Hysterectomy is the surgical removal of the uterus.
Hysterectomy has 4 different types:
This involves removal of the whole uterus including the cervix (the neck of the womb). The roof of the vagina is sewn closed with stitches leaving a blind ending vagina.
Total hysterectomy with bilateral salpingo-oophorectomy
This involves removal of the whole uterus including the cervix, and also removal of the Fallopian tubes and both ovaries.
This involves removal of the upper portion of the uterus only (the fundus), leaving behind the cervix in its normal place. This is done if the patient requests her cervix be left in place, or if other medical factors favour the cervix being left in place. Pap smears will still be required every 5 years as per normal to check the cervix after this procedure.
This involves removal of the uterus, cervix, the top portion of the vagina and the tissue alongside the uterus and cervix in the pelvis. This is usually done for cancer of the cervix and is performed by a gynaecological cancer specialist.
Reasons for hysterectomy include the following:
- Uterine fibroids causing heavy bleeding, pressure or pain.
- Unexplained heavy or irregular periods that have not responded to other managements.
- Prolapse of the uterus, when the uterus and cervix protrude into the vagina, due to the supports of the uterus becoming particularly weak.
- Endometriosis that is chronic and ongoing causing pelvic pain, period problems and pain with intercourse. Women with this condition will often decide to have a hysterectomy once they finish having children.
- Cancer of the uterus or cervix, or precancerous changes in the lining of the uterus or cervix.
- Chronic, disabling pelvic pain when no other cause for the pain can be found from investigations.
Hysterectomy can now be safely performed in one of three ways:
This is when a 10-12 cm incision is cut along the lower abdomen on the bikini line, a lot like a Caesarean section scar, allowing the abdomen to be opened up and the uterus removed through the incision. This method may be required if the uterus is very large from fibroids, extensive surgery is required for a cancer, or if there is known to be a lot of scar tissue in the abdomen from prior surgery or ongoing endometriosis.
This is when the vagina is incised on either side of the uterus allowing the uterus to be removed through the vagina. The most common reason for this surgery is when there is prolapse present, and the uterus is protruding low down into the vagina. Sometimes, this method can be used without major prolapse being present as long as the uterus descends enough down into the vagina to allow it to be safely removed.
Laparoscopically - Total Laparoscopic Hysterectomy
This type of hysterectomy involves using laparoscopic “keyhole” surgery to remove the uterus.
Either a total or subtotal hysterectomy can be performed with this method. Special laparoscopic instruments are used to seal and cut the blood supply to the uterus, and all stitching is performed via the keyhole ports.
The great advantage of laparoscopic hysterectomy is that the recovery is much quicker than the open abdominal approach, meaning less time in hospital and less time off work and usual activities. The time of the operation is a bit longer though than the abdominal or vaginal approach. Occasionally, if the uterus is quite large, or the access to the uterus is difficult or other difficulties arise during the surgery, then the operation may need to be converted to the open abdominal approach to complete the operation safely.
Whatever the type or method of hysterectomy, it is important to remember that a hysterectomy is a major operation, and while it most often goes very well, there are a number of possible risks and complications associated with it.
This can occur during the operation and can require a blood transfusion during the operation to replace the blood loss. Heavy bleeding can also occur internally after the surgery has finished and the patient is back on the ward. This will often mean that a second operation is required to re-enter the abdomen to stop the bleeding that has started after the hysterectomy was completed. This is an uncommon complication.
As with all surgery, infection is a risk. Infection can occur at the wound site on the skin, or can occur deep in the pelvis where the surgery has been done. Often antibiotics will sort this out, but occasionally a second operation to wash out the infection in severe cases may be required.
Damage to nearby organs
Nearby organs are at risk of damage during a hysterectomy. The bladder sits very close to the front of the uterus and can be damaged. The bowel sits at the back of the uterus and also rarely can be damaged. The ureters, which are the small tubes that bring the urine down from the kidneys to the bladder also run very close to the sides of the uterus and can be damaged during a hysterectomy.
Damage to other organs is rare during a hysterectomy and is immediately repaired during the operation if it occurs. Very rarely, an organ can be damaged during a hysterectomy and it is not seen at the time, and it becomes apparent a day or two after the operation as the patient becomes unwell. This will mean a second operation will need to be performed to repair the damage to the specific organ.
Deep Vein Thrombosis
Any surgery performed in the pelvis increases the risk of forming deep vein clots. These can travel to the lungs and be life threatening. Clexane injections and below knee compression stockings are used to try and reduce the risk of these clots forming.