Hysterectomy / Surgical Removal Of Uterus
Hysterectomy - Overview
Nomenclatures: Hysterectomy/Abdominal Hysterectomy/ Vaginal Hysterectomy/ Laparoscopic Hysterectomy/Total Abdominal Hysterectomy with Bilateral Salpingo- Oophorectomy
A Hysterectomy is the second most common surgery among women. The most common is cesarean section delivery. It is usually performed by gynecologists.
There are several types of hysterectomies:
Total hysterectomy is removal of the entire uterus and the cervix. This is the most common type of hysterectomy.
Partial hysterectomy is a procedure done where the cervix of the uterus is left behind but the upper section of the uterus is removed.
Radical hysterectomy is usually done for cancer of the organ and it means removal of the uterus along with the cervix, the upper part of the vagina, and the surrounding tissues.
In many cases, surgical removal of the ovaries (oophorectomy) is performed concurrent with a hysterectomy. The surgery is then called "Total Abdominal Hysterectomy with Bilateral Salpingo- Oophorectomy", abbreviated as TAH-BSO.
A hysterectomy may be done through an abdominal incision (abdominal hysterectomy), a vaginal incision (vaginal hysterectomy), or as a laproscopic procedure (laparoscopic hysterectomy).
Depending on the medical history and the indication for surgery, the doctor will help the patient decide which type of hysterectomy is most appropriate.Hysterectomy - Indications
Hysterectomy may be recommended for:
Endometrial cancer, which is cancer that starts in the endometrium- the inner lining of the uterus
Cancer of the cervix or severe cervical dysplasia - a precancerous condition of the cervix
Cancer of the ovary
Endometriosis happens when the tissue lining the inside of the uterus grows outside the uterus on the ovaries, fallopian tubes, or other pelvic or abdominal organs. When medication and surgery fails to cure endometriosis, a hysterectomy is often recommended.
Persistent vaginal bleeding. If the periods are persistently heavy, not regular, or lasts for many days and medication does not help to control the bleeding, a hysterectomy may bring relief.
Moderate or Severe Prolapse of the Uterus - when the uterus moves from its usual place down into the vagina. This can lead to urinary problems, pelvic pressure, or difficulty with bowel movements
Complications during childbirth (like uncontrollable bleeding) Hysterectomy - Preoperative work up
Preoperative evaluation includes the following:
A complete history and physical examination to rule out any co-morbid conditions such as diabetes mellitus, hypertension, cardiac disease or asthma.
Use of medications such as use of aspirin, oral hypoglycemics, heparin, or warfarin should be documented
Biopsy of the endometrium, which is the inner lining of the uterus is essential to rule out cancer or pre-cancer of the uterus. This procedure is called endometrial sampling.
PAP smears to rule out cervical cancer maybe necessary in some cases..
Ultrasonography to study the pelvic anatomy ans assess the size of the uterus.
CBC count (complete blood count), blood type and cross match.
ECG and chest radiograph to assess the cardiac and respiratory systems.
1. Informed consent- written consent is obtained from the patient prior to performing the surgery.
2. It is recommended that the patient take nothing by mouth (food, water, etc.) for at least 6 hours before the scheduled operation or after midnight if the operation is planned in the first few hours of the morning.
3. Painkillers and antibiotics may be prescribed before the procedure.
4. A sedative maybe useful to relieve the anxiety of surgery.
5. The Abdomen and genital area maybe shaved and prepared for the surgery.
6. Before surgery or during the previous night a bath maybe advisable. During the bath thorough cleaning of the abdomen and genital area with soap and water a few times can help in lowering the bacterial count and lessen the chances of any infection from surgery.
7. An enema maybe administered to the patient prior to performing the surgery. Sometimes a laxative maybe given to clear the bowels on the previous night. Hysterectomy - Surgical Operation
There are two main techniques used to perform hysterectomies, Open technique and Minimally invasive techniques.
Open technique is a total abdominal hysterectomy (TAH)
Minimally invasive techniques are -
- Vaginal Hysterectomy
- Laparoscopic Hysterectomy
The ideal surgical procedure for each woman depends on her particular medical condition.
A. Open technique
In November 1843, Charles Clay performed the first hysterectomy in Manchester, England. The body of the uterus was removed while the cervix remained intact. In 1929, Richardson, MD, performed the first TAH (total abdominal hysterectomy), in which the entire uterus was removed (Johns, 1997).
Abdominal hysterectomy can be performed under spinal anesthesia or general anesthesia. The patient remains awake during a spinal anesthesia, with only lower section of the body being numbed to prevent pain. When given a general anesthetic, the person is unconscious.
The steps of the surgery are:
1. The abdominal hysterectomy begins via a surgical incision 6-8 inches long, made either vertically, running from the navel downwards or horizontally, running along the top of the pubic hairline and is popularly referred to as Pfannenstiel incision.
