Pearl obstetrics | gynaecology


Hysterectomy

  • Different types of hysterectomy

Hysterectomy | Glengarry Private Hospital

Hysterectomy is an operation to remove the womb (uterus). It is done for many different medical reasons. Common reasons for a hysterectomy include heavy and/or irregular periods, painful periods, fibroids, adenomyosis, endometriosis, pelvic pain, prolapse, and cancer. Less commonly, a hysterectomy is performed after problems with bleeding in pregnancy or childbirth.

Hysterectomy, no matter which type, is a major operation – many women will try some other treatment or treatments first before resorting to it. However, once a positive decision to have a hysterectomy has been made, the vast majority of women do very well, albeit after a period of recovery & adjustment, physically and emotionally. Even though most are completed using keyhole methods, recovery takes several weeks.

Any surgical or invasive procedure carries risks. Before proceeding, you should do your own research. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner. For instance, your GP’s opinion will be very helpful. With an operation with as much potential impact as a hysterectomy, another perspective is very valuable,

Hysterectomy types

Vaginal hysterectomy | VH

This route is most commonly used when there is prolapse. It’s the best option in terms of recovery time, and also is associated with the fewest complications. It’s often combined with a vaginal repair if the front or back of the vagina is weak/prolapsing also. Access to remove the ovaries can sometimes be difficult – this is when we use the laparoscope.

Laparoscopic-assisted hysterectomy | LAVH

We’ll often do a laparoscopic hysterectomy rather than a pure vaginal hysterectomy if the patient has had C-sections before, has known endometriosis or adhesions, or wishes to be certain of removing the tubes or ovaries. LAVH is particularly used when a vaginal repair is performed at the same time.

Total laparoscopic hysterectomy | TLH

A TLH is a good option if there is no laxity ie. the patient hasn’t had vaginal births and the vagina is narrow, making access difficult, or if the patient has had C-section previously. There is slightly more risk of damage to the ureter with this technique (this is still rare though), and also this technique leads to less strength at the top of the vagina than VH or LAVH.

Laparoscopic subtotal hysterectomy | LaSH

This is where the cervix is left behind. There are some benefits & some downsides compared with total hysterectomy, and these depend upon the individual patient. It’s a good choice for women with a tendency to constipation as a full hysterectomy may worsen this. It’s also good for women who get benefit from the cervix during sex. The LaSH method possibly reduces the chance of prolapse in later life, as the support at the top of the vagina is not disrupted (but only if there is no existing prolapse). A LaSH is a good choice when there are large fibroids which may distort the anatomy and increase the potential for complications during total hysterectomy. Smears are still required which is a disadvantage. Leaving the cervix is not the best choice for women who already have vaginal laxity or prolapse, nor for those who have pain during sex.

Total abdominal hysterectomy | TAH

This is used occasionally when there are massive fibroids, and also for more advanced cancers of the womb & most cancer of the ovary (along with additional sampling & procedures). In the case of massive fibroids, we will try & do the “top” part of the hysterectomy with the laparoscope, through upper abdominal keyhole incisions under the ribs, hopefully allowing a bikini style incision for the “bottom” part of the hysterectomy including fibroid removal (instead of a midline cut).

Radical hysterectomy

Used by gynae-oncologists for invasive cervical cancers, in conjunction with removal of glandular tissue from the pelvis

Subtotal abdominal hysterectomy | STAH

Used when there are massive fibroids when laparoscopy is not realistic and the cervix is to be left. See the text above for TAH, which applies here. The benefits & issues with leaving the cervix are the same as those noted above under LaSH.

 

Ovaries

The ovaries can be taken away at the same time as the hysterectomy, or left if healthy. There is some evidence that the ovaries should be left before the age of 55yrs if healthy and there is no family history of ovarian cancer. There may be significant benefits for brain function and a reduction in mortality if they’re left. This does leave the small risk of ovarian cancer. However, removing the Fallopian tubes reduces this risk by about half while preserving the benefits of leaving the ovaries.

 

Fallopian tubes

The tubes are removed at all times (if practical) as this lowers the risk of ovarian cancer by up to 50%. It is thought that many of the more aggressive types of “ovarian” cancers actually start in the Fallopian tubes. Removal of the tubes is called a bilateral salpingectomy.

 

Risks of hysterectomy

All operations have risk that must be accepted during the informed consent process. However, most patients have no major problems.

Occasional risks

  • Infection – minor wound infections or UTIs mostly; occasional chest infections – approx 5%
  • Bleeding during surgery – said to be around 5%.
  • Adhesions – here scar tissue forms after the operation sticking things together, most commonly the bowel to the operation site. Most of the time there is no big issue with this. The chance depends on how extensive the initial surgery is.
  • Skin healing problems can occur – widened or “heaped” scars, numbness round incision (common initially and usually improves), painful & tender scars (usually settles but can be due to nerve entrapment – can be treated with steroid injection or further surgery)
  • Menopause is generally hastened by a couple of years if the ovaries are left at hysterectomy. Menopause is immediate if the ovaries are removed – we can use HRT to alleviate this.

 

Rare risks

  • Damage to other organs, such as bowel, ureters or bladder. 0.5-2% risk is generally quoted. The risk is said to be slightly higher with total laparoscopic hysterectomy. The more difficult the hysterectomy the more likely this is.
  • Blood clots in the legs, going to the lungs – pulmonary embolism. Very rare. We’ll thin the blood if there’s an increased risk of this.
  • Anaesthetic complications. Modern anaesthesia is very safe.
  • Very rarely, severe problems or deaths occur. The overall risk is 1/10,000, and there will generally be a pre-existing health problem. There is no more risk of this than living your life normally.

 

Recovery

Recovery is highly variable depending upon patient, pre-existing health, type of hysterectomy, and other factors. Recovery in two weeks or so is not unusual in vaginal or laparoscopic hysterectomy. Recovery can take up to 2-3 months if open surgery is needed eg. for massive fibroids. Recovery can also be delayed if an infection or other complication occurs afterwards. For most of our patients, the average recovery is 2-3 weeks for vaginal & laparoscopic hysterectomy and 6 weeks for open hysterectomy.


Hysterectomy

We perform different types of hysterectomy for benign indications. Many women will be suitable for keyhole surgery with minimal or no external scars.


PEARL obstetrics | gynaecology

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