What is a hysterectomy?
Hysterectomy refers to the removal of the uterus (or part of) only. If the ovaries or fallopian tubes are removed then this will be stated separately as oophorectomy (removal of ovary), salpingectomy (removal of fallopian tube) or salpingo-oophorectomy (removal of ovary and tube). As a treatment for noncancerous uterine conditions, hysterectomy often improves the quality of life for most women. This is often due to the fact that heavy &/or painful bleeding are eliminated by hysterectomy.
Types of hysterectomy
Total abdominal hysterectomy
Hysterectomy is achieved through open surgery. All parts of the uterus are removed, including the cervix.
Hysterectomy is performed via the vagina without any abdominal incisions. All of the uterus is removed, including the cervix.
Laparoscopically assisted vaginal hysterectomy
Hysterectomy is achieved through a combination of laparoscopic and vaginal surgery. No open surgery is performed. All of the uterus is removed, including the cervix. The degree of laparoscopic and vaginal surgery varies per surgeon and individual circumstance.
Total laparoscopic hysterectomy
Hysterectomy is achieved entirely through laparoscopic surgery. No open surgery is performed. Removal of the uterus is achieved by delivery through the vagina or by morcellation through the laparoscopic route.
Subtotal hysterectomy refers to removal of the body of the uterus with preservation of the cervix. This is most commonly achieved through open surgery but can also be performed by the vaginal or laparoscopic routes. Women who have had a subtotal hysterectomy require ongoing surveillance Pap smears.
Robot assisted hysterectomy
Robotic surgery is essentially laparoscopic surgery assisted by using a robotic machine. The surgery is performed in steps similar to a TLH however the setup procedure is longer and more complex. Robotic surgery may have a role to play in very difficult surgery or when the surgeon is not trained in advanced conventional laparoscopic surgery.
The uterus viewed through the laparoscope. Before the procedure commences, a thorough inspection of the pelvis and abdomen is made.
If the hysterectomy also involves removal of the uterus and ovaries, the upper pedicles for these are freed first and can be delivered separately or left attached to and delivered with the uterus.
If the ovaries and fallopian tubes are to be preserved during hysterectomy, the vascular pedicles will need to be preserved as well. Dissection remains close to the uterine body.
As dissection proceeds, it is important to ensure that the ureter and bladder are lateral & inferior (respectively) to the area of dissection, especially as the surgery takes place near the cervix and uterine arteries.
The bladder peritoneum is identified at the point where it overlaps the upper part of the cervix. Dissection begins, taking care not to injure the bladder. The bladder ‘pillars,’ found on either side of the cervix are mobilised making it easier to move the bladder peritoneum and bladder further down off the cervix.
Further mobilisation of the bladder peritoneum is necessary if a TLH is being performed as it allows an incision to be subsequently made in the upper aspect of the vaginal wall, immediately below the cervix. If an LAVH is being performed then this degree of dissection is not required.
The uterine arteries are the principle blood supply of the uterus and enter on either side of the cervix, above where the ureter passes forwards into the bladder. These arteries are identified, sealed and divided so that the paracervical tissues can be dissected away with minimal blood loss.
The uterus has been removed through the vagina, the vaginal vault closed and the pelvis checked to ensure that there are no bleeding vessels. A vault suspension can now be carried out if required.
Positioning required for a vaginal hysterectomy. The patient in a modified lithotomy position. The surgeon sitting between the patients legs with good exposure of the operating field and good lighting.
The cervix needs to be identified and traction placed on it. The cervix may be right at the top of the vagina with minimal descent or may be much lower within the vagina or outside the vagina because of varying degrees of uterine prolapse &/or cervical elongation.
Paracervical infiltration is achieved using a local anaesthetic mixture. This achieves two purposes; improvement of the dissection plains and improvement of analgesia.
The uterosacral ligaments (main supports of the uterus) are divided on each side. The uterine arteries are then identified, sealed and divided on both sides and finally the upper pedicles (infundibulo-pelvic ligaments) are ligated and divided.
The uterus is then delivered through the vagina, a check made that there are no bleeding vessels and then the vaginal vault can be closed making sure that no bowel is caught in the sutures.
Once the hysterectomy has been completed and the vaginal vault closed, additional procedures such as a vault suspension, vaginal repair or incontinence surgery can then be carried out.
da Vinci robotic system
- Morbidly obese patients
- Genital tract cancer surgery, especially lymph node dissection
- Difficult pelvic access due to size or shape of uterus
- 3-D view
- Magnification of view
- Availability of intricate tools that move in several directions
- Cost of the machine (>1 million dollars)
- Maintenance costs of the machine
- Cost of disposable instruments
This involves the removal of the uterus together with the round ligament, broad ligament, cardinal ligament and uterosacral ligament together with the upper 1/3rd to 1/2 of the vagina.
The main indications for radical hysterectomy are:
- Stage IB or IIA cancer of the cervix
- Selected patients with stage II adenocarcinoma of the endometrium
Open hysterectomy is still an all too common procedure. Many, but not all surgeons have the training and skill to carry out most hysterectomies through a more minimally invasive route (laparoscopic &/or vaginal approaches).
The large uterus poses a challenge whatever route is employed. There are issues related to lateral access so that the uterine arteries can be ligated safely. There are issues related to preservation of the ovaries if that is desired because of the pressure effect of the uterus or the position of the ovary, particularly if high up on the fundus of the uterus.
Finally there is the need to remove the uterus. Surgeons performing TLH surgery often morcellate the uterus and ‘suck’ it out, however there have been significant concerns raised about the risk of tiny tissues being deposited in the abdomen, which have the ability to subsequently grow into larger masses.
Open hysterectomy still has a significant role to play for certain patients.
Indications for hysterectomy
Usually, more conservative measures have been exhausted, failed or declined for benign conditions
- Heavy periods
- Painful periods
- Prolonged periods
- Fibroid uterus
- Grade 2-4 uterine prolapse
- Elongated cervix
- Deep dyspareunia related to upward movement of uterus
Cancer of the:
- Fallopian tube
- 1st degree family history of cancer of any of the above
Risks of hysterectomy
- Blood vessels
- Bleeding requiring transfusion
- Pelvic collection (blood)
- Deep vein thrombosis
- Cerebrovascular accident
- Pulmonary embolus
- Complications of anaesthesia
- Allergic reactions to drugs
- Pain during intercourse
- Urinary dysfunction
- Possible earlier menopause
Although hysterectomy is the second most common surgery among women in the United States (after caesarean section), most women do not have any complications during or after the surgery. Though uncommon, some women feel worse following surgery and regret the decision to have an elective hysterectomy.