2. On entering the abdomen the attachments of the uterus and its blood supply are dissected and separated.
3. The blood vessels are tied to prevent bleeding and to help in healing.
4. The uterus and cervix are then separated from the surrounding pelvic tissues by applying instruments and cutting at different levels until the upper portion of the vagina is reached.
5. The top of the vaginal tissue is closed with sutures, and the surgical wound is closed in layers.
The advantage of an open abdominal procedure is that the surgeon can see the uterus and other organs and has more room to operate than if the procedure is done vaginally.
On the other hand, the disadvantages of abdominal hysterectomy are:
Longer hospital stay.
Greater discomfort than following a vaginal procedure.
A visible scar on the abdomen. Hysterectomy - Uterus Anatomy
Female Reproductive System
The female reproductive organs are made up of the vulva, the vagina, the uterus, the fallopian tubes, and the ovaries.
The uterus is a hollow, pear-shaped organ that is the home to a developing fetus. The uterus is divided into two parts: the lower part of the uterus that opens into the vagina is called the cervix, and the main body of the uterus, is called the corpus. The uterus has three layers.
Endometrium This is the innermost layer of the uterus. The thickness of the endometrium is regulated by hormones and so varies according to the phase of the menstrual cycle. Another name for this lining layer is the mucosa.
Myometrium This middle layer is a thick wall made of smooth muscle cells.
Serosa The outermost layer consists of a membrane called the serosa. This thin layer merges with connective tissue (ligaments) that suspends the uterus in the pelvis.
The blood supply to the uterus is through the uterine arteries, which are branches of the Aorta, which is the main blood vessel of the body.
The vagina is a canal that joins the cervix to the outside of the body. It also is known as the birth canal.
The ovaries are small, oval-shaped glands about the size of an almond that are located on either side of the uterus. The ovaries produce eggs and hormones.
The Fallopian tubes are attached to the upper part of the uterus and serve as tunnels for the ova to travel from the ovaries to the uterus. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. The fertilized egg then moves to the uterus, where it implants to grow into an embryo.Hysterectomy - Surgical Operation
B. Minimally Invasive Techniques - Vaginal hysterectomy
In a vaginal hysterectomy, the uterus is removed through the vaginal route. Prior to surgery, the patient is given a spinal or a general anesthesia.
After anesthesia the woman is positioned in a legs flexed and apart position called the Lithotomy position.
1. The skin surrounding the vagina is cleaned with an antibacterial solution.
2. A surgical incision is then made in circular fashion around the cervix and through the upper vagina to expose the tissue and blood vessels around the cervix and uterus.
3. The tissues and vessels are cut and tied to achieve Haemostasis (controlling bleeding)
4. The uterus and cervix are then removed from the top of the vagina.
5. The upper part of the vagina where the surgical incision was made is closed with suture material.
There is no visible scar in vaginal hysterectomy and healing is faster in compaision to abdominal hysterectomy.
The disadvantages are -
There is less room for the surgeon to visualise and operate.
It can only be used for smaller sized uterus
It requires that adjoining organs like the bladder is not damaged. Hysterectomy - Surgical Operation
C. Minimally Invasive Techniques -Laparoscopically assisted vaginal hysterectomy (LAVH)
This is similar to the vaginal hysterectomy procedure described above, but to help with better dissection of the abdominal tissues laparoscopy is used.
A laparoscope is a thin cylindrical telescope with a magnifying glass-like device at the end of it. Certain women would be best served by having laparoscopy used during vaginal hysterectomy as it allows the rest of the abdomen to be carefully inspected during surgery.
The procedure is performed under general anesthesia.
1. After administering anesthesia the abdomen and vagina are prepared with an antiseptic solution.
2. LAVH begins with several small abdominal incisions inferior to the belly button, which allow the insertion of the laparoscope and other surgical tools.
3. In order for the surgeon to observe the inside of the body clearly, the peritoneal cavity is inflated with gas (usually carbon dioxide).
4. A camera, which is attached to the laparoscope, captures and produces a continuous image that is magnified and projected onto a television screen.
5. Using the laparoscopic surgical tools, the tissues and vessels surrounding the uterus are cut and tied.
6. The uterus and cervix is then removed through the vagina, and the top of the vaginal cuff is sutured.
The fallopian tubes and ovaries also may be removed during this surgical procedure.
Compared to simple vaginal hysterectomy or abdominal hysterectomy, LAVH can be a more expensive procedure and is more prone to complications. It requires longer to perform, and is associated with longer hospital stay.
If a woman has a history of prior surgery to the abdomen, or if she has a large pelvic tumour, LAVH is not indicated and a regular abdominal hysterectomy is probably best.Hysterectomy - Complications
Other risks of hysterectomy are:
Damage to the urinary tract, bladder or rectum during surgery, which may require further surgical repair
Loss of ovarian function
Early onset of menopause Hysterectomy - Convalescence
The average hospital stay depends on the type of hysterectomy performed, but is usually from 2 to 3 days. Complete recovery may require 2 weeks to 2 months. Recovery from a vaginal or laparoscopic hysterectomy is faster than from an abdominal hysterectomy, and may include less pain.
