| |
 What
is uterus? |
| What
is hysterectomy? |
| Why
should one go for hysterectomy? |
| Before
the surgery |
| The
surgery |
| Abdominal
hysterectomy |
|
Vaginal
hysterectomy |
|
Laparoscopic
method |
| --Laparoscopic
Assisted Vaginal Hysterectomy (LAVH) |
| --Total
Laparoscopic Hysterectomy |
| After
the surgery |
| Benefits
and drawbacks |
 |
| |
|
| |
| What
is uterus? |
| |
| Uterus is a hollow, muscular, pear
shaped organ often referred to as Womb since Biblical
times. It has two tubes called fallopian tubes connected
to it at one end and to the ovary at the other. When an
egg cell is released from an Ovary it travels to the uterus
via these fallopian tubes. It is a very remarkable organ
capable of expanding to contain a full-grown baby and
of shedding its lining up to 500 times during the life
that is during the time of monthly period. The resultant
stresses and strains on its supporting structures during
pregnancies and the repeated shedding and re-growth of
its lining may lead to problems. |
| |
|
|
| |
|
|
|
| |
| What
is hysterectomy? |
| |
| Hysterectomy merely means surgical
removal of uterus. It is the second most common major
operation performed today. Hysterectomy involves removal
of the uterus, and sometimes the ovaries too (oophorectomy).
Often one or both ovaries and fallopian tubes are removed
at the same time a hysterectomy is done. So depending
upon what is removed, hysterectomy can be classified as: |
| |
|
Sub-total or partial hysterectomy
It involves the removal of Fallopian tubes and
the upper two-thirds of the uterus only, preserving
the cervix.
|
|
Hysterectomy with ovarian
conservation
It involves the removal of the Fallopian tubes,
uterus and the cervix, while preserving the ovaries.
|
|
Hysterectomy with oophorectomy
It involves the removal of the Fallopian tubes,
uterus and cervix, together with one or both sets
of ovaries. |
|
Radical or Wertheim's hysterectomy
It involves the removal of the Fallopian tubes,
uterus, cervix, ovaries as well as nearby lymph
nodes and the upper portion of the vagina. This
type of hysterectomy is used in the treatment of
some gynaecological cancer cases. |
|
|
| |
| Before having a hysterectomy, it is
very important to discuss the implications you're your
gynaecologist and partner. Your doctor may recommend a
hysterectomy if none of the treatments for the various
conditions have worked. Ofcourse in some cases, there
is no other choice than hysterectomy. |
| |
|
|
|
| |
| Why should one go for hysterectomy? |
| |
| Hysterectomy is used to treat: |
| |
- Fibroids- This is the most common reason
for which hysterectomies are done. For many women
with fibroids, symptoms are minimal and require no
treatment. Also, the fibroids often shrink after menopause.
But in some cases, fibroids can cause heavy bleeding
or pain in some women.
- Endometriosis- This happens when the tissue
lining the inside of your uterus grows outside the
uterus on your ovaries, fallopian tubes, or other
pelvic or abdominal organs. The surrounding tissue
may become scarred, and often other organs such as
the uterus, bladder or the rectum may become stuck
down in these scars (adhesions). When medication and
surgery do not cure endometriosis, a hysterectomy
often is performed.
- Uterine prolapse- This is 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.
- Cancer- Cancer of the uterus, cervix, or
ovary, is another cause for hysterectomy.
- Persistent vaginal bleeding- If menstrual
flow is heavy, not regular, or last for many days
and non-surgical methods have not helped to control
bleeding, a hysterectomy may bring relief. But ofcourse
the physician screens the candidate if she is suitable
for the surgery.
- Chronic pelvic pain- Surgery is a last resort
for women who have chronic pelvic pain that clearly
comes from the uterus.
|
| Often a doctor will have a fairly
good idea of the type of the problem after examining and
listening to the patient's symptoms. The doctor will make
detailed notes of medical history and the patient's concerns.
