Hysterectomy

A hysterectomy is a surgical procedure, in which the uterus is removed from the body. The surgery is most commonly performed as a treatment for diseases and conditions, including cancer (endometrial, ovarian, uterine), fibroids (leiomyomas), adenomyosis, endometriosis, pelvic pain, pelvic organ prolapsed, and abnormal bleeding.

 

MODERN TECHNOLOGY

However, with the exception of cancer, there are excellent alternatives to hysterectomy for most of the diseases and conditions for which hysterectomy is commonly performed.  Modern technology has also made the actual method of removal in many instances minimally invasive.  Removal of the uterus will permanently eliminate the prospect of natural fertility and childbirth.

VARIATIONS

There are three variations of hysterectomy.

  • Total Hysterectomy: In this procedure, the entire uterus is removed, along with the cervix. This may be accompanied with or without a bilateral salpingo-oophorectomy to remove the tubes and ovaries as well.
  • Subtotal Hysterectomy: In a subtotal hysterectomy, the top of the uterus (fundus) is removed, but the cervix is left and remains in the body.
  • Radical Hysterectomy: Radical hysterectomy is often performed in cases of cancer (particularly of the cervix).The tissue adjacent to the uterus (parametria) is removed with the uterus in an attempt to eliminate cancerous tissue, which may have spread into these areas, as well as surgically stage the disease.

SURGICAL TECHNIQUES

Just as there are several types of hysterectomy procedures, there are many different surgical techniques that can be used to remove the uterus.

  • Laparotomy (abdominal hysterectomy): This is still the most common type of hysterectomy performed. An abdominal incision (usually low transverse, like a caesarian section but occasionally vertical) is made (5-6 inches).  The technique is slowly being replaced by less invasive methods (see below) as information and technology spreads and advancements in minimally invasive techniques and instrumentation are made.
  • Laparoscopic hysterectomy (total or supracervical): Small (about an inch) incisions (3-5 inches) are made in various locations in the abdomen, and the surgery is performed with long instruments passed through these small incisions. The surgery is viewed by the laparoscope, a telescope-like instrument usually attached to a video camera with images displayed on flat panel high definition TV’s. The uterus is then dissected and removed by morsellation (cutting it into small pieces which can be extracted through the small tubes through the abdominal wall).
  • Laparoscopically assisted vaginal hysterectomy (LAVH): Similar to a laparoscopic hysterectomy, except the uterus is usually extracted as a whole through the vagina and /or the last part of the removal is done by surgery through the vagina in a combined approach.
  • Robotic-assisted hysterectomy: Essentially a laparoscopic surgery, by which a robot takes remote control of the laparoscopic instruments.  Robotic instruments allow for greater control and precision than laparoscopic methods alone, but the surgery is more costly, and in many cases, may not improve recovery or outcomes.  Studies are currently being conducted to help determine the best role for robotic surgery as compared to laparoscopic surgery.
  • Vaginal hysterectomy: In this surgery, the uterus is removed entirely through the vagina. There are no visible scars and shorter overall recovery time.

This procedure is best when there is adequate room in the vagina (i.e. patients who have previously given birth vaginally or when prolapse is an indication for the surgery).

SUMMARY

Because of quicker recoveries, reduced costs, and shorter hospitalization periods, minimally invasive hysterectomy options are gaining popularity. The American Association of Gynecologic Laparoscopy has made a position statement stating that minimally invasive methods are preferred, and patients should be specifically referred to qualified surgeons. Complications from surgery are generally rare but can occur, such as infection, bleeding, adjacent organ injury, fistula, emboli, and anesthetic risk.

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