Intravenous and oral medications are used after the surgery to relieve postoperative pain. A catheter may remain in place for 1 to 2 days to help the bladder pass urine. The following are some useful tips to help you recover after hystrectomy -
A sanitary towel will need to be worn to absorb any vaginal bleeding, which is usually similar to a light period.
Moving about as soon as possible helps to avoid blood clots in the legs and other problems.
Walking to the bathroom as soon as possible is recommended.
Normal diet is encouraged as soon as possible after bowel function returns.
Avoid lifting heavy objects for a few weeks following surgery.
Sexual intercourse should be avoided for 6 to 8 weeks after a hysterectomy.
If the ovaries have been removed (oopherectemy) in premenopausal women, the patient experiences menopausal symptoms like hot flashes, vaginal dryness, and mood disturbances. They are more prone for osteoporosis. A hormonal replacement treatment maybe required.Hysterectomy - Support Groups
1. HERS Foundation (Hysterectomy Educational Resources and Services) www.hysterhome.com/
Hysterectomy.htmlHysterectomy - FAQs
1. Who performs a hysterectomy?
A gynecologist performs a hysterectomy.
2. Will I still menstruate after I have a hysterectomy?
After a hysterectomy you will no longer menstruate or be able to conceive, but you will still be able to engage in sexual activities.
3. Can having a hysterectomy affect my sexuality?
Different women experience sexuality differently. For some women, a hysterectomy may change their sexual experience. For other women, hysterectomy will not affect their sexual enjoyment. However, if your uterus is causing you to have pain with intercourse, a hysterectomy may relieve that pain and make intercourse more pleasurable.
4. When are the sutures removed after a hysterectomy?
For women who have had an abdominal hysterectomy, the clips or stitches that seal the incision will be removed on around the fifth to seventh day after the operation. Stitches used for a vaginal hysterectomy are internal and don't need to be removed.
5. What are the alternatives to hysterectomy?
Hysterectomy may be the only effective treatment for certain types of cancer. However, some conditions may have other treatment options. For example, excessively heavy and painful periods can also be treated with medicines, hormones, or by relatively minor surgical procedures to remove part of the lining of the womb using heat or microwave energy (endometrial ablation).Hysterectomy - Glossary
Abdominal: Relating to the abdomen, that part of the body that contains all of the structures between the chest and the pelvis.
Benign: A noncancerous growth A benign tumor does not invade surrounding tissue or spread to other parts of the body.
Biopsy: The removal of a sample of tissue for purposes of diagnosis.
Cancer: An abnormal growth of cells, which tend to proliferate in an uncontrolled way and, in some cases, to metastasize, to spread to distant organs.
Cervix: The cervix is the lower, narrow part of the uterus . The uterus, a hollow, pear-shaped organ, is located in a woman's lower abdomen, between the bladder and the rectum. The cervix forms a canal that opens into the vagina, which leads to the outside of the body.
Cervical dysplasia: Changes in the cells lining the cervix. Cervical dysplasia involves a sequence of cellular changes from mild to severe that are not yet cancerous but constitute the prelude to cancer of the cervix.
Endometrial cancer: Cancer of the inner lining of the uterus. Endometrial cancer occurs most often in women between the ages of 55 and 70 years. It accounts for about 6% of cancer in women.
Endometriosis: In endometriosis, the endometrial cells that normally grow inside the uterus grow outside the uterus.
Fibroids: Fibroids are common, benign tumors of smooth muscle in the uterus. Uterine fibroids are the most common reason for performing a hysterectomy.
Hormone: A chemical substance produced in the body that controls and regulates the activity of certain cells or organs.
Lithotomy position: Position in which the patient is on their back with the hips and knees flexed and the thighs apart. The position is often used for vaginal examinations and childbirth
Oophorectemy: The removal of one or both ovaries by surgery. Also known as ovariectomy.
Ovary: The female gonad, the ovary is the reproductive gland in women. They are two in number and are located in the pelvis, one on each side of the uterus. Each ovary is about the size and shape of an almond. The ovaries produce eggs (ova) and female hormones. During each monthly menstrual cycle, an egg is released from one ovary. The egg travels from the ovary through a fallopian tube to the uterus. The ovaries are the main source of female hormones, which control the development of female body characteristics, such as the breasts, body shape, and body hair. They also regulate the menstrual cycle and pregnancy.
Pap Smear: A screening test for cervical cancer based on the examination under the microscope of cells collected from the cervix. The cells are smeared on a slide and can help study premalignant (before cancer) and malignant (cancer) changes as well as changes due to noncancerous conditions such as inflammation from infections.
Postmenopausal: After the menopause. Postmenopausal is defined formally as the time after which a woman has experienced twelve (12) consecutive months of amenorrhea, which is lack of menstruation.Hysterectomy - References
Compiled by: Dr.Paderla Anitha/M
Edited by: Dr.Sunil Shroff