Hysterectomy is a dreaded term that women fear to hear. However, it is an operation that can be life improving if not life-saving for many.
A hysterectomy is the removal of the womb. There are 2 types of hysterectomy:
- Total hysterectomy: This is the removal of the whole womb including the neck of the womb (cervix).
- Subtotal hysterectomy: This is the removal of the body of the womb but leaving the neck of the womb behind.
Whilst for many, the total hysterectomy is the one performed, there are reasons at times to undertake a subtotal hysterectomy. These may include personal choices for the woman through to difficulties encountered during the procedure that requires the cervix to be left behind.
You will note that there is no mention of removal of the tubes or ovaries. This is because a hysterectomy only relates to the womb. However, these days, I do advocate removal of the tubes as well as there is now enough evidence to implicate some ovarian cancers starting in the tubes. So it is logical to remove the tubes as well during the procedure as it is easy to do and will assist in reducing the risk of ovarian cancer in the individual. Whether or not the ovaries are removed, will depend on the reason for the hysterectomy, menopausal status of the woman and her personal choices.
Common reasons for a hysterectomy include:
- Heavy periods
- Pain from periods, pelvic infection, endometriosis
- Persistently abnormal Cervical cells on CST ( new term for pap smears)
There are 3 ways to undertake a hysterectomy…..3? I hear you ask. Yes, 3 ways or rather 2 with the third a combined approach.
- Abdominal – through a big cut in the tummy.
- Vaginal- this is performed through the vagina with no cuts in the tummy
- Keyhole surgery -This is done with through small cuts in the tummy and the womb is removed through the vagina.
Each has their risks and benefits.
The Abdominal cut is usually used for women with significant problems like large lumps in their tummy like big fibroids, severe scarring that may render keyhole more difficult or the need for another concomitant operation to be done. It results in a slower recovery and potentially more complications due to the presence of a large cut. However, in some it will be the method of choice. It certainly is a fall back procedure if we experience complications with either the vaginal or keyhole methods. Recovery is usually a long hospital stay of 5-6 days with a 6 -7 week recovery.
The Vaginal approach is good for recovery and I would utilise this if there is a prolapse to be dealt with. However, it is harder if not impossible to completely remove the tubes as well. Access can be difficult in some. If the womb is too big, then it may not be possible to safely or easily remove it. The recovery is quicker than a big cut. I would say most will be in hospital for 2-3 days and expecting a 4 – 6 week recovery
For myself, I prefer the Keyhole approach. Using this technique I can easily get the tubes and remove them at the same time. I also get to have a good look into the pelvis to check the ovaries and ensure there are no other problems like endometriosis or adhesions present. In certain cases, prolapse can be treated at the same time by tightening the ligaments at the top of the vagina. It also allows good control of bleeding which is important to minimise problems in the recovery phase. This approach can also be used for large fibroids or ovarian cysts and so the limitation is less than the vaginal approach. The womb is usually removed through the vagina. In my experience the recovery can be quicker than the vaginal approach. It can be performed as a day case or overnight stay with recovery as quick as 2 weeks.
In keyhole surgery, I now undertake the procedure using either:
There are significant advantages in the robotic approach over the laparoscopic one in some cases and I would favour this where possible. However, the traditional laparoscopy procedure is still suitable for most women and I would not have any hesitation in using it.
The take home message is that with the advent of keyhole surgery, the procedure is better tolerated and the recovery is vastly improved from the traditional abdominal one. It should therefore no longer be a procedure to be feared but instead be considered as a viable alternative to other conservative options.
These notes reflect my personal opinion and are intended for general advice only. It should not be used for any one individual case. You should consult your own doctor to determine the appropriate management of your own individual situation.