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Hysterectomy: Surgical Removal of the Uterus

By the age of 60, one in three women will have a hysterectomy.

A hysterectomy is carried out to treat various problems associated with periods, pelvic pain, tumors and other related conditions. The problem you are experiencing will determine what type of operation is required and whether the fallopian tubes, ovaries, and cervix will also be removed. Before you decide what to do, it is important that you understand why your doctor has suggested this surgery and what your options are. If you are still having your periods, a hysterectomy will stop them and you will no longer be able to get pregnant. Since this is a major operation, your doctor may suggest other medical treatments that should be tried first. You may also decide not to go ahead with the operatio and live with the problem, but sometimes, there is no alternative. Some conditions which have no alternatives might include cancer, unbearable pain and bleeding.

Your Doctor Might Suggest a Hysterectomy for Various Reasons

Uterine Fibroids (myomas)

These are non-cancerous tumors of different sizes that usually shrink after menopause. Fibroids are common and normally don’t need treatment unless they cause symptoms. However, larger fibroids can press against the pelvic organs and may cause bleeding, pain during sex, anemia, pelvic pain, or bladder pressure. This is the most frequent reason for a hysterectomy.

Endometriosis

When the tissue lining the uterus grows outside of the uterus and onto surrounding organs, it can cause painful periods, abnormal vaginal bleeding, scarring, adhesions, and infertility (difficulty getting pregnant). It is the second most common reason for women to have a hysterectomy.

Uterine prolapse

The uterus moves down into the vagina because the tissues that hold the uterus in place weaken. The condition may lead to urinary incontinence (problems holding your urine), pelvic pressure or difficulty with bowel movements. Childbirth, obesity, persistent cough or straining, and hormonal changes (loss of estrogen after menopause) are typical causes.

Pelvic Pain

There are many causes and symptoms (ex: painful periods and intercourse) of pelvic pain, and not all can be successfully treated with a hysterectomy. That is why it is important to carefully diagnose the problem and try other treatments first. Endometriosis, fibroids, adhesions, infections or injury may be a few causes of pelvic pain.

Abnormal Uterine Bleeding

Common causes are hormonal imbalances, fibroids, polyps, infections of the cervix and cancer. Related symptoms may include heavy or long periods, bleeding between periods or bleeding after menopause. Other surgical or medical approaches can treat the condition successfully – discuss your options with your doctor.

Cancer

Depending on its extent, endometrial cancer (cancer of the lining of the uterus), cervical cancer and cancer of the ovaries or fallopian tubes often require a hysterectomy to stop it from spreading to other organs.

Hysterctomy Procedure

Hysterectomy is performed in a hospital setting, and generally requires approximately two hours in the operating room. Patients are given general or spinal anesthesia plus sedation so that they feel no pain. Heart rate, blood pressure, blood loss, and respiration are closely observed throughout the procedure. After surgery, patients are transferred to the recovery room where they can be monitored while waking up. Most patients will then be transferred to a hospital room, where they will spend one to two nights.

Hysterectomy Complications

A number of complications can occur as a result of hysterectomy. Fortunately, most can be easily managed and do not cause long-term problems.

Hemorrhage — Excessive bleeding occurs in a small number of cases and may require a return to the operating room to identify and stop the bleeding.

Infection — Low-grade fever is common after hysterectomy, is not always caused by infection, and usually resolves without treatment. However, a high or persistent fever may signal an infection. Serious infection occurs in less than ten percent of women, and can usually be treated with intravenous antibiotics. Much less commonly, patients require another surgical procedure.

Constipation — Constipation occurs in most women following hysterectomy, and can usually be controlled with a regimen of stool softeners, dietary fiber, and laxatives.

Urinary retention — Urinary retention, or the inability to pass urine, can occur after abdominal hysterectomy. It is more common in women who have vaginal hysterectomy. Urine can be drained using a catheter until retention resolves, usually within 24 to 48 hours.

Blood clots — Pelvic surgery increases the risk of developing blood clots in the large veins of the leg or lung. The risk is increased for approximately six weeks after surgery. Medications may be given to some women to prevent blood clots. In addition, women taking oral contraceptives or hormone replacement should ideally discontinue them prior to surgery since they can further increase the risk of blood clots. Women who are sexually active and premenopausal should use alternative methods of birth control to prevent pregnancy before surgery.

Damage to adjacent organs — The urinary bladder, ureters (small tubes leading from the kidneys to the bladder), and large and small intestines are located in the lower abdomen and pelvis and can be injured during hysterectomy. Injury occurs in less than one percent of all women undergoing hysterectomy, and can usually be detected and corrected at the time of surgery. If detected after surgery, another operation may be needed.

Early menopause — Women who have undergone hysterectomy may experience menopause earlier than the average age of menopause (age 51). This may be due to an interruption in blood flow to the ovaries as a result of removing the uterus.

