Difference Between Extrafascial Hysterectomy and Simple Hysterectomy
Extrafascial hysterectomy and simple hysterectomy are essentially the same procedure—both terms refer to removal of the uterus and cervix while leaving the parametrial tissues (cardinal and uterosacral ligaments) largely intact, in contrast to radical hysterectomy which removes these structures more extensively. 1, 2
Terminology and Classification
Simple hysterectomy and extrafascial hysterectomy are synonymous terms used interchangeably in gynecologic surgery, both classified as Type A in the Querleu and Morrow classification system 2
The term "extrafascial" specifically refers to the surgical plane of dissection—the procedure removes the uterus with its outer fascial layer but preserves the parametrial tissues 1, 3
Total abdominal hysterectomy (TAH) is commonly referred to as extrafascial hysterectomy in surgical practice 3
Anatomic Extent of Resection
In extrafascial/simple hysterectomy, only minimal portions of the cardinal and uterosacral ligaments are removed along with the uterus, preserving most parametrial structures 1, 2
The procedure involves cutting parametrial tissue along the circumference of the cervix in three sequential steps: (1) uterine artery and upper cardinal ligament, (2) sacrouterine ligament and posterior cardinal ligament, (3) vesicouterine ligament and anterior cardinal ligament 3
This contrasts sharply with modified radical hysterectomy (Piver Type II), which removes more extensive parametrial tissue and divides the uterine vessels lateral to the uterus 4
Clinical Indications
For Benign Disease
Extrafascial/simple hysterectomy is the standard approach for all benign gynecologic conditions requiring hysterectomy 1, 5
Microinvasive cervical tumors can be acceptably treated with simple extrafascial hysterectomy with low morbidity 5
For Malignancy
For stage I endometrial cancer without cervical involvement, extrafascial hysterectomy is the standard surgical approach (level of evidence B) 4
For early-stage cervical cancer (stage IA1) without lymphovascular space invasion (LVSI) and negative margins, extrafascial hysterectomy is appropriate 4
When stage II endometrial cancer involves macroscopic cervical lesions, modified radical hysterectomy (Piver Type II) becomes the standard, not simple/extrafascial hysterectomy 4
Critical Clinical Decision Point
The key distinction is NOT between "extrafascial" and "simple" hysterectomy (they are the same), but rather between simple/extrafascial hysterectomy versus modified radical or radical hysterectomy:
Simple/extrafascial hysterectomy: Minimal parametrial resection, appropriate for benign disease and early-stage endometrial cancer confined to the uterus 4, 1
Modified radical hysterectomy (Piver II): More extensive parametrial resection, indicated for cervical involvement in endometrial cancer or early cervical cancer 4
Radical hysterectomy (Piver III): Most extensive parametrial and paracervical tissue removal, reserved for bulky cervical involvement where simple hysterectomy would "cut through" tumor 4
Common Pitfalls to Avoid
Performing unnecessary radical procedures for benign disease increases surgical morbidity without oncologic benefit, particularly in patients with obesity and diabetes who already have elevated surgical risks 4, 1
Performing inadequate surgery (simple hysterectomy) when modified radical hysterectomy is indicated can compromise oncologic outcomes and necessitate reoperation or additional adjuvant therapy 1
When preoperative staging fails to show macroscopic cervical invasion, modified radical hysterectomy provides no added survival benefit over simple hysterectomy in endometrial cancer 4
Cervical involvement does not automatically mandate radical surgery—the extent of surgery should be tailored to whether simple hysterectomy can achieve clear margins, with postoperative radiation therapy often used to reduce locoregional recurrence risk 4