Hysterectomy is surgical removal of the uterus. Hysterectomy may be recommended as the final or ultimate treatment for many conditions affecting women including abnormal bleeding, severe cramping, fibroids, prolapse (dropping of uterus,) endometriosis, chronic pelvic pain, and cancerous or precancerous conditions. If less invasive options have failed or are not appropriate, the surgeon will review the relative risks and benefits of a hysterectomy.
RISKS AND BENEFITS
Benefits: The benefits of a hysterectomy are that the symptoms caused solely by the uterus will be relieved permanently. Most studies show significantly improved quality of life for women after hysterectomy.
Risks: Hysterectomy is a very safe procedure, however all surgery carries risk. The most common risks are infection, bleeding, and minor injury to the bladder. Less frequent complications include injury to ureters, intestines, nerves or blood vessels, reactions to anesthesia, and deep vein thrombosis (blood clots in the legs or lungs,) or more serious events. Most complications are recognized and fixed immediately to avoid long term effects. Measures taken to avoid these risks include appropriate surgical planning, routine antibiotics, careful surgical technique to minimize blood loss and avoid injury to adjacent pelvic organs, routine use of leg compression devices, and additional measures as needed depending on each individual patient’s medical and surgical history.
TYPES OF HYSTERECTOMY
Total Hysterectomy: Removal of the entire uterus including the cervix.
Supracervical Hysterectomy (requires Laparoscopic or Abdominal approach): Removal of just the superior portion of the uterus, leaving the cervix in place. Sometimes this is performed due to severe adhesions (scar tissue) around the cervix or patient preference. Except for a slightly earlier postoperative return to intercourse (two weeks instead of six,) most studies do not show any known benefit of keeping the cervix. If the cervix is retained, the risk of developing cervical cancer will remain and regular pap smears will need to be continued. Some women may develop painful sex or cyclic spotting from the retained cervix and may decide later to have the cervix removed (a Trachelectomy.) If a woman feels strongly about retaining her cervix, she should discuss the issue with her doctor.
WHAT ABOUT THE TUBES AND OVARIES?
Many women are surprised to learn that a hysterectomy does not refer to removal of the tubes (salpingectomy) or ovaries (oophorectomy). Removal of fallopian tubes is becoming more common as recent studies have shown that some forms of ovarian type cancer actually originated from the distal fallopian tube. Healthy ovaries serve to provide a woman with her own natural hormones. In an average woman, the benefit of retaining ovaries outweighs the risk of developing ovarian cancer. However, each patient should discuss with her doctor whether her age or any personal or family history puts her at elevated risk for ovarian cancer, in which case removal of tubes and ovaries would be recommended at the time of hysterectomy.
WAYS THAT A HYSTERECTOMY CAN BE PERFORMED:
Vaginal Hysterectomy (Incision-less): The uterus is removed through the vagina by making an incision around the cervix and there are no abdominal incisions at all. Many patients are excellent candidates for this approach, even those with moderately enlarged uteri. Most patients are discharged the same day. Most of the published literature and professional opinion in our field supports that, when feasible, vaginal hysterectomy is the safest and most cost effective approach. Recovery time is 2 weeks except no intercourse for 6 weeks to allow the vaginal incision to fully heal.
Laparoscopic Assisted Vaginal Hysterectomy: In this approach, the abdomen is distended with gas, a small incision is made near the navel, and a long lighted camera is placed through it so the surgical team can see the organs on monitors. Two to three other small incisions are made in the abdomen for instruments to be used in the surgery. The upper attachments of the uterus are divided with laparoscopic instruments until the surgery is able to be completed vaginally. The remainder of the detachments are done vaginally, the uterus is removed through the vagina and the incision is closed through the vaginal approach. Hospital stay and recovery is similar to vaginal hysterectomy with the addition of very small abdominal incisions.
Total Laparoscopic Hysterectomy: All of the attachments of the uterus are divided using the laparoscopic tools through the ports, the uterus is either pushed out through the vagina or morcellated through the incisions (in shaved or chipped pieces) and the vaginal incision is stitched laparoscopically. None of the surgery is done vaginally. Recovery time is similar to Laparoscopic assisted vaginal hysterectomy.
Robotic Hysterectomy: Similar to total laparoscopic hysterectomy. The surgeon controls a robot attached to the instruments. The laparoscopic incisions may be placed higher on the abdomen to accommodate the robotic arms. Some patients may not tolerate the steeper positioning and often longer operating times required. There is a higher cost for robotic surgery. Most patients do not need the robot. However, in certain very complex or difficult cases, the robotic approach will prevent the need for a more invasive abdominal approach and is ultimately safer and more efficient with less pain and a shorter recovery time.
Abdominal Hysterectomy: A more traditional approach best for cases of unusually large uteri or when the vaginal or laparoscopic approach is not feasible for a patient’s situation. A horizontal (bikini line) or vertical incision approximately six inches long is made in the lower abdomen. It is associated with greater risk of complications, more pain, longer hospitalization (two to three days), and longer healing and recovery times of six to eight weeks. However, this approach allows the surgeon excellent access to all the abdominal and pelvic organs and may be necessary for certain conditions.
Vaginal hysterectomy is overall the safest, most cosmetic and least invasive approach and is the preferred approach, if possible. No matter which approach is used, early walking, diligent management of postoperative pain and nausea, prevention of constipation, and close postoperative observation will help to assure your swift return to normal activities. You and your surgeon will decide the best approach for you.