Considering a hysterectomy as an option
Hysterectomy is a commonly performed procedure usually recommended for the following reasons: Persistent abnormal bleeding related to fibroids, polyps, or other causes; Pelvic relaxation; Pain related to the uterus or ovaries; Asymptomatic large fibroids; or Pre-cancerous change of the endometrium or recurrent severe dysplasia of the cervix. There are other indications as well that are not listed here.
If you are reading this section it is probable because you are considering hysterectomy as an option for your particular situation. If so, read on. I will describe in a very basic way some initial thoughts about the procedure. Since the information here is basic and brief, you should schedule an appointment to discuss in depth whether you should consider this procedure or maybe a less invasive alternative.
When the decision is made that hysterectomy is necessary, the most important step is in deciding which route is best for you. Most hysterectomies done in the U.S. are done through an abdominal incision. However, I feel strongly that the majority of these procedures can be done in a minimally invasive fashion.
What does the term minimally invasive mean? “Laparoscopy” allows for big operations to be completed with tiny abdominal incisions which ultimately allow patients to return to normal activity very quickly after surgery. That is the definition of minimally invasive hysterectomy.
HOW IT IS DONE
With an instrument called the laparoscope, a small incision is made in the umbilicus and a camera is placed through this incision. Then two or three smaller incisions are placed in the lower abdomen so that instruments can be used to perform the hysterectomy. The ligaments attached to the uterus and blood vessels providing blood to the uterus are cauterized and separated. When the uterus has been completely freed from it’s attachment to the lower pelvis, it is removed through a 3/4 inch incision (regardless of the size) and sent to a pathologist for histologic evaluation (to confirm the presence of fibroids or polyps, but also to assure the absence of an undetected cancer). The procedure generally takes from one (1) to three (3) hours, depending difficulty involved.
The procedure just described is called either Laparoscopic Supracervical Hysterectomy
(if the cervix is left in place) or Laparoscopic Total Hysterectomy (if the cervix is removed). The decision to remove or leave the cervix should be discussed and decided upon prior to surgery.
WHAT I WOULD RECOMMEND
I have performed these two minimally invasive procedures since 1998, and have performed hundreds. I feel completely comfortable in performing them with the laparoscope usually regardless of uterine size. At our hospital, however, most hysterectomies are still performed through a 6 to 8 inch abdominal incision. I am disappointed by this, because the recovery process is so much better with the minimally invasive approach.
AFTER THE PROCEDURE
Following the laparoscopic hysterectomy procedure, nearly all of my patients are ready and able to be discharged from the hospital the following day. Rarely, patients may require a two day stay in the hospital following surgery. The recovery after hospitalization is variable, but certainly much quicker that other methods of hysterectomy.
I always share the rare experience of a colleague of mine who I operated on late one afternoon. I performed a Laparoscopic Total Hysterectomy on her and came in early the next morning to “round” on her. When she wasn’t in her room, I went to make rounds on my other patients, planning on returning later to see her. To my surprise, I found her in her scrubs making rounds on her patients!! I said, “How is my patient feeling this morning” to which she replied, “I can’t believe how much better I feel now compared to how I felt prior to my procedure!!” Later that night she was back to work full time and never skipped a beat. Now I don’t find this recovery time to be normal, and I certainly recommend taking time off for recovery, but my colleague has been known to be fairly stubborn.
Usually, recovery lasts for 7 – 14 days. This is much different from the usual 6 weeks for vaginal or abdominal hysterectomies. Most of my patients are able to get around normally without strenuous activity in 3 – 4 days. I do, however, encourage them to rest for longer. I find the most irritating side effect from surgery to be fatigue. I always share with my patients that this type of surgery is deceiving. Even though there are only 3 – 4 small incisions, it still is major abdominal surgery! To some degree, the body undergoes something like a marathon while asleep under anesthesia. For that reason, it takes weeks to recovery from basic fatigue. Even though physically my patients feel fine, they do complain of feeling tired. The treatment for this is, of course, rest and sleep.
RISKS ASSOCIATED WITH THE LSH OR LTH
As with any surgical procedure there are risks and there may be unforeseen complications (just as it is possible to have an adverse event when driving around town). Most patients go through surgery with little difficulty, but problems can occur ranging from trivial to fatal. We try to keep these risks in perspective, as they are indeed uncommon. The more common complications seen in the postoperative period include nausea, vomiting, pain, infection, poor healing, or formation of adhesions (scar tissue in the abdomen). Unexpected reactions may occur from any drug or anesthetic given. Unintended intra-operative injuries may occur to other pelvic or abdominal structures, such as fallopian tubes, ovaries, bladder, ureter (tube carrying urine from the kidney to bladder), or bowel. Such injuries are extremely rare and may require immediate or later additional surgery to correct the problem. Dangerous blood clots may form in the legs or lungs (a rare event since the advent of anti-thromboembolic compression stockings that are used routinely during surgery). Finally, it should be understood that it is impossible to list every possible undesirable effect, and that the condition for which surgery is done is not always cured or significantly improved and in rare cases, may even be made worse. This is a general description of risks associated with just about any surgical procedure, so please don’t think I list them because they are common.
OTHER OPTIONS TO CONSIDER
Although I feel strongly the hysterectomy should be done in a minimally invasive fashion, I would still urge women to consider other options if possible. I am happy to explore these options with you. I recommend for my patients what I would recommend for my wife, sister, or mother. There are other alternatives that may be associated with less risk and may accomplish the same goal. For example, Office Endometrial Ablation may be successful in decreasing menstrual bleeding if heavy or prolonged menstrual flow is an issue. Removing large fibroids while preserving the uterus is also a feasible laparoscopic option patients may consider. In performing this procedure, called Laparoscopic Myomectomy, an incision is made in the uterine wall and the fibroid is shelled out. The defect is closed with suture and heals well. For women with mild uterine prolapse associated with discomfort or pain with intercourse, Laparoscopic Uterine Suspension is an excellent and easy procedure with an even quicker recovery. With age and childbirth, the ligaments that hold the uterus in a normal position are stretched and lengthened, allowing the uterus to fall deeper into the pelvis and lower into the vagina. With this procedure, the ligaments are shortened, thus re-suspending the uterus back to its original position. These options should be discussed whenever hysterectomy is considered.
If you have any questions, please don’t hesitate to ask. Our goal is for you to be comfortable with the decision you have made.
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