential steps:
  1. Clamping and cutting the uterine artery and upper part of cardinal ligament
  2. Clamping and cutting the sacrouterine ligament and posterior half of cardinal ligament
  3. Clamping and cutting the vesicouterine ligament and anterior half of cardinal ligament 2
• This technique moves the ureter progressively further from the surgical field with each transection, reducing risk of ureteral injury 2

Clinical Indications

• Total/extrafascial hysterectomy is indicated for:
  • Uterine fibroids causing symptomatic menorrhagia or pressure symptoms 1, 3
  • Adenomyosis causing heavy menstrual bleeding or pelvic pain 3
  • Stage IA1 cervical cancer without lymphovascular space invasion (LVSI) 1
  • Endometrial cancer (when appropriate based on staging) 1

Comparison to Other Hysterectomy Types

• Modified radical hysterectomy (Piver type II) removes more parametrial tissue than total/extrafascial hysterectomy and is typically used for stage II cervical cancers with macroscopic cervical lesions 1
• Radical hysterectomy (Piver type III or IV) removes even more parametrial tissue and is used for more advanced cervical cancer 1
• Supracervical hysterectomy preserves the cervix, unlike total/extrafascial hysterectomy which removes both uterus and cervix 1

Surgical Approaches

• Total/extrafascial hysterectomy can be performed via:
  • Abdominal approach (laparotomy)
  • Vaginal approach (preferred when technically feasible) 3
  • Laparoscopic approach
  • Robotic-assisted approach 4
• The American College of Radiology recommends that when hysterectomy is indicated, the least invasive route should be chosen, with vaginal being preferred when technically feasible 3

Benefits and Considerations

• Vaginal approach offers shorter operating times, faster recovery, and better quality of life compared to abdominal approaches 3
• Robotic-assisted approach may be beneficial for patients with obesity or complex pathology 4
• Total/extrafascial hysterectomy has lower complication rates compared to more radical procedures 1
• For early cervical cancer, extrafascial hysterectomy is sufficient for stage IA1 without LVSI, while more radical approaches are needed for more advanced disease 1

Common Pitfalls and Caveats

• Potential complications include ureteral injury, intestinal damage, and bladder injury 2
• Following the correct tissue plane is crucial to avoid these complications 2
• For patients with endometrial cancer, the extent of surgery should be guided by disease staging and risk factors 5
• Uterine preservation options should be discussed before proceeding with any hysterectomy, especially for younger patients 3