The physician will then inform the patient about different
types of hysterectomy procedures. It is important that
women understand the full implications of the removal
or certain reproductive organs so that they can be properly
prepared for any resultant side effects. |
| |
|
|
|
| |
| Before
the surgery |
| |
The doctor will once again examine
the patient thoroughly. The blood will probably be tested
for hormone levels and also a pelvic ultrasound scan may
be recommended. If the scan shows any abnormalities or
is unclear, the doctor may want to investigate further
using hysteroscopy, a procedure in which a viewing device
is inserted into the uterus. A sample of the lining of
the womb (endometrium) may be taken. Endometrial sampling
is done either as an outpatient procedure, or by D&C-dilatation
and curettage, usually when under a general anaesthesia.
In a D&C, the cervix is opened (dilatation) and the
lining of uterus (the endometrium) will be systematically
scraped (curettage) with a long, thin instrument. The
strips of the lining will then be examined under a microscope.
Preparation for both vaginal and abdominal hysterectomy
is similar. She will be given a suppository to empty the
bowels the night before. She will be told not to eat or
drink anything on the day of the surgery about 6 to 8
hours before the surgery. Anaesthesia is given. It can
be general, epidural or spinal anaesthesia. A catheter
(a narrow silicon tube) is inserted into the bladder to
empty it. The operation area is cleaned thoroughly with
antiseptic before the operation. |
| |
|
|
|
| |
| The surgery |
| |
| The actual hysterectomy operation
can be performed in several different ways. The method
chosen will depend on the surgeon's skills, expertise
and preference, the reason for the hysterectomy and the
woman's characteristics (e.g. weight, previous pelvic
surgery, if she has had children). There are presently
following ways to perform a hysterectomy: |
| |
- Abdominal hysterectomy
- Vaginal hysterectomy
- Laparoscopic method
|
| Abdominal
hysterectomy |
| |
| Initially this used to be the only
method to remove the uterus. Ofcourse now options like
laparoscopy have become the preferred choice of surgeons
all over the world. But in some cases this method is still
employed e.g. When there is a need for extensive exploration
(in the case of cancer)or if the uterus is enlarged or
if the woman has never had children or is obese. This
surgery requires a four to eight inch abdominal incision
to remove the uterus, and ovaries, if needed. An abdominal
hysterectomy can be performed in two ways, with a vertical
incision or a bikini line cut. A vertical incision generally
involves a cut from the navel to the pubic hairline. The
bikini line cut, as its name suggests, is done horizontally,
directly above the pubic hairline. It leaves a less obvious
scar and results in a shorter recovery time. The presences
of large fibroids, extensive adhesions or endometriosis
are other examples where this procedure is often preferred.
The advantages of an abdominal hysterectomy are lower
incidence of damage to the urinary tract and blood vessels.
It also allows the repair of a prolapse at the same
time. But it is the least preferred route by patients
because of the hospital stay, abdominal scar, pain,
and disability; but it is sometimes the only route possible.
|
| |
| Vaginal hysterectomy |
| |
 This
is the next most frequently employed technique of hysterectomy.
The surgeon operates entirely through the vagina, pulling
the uterus down through the vagina into view, disconnecting
the cervix and then the rest of the uterus. To use the
vaginal route, a woman must usually have had a baby or
two which widens the vagina and relaxes the connections
of the uterus so it can be pulled down into the vagina
to do the operation. There is no abdominal scar. It usually
requires only two days in the hospital and about two weeks
away from work. Vaginal hysterectomy is always preferred
route if all the specific requirements are met-i.e. small
uterus, no cancer, and vaginal laxity. It can not always
be done for massive uterus. It is also not always possible
to remove the ovaries because they are attached much higher
in the pelvis than the uterus and cannot always be pulled
down into the vagina for surgical removal. |
| |
|
The advantages of this method are
less pain, a shorter hospital stay and recovery time
and the absence of a visible scar. A review of different
surgical approaches to hysterectomy for non-cancerous
conditions concluded that a vaginal hysterectomy should
be performed in preference to an abdominal hysterectomy
where possible.
