A hysterectomy is a surgical procedure that entails the removal of the uterus.
Alternatives to hysterectomy
While a hysterectomy is usually the most definitive treatment, many other treatments exist for management of symptoms such as abnormal uterine bleeding. Depending on the cause of your problem we will discuss all the possible treatment options available. Some women decide to have a more conservative “watch and wait for” approach, although this may require intervention further down the line, other women who have completed their families may opt for hysterectomy straight away. The decision to have a hysterectomy must be an informed decision that is suitable for you and your needs.
What is removed during a hysterectomy?
During a routine total abdominal hysterectomy, the uterus, cervix and fallopian tubes are usually removed. Occasionally the fallopian tubes are left in situ if for example, a vaginal hysterectomy is performed. There is evidence to suggest that removal of the fallopian tubes at the time of hysterectomy reduces your risk of developing ovarian cancer and hence is considered by some surgeons.
A supracervical hysterectomy is the removal of the uterus but not the cervix, although this is rarely done it may be indicated in certain instances such as prolapse surgery.
A radical hysterectomy is indicated for gynaecological cancers such as cervix cancer also includes removal of structures around the uterus and the lymph nodes or glands in the pelvic area.
Removal of the ovaries and fallopian tubes known as a bilateral salpingo-oophorectomy may be indicated at the time of your hysterectomy if you:
- Are postmenopausal
- Are undergoing a risk-reducing bilateral salpingo-oophorectomy because you have a risk of developing ovarian or breast cancer or are a BRCA gene carrier
- Are undergoing a hysterectomy for some gynaecological cancers
- Or if at the surgeon’s discretion the ovaries or fallopian tubes have cysts or growths on them such as endometriosis or non-cancerous growths or if cancer is suspected
- In special circumstances such as gynaecological cancers, the pelvic and para-aortic lymph nodes made be removed or sampled using the sentinel lymph node sampling technique. This will be discussed in more detail under those specific surgeries if Dr Guzha finds you a candidate.
Menopause after hysterectomy
If your ovaries are removed when you have not yet gone through menopause, you may develop severe menopausal symptoms such as hot flushes, sleep disturbance and vaginal dryness. You may also be at an increased risk of developing osteoporosis. It is because of this that we aim to preserve the ovaries of premenopausal women. If your ovaries are however removed, hormone therapy if the form of a cream, a patch or a pill may be indicated to treat the symptoms. This can be started shortly after the surgery.
Routes of hysterectomy
A hysterectomy can be performed in 3 different ways.
- Through the abdomen (Abdominal hysterectomy)
- Through the vagina (Vaginal hysterectomy)
- Via laparoscopy also known as keyhole surgery (laparoscopic hysterectomy)
The chosen route of hysterectomy depends mostly on your history and clinical examination, for example, a large uterus will be removed abdominally whereas a small uterus will be removed via one of the minimally invasive techniques such as vaginally or laparoscopically
In an abdominal hysterectomy, the uterus is removed through a cut on the abdominal wall. This may be the same place where a caesarean section is performed, or it may be indicated to cut you down the middle in the event of a cancer operation or a very large womb. Dr Guzha will discuss and plan this with you beforehand.
The benefit of an abdominal hysterectomy is that the surgeon has a good view of what is going on in your pelvis and abdomen making it easier to safely removed the womb in complex cases such as cancer or where someone might have lots of scar tissue or adhesions from previous operations, infection or endometriosis.
