Introduction
Approximately, 600,000 hysterectomies are performed in the United States annually. Vast majority of these hysterectomies are done for benign medical reasons. Hysterectomies may be performed using an abdominal, vaginal or laparoscopic approach. Using the abdominal or laparoscopic technique, the hysterectomy can be divided into two categories; total hysterectomy and subtotal hysterectomy. There is no indication for removal of cervix in most total Hysterectomies. Total hysterectomy is preferred over Subtotal Hysterectomy for prevention for future cervical cancer and menstrual bleeding. Our modified subtotal hysterectomy will give physicians an option to remove cervical canal and T-Zone during Subtotal hysterectomy for prevention of cervical cancer and menstrual bleeding.

Historic Background of Hysterectomy
The first hysterectomy was performed by Charles Clay in November 1843. This hysterectomy was performed due to a large myomatous uterus. The operation was successful, however, the patient died on the fifteenth postoperative day. The first patient to survive a hysterectomy was in 1853, it was performed by Walter Burnham. Out of his subsequent 15 patients, three patients did not survive. These early hysterectomies were all subtotal hysterectomies. In 1929, Dr. Richardson performed the world’s first total hysterectomy. He recommended the excision of the cervix, for prevention of a future carcinoma. The incidence of a cervical carcinoma during that time was 0.4%. Despite Dr. Richardson’s recommendation, subtotal hysterectomy remained the preferred surgical technique until the late 1940's. Prior to 1950, about 95 percent of the hysterectomies were supracervical. Supracervical hysterectomies were preffered for prevention of peritoneal contamination with vaginal bacterial flora and for prevention of peritonitis. However, in the 1950's, when penicillin and other antibiotics became available, Dr. Richardson’s technique of total abdominal hysterectomy started to become popular. Once again, the focus was on prevention of a future carcinoma of the cervical stump. During subsequent decades in the 1950's and 1960's when various antibiotics became available and infectious morbidity had decreased, total abdominal hysterectomy became the standard of care.

In 1991, Dr. Kurt Semm published his technique known as, Classic Abdominal Semm Hysterectomy, or CASH. His technique involved coring out the entire transformation zone and the endocervical canal, followed by laparoscopic ligation of vascular pericles. The uterus was then morcellated and removed through laparoscopic incision sites. Dr. Kurt Semm removed the inner cervix using a manual serrated morcellator. Various studies showed that Semm hysterectomies had various benefits over traditional hysterectomy. These benefits included shorter recovery time, lower complication rates and less destruction to the pelvic anatomy. However, in spite of these benefits, the Semm hysterectomy never became popular due to technical difficulties. Our Modified subtotal hysterectomy has some similarity with Semm hysterectomy except here “Hysterectomy Electrode” is used for removal of inner cervix and transformation zone instead of Manual morcellator .

Present Options for Hysterectomies
The hysterectomies can be performed with traditional total, subtotal, intrafascial, vaginal or laparoscopic approach. Total abdominal hysterectomy is the standard of care today. In the vast majority of the hysterectomies performed, there is no need for removal of the cervix, however, total hysterectomy is performed as standard of care for the prevention of future cervical cancer and menstrual bleeding. Subtotal Hysterectomy is mostly performed for difficult surgical cases and is criticized for future risk of carcinoma of cervical stump and cost of its preventive care. For removal of cervical canal and T-Zone, many physicians have tried intrafacial hysterectomy or performed supracervical hysterectomy and tried to destroy the cervical canal using electrocautery needle or cone biopsy electrode. However the procedures are never uniform and results are variable. Total hysterectomy continued to be the standard of care for benign medical conditions. Total hysterectomy has increased risk for ureter injury, longer recovery period, and increased risk for vaginal cuff hematoma, abscess, distortion and prolapse. The supracervical hysterectomy has shorter recovery time, reduced or no risk for ureter injuries. However, supracervical hysterectomy has increased risk of future cervical dysplasia, cancer, cervicitis, and menstrual bleeding.

New Hysterectomy Option : Modified Subtotal Hysterectomy
During Modified subtotal hysterectomy, the entire inner cervix and transformation Zone is removed using a “hysterectomy electrode” along with suracervical hysterectomy. Food and Drug Administration recently approved this “Hysterectomy Electrode” for excision of the inner cervix during supracervical hysterectomy. This “Hysterectomy Electrode” has Parallel wire and is used for uniform cylindrical excision of entire cervical Canal and Transformation Zone. All the benefits of Electrosurgical Electrode technology developed in 1980s, for removal of abnormal cervical tissue, as an alternative to cone biopsy, cryotreatment and laser treatment to the cervix, is used here. The safety of the electrode technology is well established during the last 20 years of use. This excision of inner cervix will take only few munites and will reduce significant surgical time and bleeding over total hysterectomy. This procedure will preserve all the peripheral cervical tissue with all ligament attachment and nurovascular supply. Subsequently supracervical hysterectomy is performed using abdominal or laparoscopic approach as preferred by the surgeon. The uterus is amputated at the level of internal Os. The cervical stump is approximated with interrupted absorbable sutures. This mini cerrvical stump usually heals within two to three weeks. Risks for cervical stump hematoma, infection, prolapse or distortion is very rare compared to vaginal cuff healing.

This Modified Subtotal hysterectomy technique will have all of the benefits of both total and subtotal hysterectomy and will also avoid all of the risks associated with total and subtotal hysterectomy.

In summary, the following advantages of Modified subtotal hysterectomy, are based on similar Semm Hysterectomy(CISH):

1. No risk for ureter injury.
2. Reduced operating time and bleeding than total hysterectomy.
3. Preserves the support ligaments of the cervix and vagina.
4. Preserves the neuro-vascular supply in cardinal and utero-sacral ligaments.
5. Faster cervical healing at approximately two to three weeks, compared six to eight weeks for vaginal cuff healing.
6. No risk of vaginal cuff abscess hematoma distortion and prolapse.
7. No menstrual bleeding, as with some supracervical hysterectomy.
8. No, risk of cervical cancer, dysplasia, cervicitis compared to subtotal hysterectomy.