|
| |
| Laparoscopic hysterectomy |
| |
|
 This
merely means a hysterectomy in which any part of the
operation is performed laparoscopically. Laparoscopy
is a minimally invasive approach that involves specialized
video equipment and instruments that allow a surgeon
to remove the uterus through four tiny incisions, most
of which are less than a half-centimetre in size. It
allows the uterus to be detached from inside the body
by laparoscopic instruments while the doctor is viewing
the uterus, tubes, and ovaries through a camera attached
to a telescope.
All laparoscopic surgery is performed under general
anaesthesia with endotracheal intubation. The use of
a naso-gastric tube avoids injury to the stomach and
reduces bowel distension. The patient is placed in the
dorso-lithotomy position, with the legs supported by
stirrups and adjusted to permit mobilization of the
uterus by the nurse or the assistant surgeon. Now in
this case also, just like in conventional methods, uterus
can be removed via abdomen or through vagina. But while
performing laparoscopic surgery, if the surgeon at any
time feels that it is not possible to remove the uterus
laparoscopically, he can convert into an open procedure.
This type of surgery involves passing from one to five
small plastic tubes through half-inch incisions in the
abdominal wall, providing a video picture of the inside
of the abdominal cavity. Long slender surgical instruments
can be used through these tiny "ports" to
perform operations, such as removing the uterus, ovaries
or performing biopsies. After the uterus is detached,
it is removed through a small incision at the top of
the vagina.
|
| |
| Laparoscopic surgeries have become
the preferred choice for physicians all over the world.
The first laparoscopic hysterectomy (LH) was performed
in January 1988 by Harry Reich in Pennsylvania. This new
procedure was designed to be an alternative to abdominal
hysterectomy. Laparoscopic hysterectomy can be of two
types: |
| |
- Laparoscopic Assisted Vaginal Hysterectomy (LAVH):
- Total Laparoscopic Hysterectomy
|
| Laparoscopic
Assisted Vaginal Hysterectomy (LAVH): |
| |
| This also involves removal of the
pelvic organs through the vagina but includes starting
with cutting the ovarian attachments by working through
the laparoscopes in the abdomen. This surgery is done
under general anaesthesia. After the patient is "asleep,"
a retractor is placed through the vagina into the cervix.
This helps to move the uterus around so that different
areas of the uterus can be visualized. LAVH may be performed
through 3 incisions: one 10-12 mm umbilical incision and
two 5 mm lateral incisions. Carbon dioxide gas is used
to fill the abdomen so that organs within the abdominal
cavity are not injured when the instruments are placed
inside. The laparoscope (which is similar to a periscope)
is placed through the belly button incision. The instrument
that grasps, coagulates, and cuts is placed through one
of the other small incisions and the third incision is
used for the retractor held by the assistant surgeon.
The uterus with or without the tubes and ovaries are released
from their blood supply and released from the cervix.
The cervix is then supported by placing permanent sutures
in the ligaments holding up the cervix to avoid falling
later on. The canal in the centre of the cervix is also
coagulated in order to avoid any monthly bleeding. Harmonic
scalpel is the most preferred tool for coagulation. The
uterus and tubes and ovaries (if they are being removed)
are brought out in strips and sent to pathology to be
evaluated for disease. After the abdomen is thoroughly
checked for any bleeding, the instruments are removed
and the gas that was used to fill the abdomen is emptied.