The disadvantages of an abdominal hysterectomy are that it is associated with more complications than minimally invasive techniques. It takes longer to perform than a vaginal hysterectomy and requires a longer hospital stay and recovery period. Some of the noted disadvantages/complications include:
- Wound complications such as infection or hernia
- More nerve and tissue damage and ultimately more pain then minimally invasive routes
- Increased risk of getting a blood clot in your leg or lungs compared with minimally invasive techniques
- More blood loss than minimally invasive techniques
Hospital stay 3 – 4 days
Return to work/full function ± 4 – 6 weeks
A vaginal hysterectomy is performed by surgically removing the uterus through the vagina. As a result, there are no cuts on the abdomen and healing time is much quicker than an abdominal. A vaginal hysterectomy is not indicated if the uterus is too large or there is a lot of adhesions or scar tissue in the abdomen or if one needs to have their fallopian tubes and ovaries removed to decrease cancer risk. It has the most favourable complication rate in comparison to laparoscopic and abdominal hysterectomy.
One of the disadvantages of this operation is that the surgeon is working through the vagina and can’t see the pelvic organs well.
Hospital stay 1 -2 days
Return to work/full function 4 – 6 weeks
A laparoscopic hysterectomy is performed by making a few tiny cuts or holes in the abdomen usually about 4. A camera is passed through one of these holes, and the tummy is filled up with gas. This allows the surgeon to see the pelvic organs. Small instruments are passed through the other holes/ports, and the operation is performed using those instruments. The uterus is either cut up or removed through the ports or through the vagina.
The benefit of this route of surgery in comparison to abdominal surgery is that there is a significantly shorter hospital stay as well as less risk of infection less pain and less blood loss. It also allows the surgeon to safely remove the fallopian tubes and or ovaries if indicated as a cancer risk-reducing procedure. Many international authorities recommend removing the fallopian tubes at routine benign hysterectomy as it has been shown to decrease your risk of developing ovarian cancer.
Disadvantages of this operation are that it may take longer to perform, then both abdominal and vaginal hysterectomy and the likelihood of injury to the urinary tract and bowel are higher than the other routes of hysterectomy.
Hospital stay 1 – 2 days
Return to work 2 – 4 weeks
A hysterectomy is one of the most commonly performed surgeries worldwide and is said to be one of the safest surgical procedures. However, complications can occur in any surgical procedure, and the risk of this increases with more complex cases such as cancer. Complications that may occur include:
- Fever and infection
- Bleeding resulting in the need for blood transfusion or a second operation
- Injury to the bladder or ureters. These may only become evident days after surgery and may require the second operation to repair
- Injury to bowel
- Blood clots. Precautions are taken for this during surgery, but that still doesn’t eliminate the risk completely
- Problems with your airway, breathing and heart that can be related to the anaesthesia given
- Death
Complications may only show up sometime after the surgery such as leaking urine from fistulae from urinary tract injury or even a bowl blockage from scar tissue
You will be admitted on the day of the surgery unless otherwise indicated. You will be fitted with stockings to help reduce your risk of getting clots. After the surgery, you will be given pain medication in the ward and physio will assist you with walking as soon as possible to help minimize the risk of clots. You may also be prescribed blood thinning medication for a few days to prevent clots. After abdominal surgery, you may eat the following day. After vaginal or laparoscopic surgery; you can take fluid and feeds a couple of hours after the operation.
You will have a urinary catheter in for the first 24 hours after your operation.
A physiotherapist will assist you with exercises and instruct you on postoperative activity.
You will come for a check-up 2 – 6 weeks after your operation depending on the indication of your operation or if you need to have your wound checked and stitches removed.
Pain is to be expected for the first few days, and pain medication will be prescribed. One may also experience some mild bleeding and discharge for a couple of weeks. Constipation is also common after hysterectomies and medication can be prescribed to relieve this. Difficulty passing urine is not uncommon but usually resolves with time. Some women experience profound emotional changes after a hysterectomy and may experience symptoms of depression; these usually subside without intervention.
- Get plenty of rest
- Take regular short walks and increase your distance daily
- Do not lift heavy objects for 4 – 6 weeks
- Do not push anything into your vagina and refrain from sexual intercourse for 6 weeks
After you recover, you may still need routine gynaecological exams and cancer screening. Dr Guzha will have this discussion with you at your follow up visit.