By the age of 60, one in three women will have a hysterectomy

Unfortunately, many women undergo the most invasive procedure to accomplish a hysterectomy called an abdominal hysterectomy. This procedure requires an incision in the abdomen that often results in a large scar. Abdominal hysterectomies are unnecessary for the majority of cases and cause increased pain, additional time in the hospital, and a longer recovery time for hundreds of thousands of women every year in the United States.

The healing time is two to three times less with vaginal and laparoscopic approaches to hysterectomy and has far reaching economic benefits for both the individual patient as well as society.

So, what other hysterectomy choices do women have?

Total Abdominal Hysterectomy (TAH) - performed with an “open” abdominal incision
Total Vaginal Hysterectomy (TVH) - performed with a vaginal incision
Laparoscopic Assisted Vaginal Hysterectomy (LAVH) - a combination of a laparoscopic and vaginal hysterectomy
Total Laparoscopic Hysterectomy (TLH)- performed with small incisions in the abdomen and special laparoscopic instruments are used
Laparoscopic Supracervical Hysterectomy (LSH) - a laparoscopic procedure where top part of the uterus is removed at the level of the cervix.
Robotic Assisted Hysterectomy (Supracervical or Total Hysterectomy) - the DaVinci Robot is used to assist the surgeon to accomplish a minimally invasive surgery with four or five small abdominal incisions.

There are Pros and Cons to Laparoscopic Supracervical Hysterectomy

This is when the uterus is removed and the cervix is left in place. The most compelling reason to keep the cervix is to decrease the healing time with a quicker return to normal functioning. It is important to explore this option with the surgeon to determine if you are a candidate for this approach. Many women are choosing to retain their cervix when they have a minimally invasive hysterectomy. The downside of a supracervical approach to hysterectomy is that women still need to have pap smears to screen for cervical cancer and in a very small percentage of women, there is cyclic bleeding which is often like a "mini-period".

Surgical treatment for cervical cancer involves a radical hysterectomy where the upper part of the vaginal and lymph nodes are removed. With cancer of the ovaries and uterus a staging procedure is also performed and involves removal of the ovaries along with the lymph nodes the uterus. Young women with ovarian cancer may be able to conserve their uterus if they are interested in future childbearing.

Should ovaries be removed at the time of a Hysterectomy?

This is another important choice at the time of a hysterectomy. A total hysterectomy means that the entire uterus is removed. Whether or not the ovaries are removed at the time of a hysterectomy is a different option and should also be discussed. The medical term for the removal of the tubes and ovaries is bilateral salpinoophorectomy. Current studies show that ovaries should not be removed without an indication unless the patient is 65 years or older.

For women with a family history of ovarian cancer or who have the BRCA gene mutation, there are benefits to having the ovaries removed at the time of hysterectomy. It may also be recommended for patients with breast cancer in order to decrease their risk of recurrence or spread of the breast cancer.. It is often required to remove the ovaries in the case of gynecologic cancers and certain benign conditions, such as endometriosis.

Approaches to Hysterectomy

Fortunately, there are more choices than ever before for the type of hysterectomy, as well as the surgical approach (open, vaginal or laparoscopic hysterectomy).

Open Hysterectomy

Also referred to as an Abdominal Hysterectomy. Surgeons perform the majority of hysterectomies using an open approach. With open surgery, your doctor must make a large abdominal incision – large enough to fit his/her hands and instruments inside your body. While open surgery allows your surgeon to see and touch your organs, there are some drawbacks for patients due to the long incision.

Minimally Invasive Hysterectomy

This includes vaginal, laparoscopic and robotic approaches to hysterectomy and all share the benefits of a short hospital stay, less pain, quicker recovery, and lower costs.

Vaginal Hysterectomy

With vaginal hysterectomy, the uterus is removed through the vagina, without any external incision. Surgeons may use this minimally invasive approach if the patient's condition is benign (non-cancerous), or when the uterus is a normal size and the condition is limited to the uterus. With vaginal hysterectomy, surgeons have a small working space and lack of view to the pelvic organs.

Laparoscopic Hysterectomy

During a traditional laparoscopic hysterectomy, long and thin surgical instruments are inserted through a few small incisions instead of a large open incision. One of the instruments is a laparoscope – a lighted tube with a camera at the end. The camera takes images inside the body and sends those images to a video monitor in the operating room which guides surgeons as they remove your uterus.

Robotic Assisted Laparoscopic Hysterectomy

With a robotic assisted hysterectomy, surgeons operate through a few small incisions - similar to traditional laparoscopy. The da Vinci System is the device used currently and features a magnified 3D high-definition vision system and special wristed instruments that bend and rotate far greater than the human wrist. For more complex hysterectomies, such as patients with gynecologic cancers, the surgeon may choose to use robotic assisted surgery. It is important to remember that robotic surgery is another tool that allows surgeons to accomplish minimally invasive surgery.

