The terminology for hysterectomy can be confusing. Hysterectomy means removal of the uterus. A total hysterectomy is the removal of the cervix and the uterus. If the cervix is not removed with the uterus, it is called a partial or subtotal or supra-cervical hysterectomy. Some people believe that leaving the cervix in place makes later pelvic relaxation and prolapse less likely. However, studies do not support that belief. In addition, pap smear follow-up is needed if the cervix is not removed and many patients (up to 25%) continue to have some monthly bleeding .
Sometimes removal of one or both fallopian tubes and ovaries is done with a hysterectomy. That additional portion of the procedure is called a salpingo-oophorectomy. Removal of both ovaries causes “surgical menopause.” If at least one ovary is left in place, natural menopause will occur. However, after removal of the uterus, menopause has been found to occur up to 4 years earlier even if both ovaries are left in place.
Hysterectomies can be done several ways. Abdominal hysterectomy is usually done through a horizontal “bikini” incision. A vertical incision may be needed, but usually only when surgery is being done to remove an ovarian cancer. Patients most often go home the second day after surgery and recuperation is usually 6 weeks. A vaginal hysterectomy is done through the vagina, with no abdominal incisions. Vaginal hysterectomies always involve removal of the cervix as well as the uterus. To have surgery done by this route, a woman must have some vaginal laxity which usually is present if a woman has had at least one vaginal delivery. Patients aften go home on the day after surgery. Time for recuperation varies from three to six weeks. One of the limitations of vaginal hysterectomies is that it may be difficult or impossible to remove the tubes and ovaries which may be out of reach. In addition, the pelvis and abdomen cannot be evaluated visually. Laparoscopically-assisted vaginal hysterectomy (LAVH) involves use of a laparoscope to do part of the surgery, with the remainder done vaginally. It typically requires 3 or 4 small abdominal incisions. Doing the surgery this way can be especially helpful if removal of the tubes and ovaries is desired. Disconnecting the upper uterine attachments from the pelvis using the laparoscope sometimes allows the remainder of the surgery to proceed vaginally in women with no vaginal laxity. Recuperation is similar to that for vaginal hysterectomy. Total laparoscopic hysterectomy is removal of the uterus (+/- the cervix) through the small abdominal incisions, without removing anything vaginally if the cervix is not removed, or removing the uterus and cervix through the vagina after all of the connections have been severed via the laparoscope. Finally, the da-Vinci robot is a tool for accomplishing technically difficult laparoscopic hysterectomies that might otherwise require a larger abdominal incision. There is no scientific evidence that the use of the robot involves less risk or improves outcomes when compared with the other types of hysterectomy.
As with all surgery, the risks of hysterectomy include bleeding, infection and injury to the bladder, intestines (large or small), bladder, ureters, and to the major blood vessels and nerves that run through the pelvis. The risk of injury is greater for patients who have scar tissue from prior surgery, infections or endometriosis. Surgery also increases the risk of a blood clot (DVT or deep venous thrombosis) developing in the leg(s). That risk is minimized with the use of compression stockings during and after surgery, and with having the patient get out of bed and walk no later than the morning after surgery.
Despite some patients’ experiences, studies have shown that for the vast majority of women, hysterectomy is not associated with weight gain, faster aging or an inability to have orgasms or otherwise enjoy sex. Studies also confirm that hysterectomy itself does not increase the risk of bladder leakage, prolapse of the bladder (cystocele), or prolapse of the rectum (rectocele). The strongest risk factors for those problems are having had children, smoking and obesity. Patients who have enough vaginal relaxation pre-operatively to allow hysterectomy to be performed vaginally do have a significantly higher risk of developing urinary incontinence later on. Any vaginal laxity present is an indication of weak pelvic floor muscles that will continue to weaken further with time and gravity.
Hysterectomy does make it impossible to get pregnant or carry a pregnancy. However, it need not change your sense of femininity which is controlled by your brain.
Laparoscopy involves the use of a 5 mm or 10 mm diameter lighted telescope-like instrument, the laparoscope, which is inserted through a small incision (usually in the area of the belly button). Carbon dioxide gas is put into the abdomen to expand the space and allow the gyn surgeon to visualize the pelvic and abdominal organs. Additional instruments are frequently used through two 5 mm incisions (or one 5 mm and one 10 mm incision) in the lower abdomen. A camera on the end of the “scope” projects a real-time picture on a screen and allows pictures to be taken. General anesthesia is usually used.
There are many reasons to have gyn laparoscopic surgery. Sometimes it is done as a diagnostic test, most commonly to look for causes of pelvic pain or to test whether or not the fallopian tubes are open in women attempting pregnancy. It can also be used to provide treatment, i.e. to cut scar tissue, treat endometriosis, remove ovarian cysts, ectopic pregnancies or other structures. It can be used to accomplish permanent sterilization and, in appropriate candidates, can be used to perform hysterectomies.
Laparoscopic surgery has some benefits over surgery done through a large incision. There is generally less pain, shorter recuperation and less scarring (both externally and internally). For most procedures done laparoscopically, no over-night stay is needed.
The trans-vaginal tape procedure (TVT) is an FDA approved treatment for stress urinary incontinence (SUI). A thin PROLENE (polypropylene) mesh tape is placed underneath the urethra in order to provide support without any undue tension. The procedure is done under IV sedation and local anesthesia. A small incision in the vagina and two small skin incisions are required. The patient is asked to cough during the procedure to properly adjust the tape. It takes about 30 minutes and has a quick recovery time with minimal pain. Patients go home the same day after they demonstrate the ability to empty the bladder. Though infrequent, possible complications of the procedure include bleeding, infection, injury to the bladder, erosion of the mesh through the vagina, and urinary retention (inability to empty completely) if the sling is too tight.