A history of cesareans is a risk factor in vaginal hysterectomies

This study describes the characteristics and per- and postoperative frequencies of complications in vaginal hysterectomies for benign lesions in patients with a history of cesareans. We compare these figures with the frequency of complications in vaginal hysterectomies without a history of such operations.

Over a period of 8 years we studied all the hysterectomies for benign lesions (963) conducted at the Hospital Jeanne de Flandre in Lille and at the Paul Gellé maternity clinic at Roubaix. During that time 76.94% of the hysterectomies were conducted exclusively by the vaginal route (n = 741), 10.1% (n = 98) were by the laparoscopic-assisted vaginal route, and 12.9% (n = 124) by the pure abdominal route. We selected the hysterectomies conducted by the pure vaginal route from this series. We compared two subgroups of patients that were subjected to hysterectomy by the vaginal route: patients with a history of cesarean section and those never having had cesarean delivery. In each of these groups we recorded the characteristics of the population and compared the peroperative and postoperative data of the hysterectomies. We gave special attention to peroperative complications such as bladder or digestive tract wounds and hemorrhages. We used analysis of variance tests to compare means and chi2-tests and Fisher's exact tests for comparisons of numbers. A probability of p < 0.05 was adopted as the limit of significance.

The two populations were comparable in terms of age, weight, height, parity and history of pelvic surgery causing adhesions. There was a significant difference in the number of annexectomies between the two populations. The frequency of peroperative reductions in the uterine volume was also similar in the two vaginal hysterectomy groups. We were unable to find any significant difference in uterine weight or in the operating or hospitalization time. The frequency of hemorrhages was significantly higher in the patients with a history of cesareans. The number of injuries to the bladder and intestines was higher in the patients with a history of cesareans but not significant for the bowel injuries. We compared the cumulative frequency of complications in the group of hysterectomies with a previous history of cesareans and the group without a history of cesarean section. In our patients with a history of cesareans, we recorded 13 peroperative complications out of 71 hysterectomies (18.3%). In the group of hysterectomies without history of cesareans, we recorded 24 complications out of 670 (3.58%). There was a significant difference between the cumulative frequency of complications in the two populations of patients in favor of the subgroup without past cesarean scarring (p < 0.0001).

In vaginal hysterectomy, a history of single or multiple cesareans increases the peroperative risk for hysterectomies by the vaginal route. The surgeon must take into account the history of cesareans and be attentive to the previous operating time of the bladder and uterine region especially at the time of opening the anterior peritoneal cul de sac. Nevertheless, uterine scarring as a sequel to cesareans must not be a contraindication for the vaginal route.