Types of Hysterectomy

There are many types of hysterectomy that are performed, depending on the patient's diagnosis. All hysterectomies involve removal of the uterus. What can vary are which additional reproductive organs and other tissues that may be removed. Types of hysterectomy include:

Partial or subtotal hysterectomy: This procedure, also known as a supracervical hysterectomy, involves removing the uterus, but leaves the cervix intact. This decision is often based upon patient preference. Some women feel that leaving the cervix intact will preserve sexual function following surgery.

Total hysterectomy: This procedure is most often performed for cervical cancer, and involves removal of the uterus, tissues next to the uterus, the upper part (about 1 inch) of the vagina and pelvic lymph nodes. The fallopian tubes and ovaries may also be removed.

Removal of lymph nodes: For hysterectomies performed for malignant conditions – such as uterine, cervical, or ovarian cancer – the surgeon will also remove certain lymph nodes. This procedure is often referred to as a lymph node dissection or lymphadenectomy. Lymph nodes will be removed in certain areas, depending upon the location and extent of the disease. Lymph node removal also helps your surgeon determine the extent or stage of your cancer, and can guide further adjuvant treatment, such as radiation therapy or chemotherapy.

Removal of the fallopian tubes and ovaries: These organs may or may not be removed during your hysterectomy procedure. This will depend upon your condition, age, and other factors. Often, the ovaries are left intact. Removal of the ovaries is called an oophorectomy. Removal of fallopian tubes and ovaries is called a salpingo-oophorectomy. It is recommended to remove the fallopian tubes at the time of hysterectomy because of evidence that links the most common type of ovarian cancer to originating in the fallopian tube. This is called a salpingectomy..

Radical hysterectomy: For this procedure, the uterus and cervix are removed along with lymph nodes and the upper one third of the vagina. This is necessary for women who have invasive cervical cancer.

Laparoscopic Hysterctomy Procedure

The laparoscopic route, performed through three to four small skin incisions, is a safe and effective alternative method to abdominal surgery when performed in the hands of surgeons trained in laparoscopic surgery. The route of surgery is often determined by the indication for hysterectomy, the severity of the pathology, and the surgical skills and experience of the surgeon. While it is natural for most women to go for the least invasive method, ultimately, you should discuss with your doctor who will advise and choose the safest route for your hysterectomy.

Laparoscopic Hysterectomy Complications

There are risks of all hysterectomy procedures that aren't specific to the surgical approach. (Click on YOUR RISKS on the left to review) In general, studies show that minimally invasive surgery are not more risky and actually have less blood loss and infections than an open approach.

There are some potential risks and complications which are specific to laparoscopic hysterectomy:

Injury to abdominal wall - bleeding, port site hernia.

Conversion to open surgery - in case of unexpected complications or findings such as malignancy.

Bladder or Ureteric injury - There is some concern that these may be more common in laparoscopic as compared to abdominal surgery. More recent data does not show an increased risk of urinary track injury for laparoscopic procedures over abdominal and vaginal procedures. This is probably because surgeons are becoming experienced in minimally invasive laparoscopic techniques.

Do you know the latest? Does your Doctor?

If your doctor has recommended a hysterectomy for you, there are some very important things to consider.

Take these questions to your next appointment and ask your doctor the following:

How many hysterectomies do you perform each year?

What percent are abdominal?

Laparoscopic?

If your doctor only performs a few laparoscopic surgeries per year, you should consider a more qualified surgeon.

Would you recommend a laparoscopic hysterectomy for me?

If yes, how many laparoscopic hysterectomies do you perform each year?

If no, ask why. If you don't feel comfortable with the answer, consider a new doctor.

If no, you should strongly consider a second opinion.

How often do you remove the cervix?

Be aware of a Laparoscopic Supracervical Hysterectomy option.

How often do you remove the ovaries?

If ovaries are normal, the current recomendation is for the ovaries not be removed at the time of hysterectomy unless 65 and older or if there is a benefit because of a personal history of breast cancer or a family history of ovarian cancer. There are certain gynecologic pathologic conditions of the ovaries that may benefit from removal, but we no longer remove normal ovaries in young women without an indication.

What is your conversion rate from laparoscopy to abdominal incision?

A conversion is where the doctor begins a laparoscopic surgery but decides to change to a more invasive abdominal surgery. The number should be less than 5 percent

What is your complication rate?

Major complications should be under 5 percent.

What Patients and Doctors are Saying about Pass the Pearls and Minimally Invasive Surgery

"Love supporting the cause! Women need to know they always have a choice!"
Aarathi Cholkeri-Singh




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