The incisions are closed with sutures. |
| |
| Usually two days in the hospital are
needed with two weeks away from work. This is the next
most preferred route for qualifying women. Most operating
OB/GYN doctors can do this procedure, but not all. The
doctor has to be especially trained in this procedure. |
| |
| Total
Laparoscopic Hysterectomy |
| |
| This procedure involves disconnecting
the uterus, and other structures as needed, by operating
only through the laparoscopes in the abdomen, starting
at the top of the uterus. The entire uterus is disconnected
from its attachments using long thin instruments through
the "ports." The early stages of total laparoscopic
hysterectomy are performed in the same way as LAVH. When
the broad ligament has been dissected the surgeon ties
the uterine pedicle It is essential at all times to be
aware of the position of the ureters and to ensure that
all haemostatic procedures are carried out at a distance
from them. Elevation of the uterus allows the ureters
to separate further from the uterus. Then all tissue to
be removed is passed through the vagina or through the
tiny half-inch abdominal incisions. A massive ovarian
cyst can be removed without rupturing it inside the abdominal
cavity by placing it in a sturdy surgical-grade pouch
and passing the pouch out the vagina or, after collapsing
the cyst inside the pouch, passing it out through the
"port" incision. If the uterus is massively
enlarged it can be disconnected from its attachments,
then cut into tiny pieces and passed down the vagina.
|
| |
| Abdominal scars consist of two to
four tiny one-half inch incisions, one inside the belly-button,
one in the top portion of the pubic hair just above the
pubic bone, and one each just to the middle side of the
front of the hip bone. Additionally hospitals with modern
technology offer alternative methods of achieving haemostasis(
stopping of blood). These include haemostatic clips. Automatic
stapling is popular with some surgeons. These devices
consist of two jaws each containing a triple row of micro-titanium
staples which produce haemostasis. |
| |
| TLH can thus be performed on women
who have never had children, women with narrow or long
vaginas, women with previous surgeries, women with cancer,
and women with massive organs. This technique is the least
painful and least debilitating route of surgery for women
who need hysterectomy but do not qualify to have a vaginal
hysterectomy. Laparoscopic hysterectomy has been shown
to be associated with a shorter hospital stay and recovery
than abdominal hysterectomy. Women having laparoscopic
subtotal hysterectomy may have an even faster recovery.
|
| |
|
Total Abdominal Hysterectomy
(TAH)
|
Vaginal Hysterectomy (VH)
|
|
|
|
- Large incision or "bikini cut"
(4-6 inches)
- Tissues of the abdominal wall are stretched
and uterus is removed
- Requires 3-5 day hospital stay; normal activity
can usually resume in 6 weeks
|
- Incision (approximately 1 inch) made at
the top of the vagina
- Uterus and cervix are separated from the
body and removed through the vagina
- Abdominal walls are not stretched
- Requires 1-3 day hospital stay; normal activity
can usually resume in 4 weeks
|
|
| |
|
Laparoscopically Assisted
Vaginal Hysterectomy (LAVH)
|
Laparoscopic Supracervica
l Hysterectomy (LSH)
and Total Laparoscopic Hysterectomy (TLH)
|
|
|
|
- Laparoscope (miniature camera) is inserted
through a small incision to view the uterus
and surrounding orhans
- Uterus isdetached under view of the laparaoscope
using special tools inserted through small
incisions
- Incision (approx. 1 inch) made at the top
of the vagina
- Uterus and cervix are removed through the
vaginal incision
- Requires 1-3 day hospital stay; normal activity
can usually resume in 4 weeks
|
- Using only laparoscopic tools, uterus is
seperated from the body and removed through
one of the abdominal incisions
- As LSH leaves the cervix in place; a TLH
rem0oves both the uterus and the cervix
- Requires 1-3 day hospital stay; normal activity
can usually resume in 4 weeks.
|
|
| |
|
|
|
| |
| After
the surgery |
| |
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. Removal of the ovaries along with the
uterus in premenopausal women causes immediate menopause,
and oestrogen replacement therapy may be recommended.
Some patients report that the incisions feel a little
sore and the residual gas in the belly hurts a bit. This
gas often collects under the right diaphragm and causes
the sensation of right shoulder 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.
Moving about as soon as possible helps to avoid blood
clots in the legs and other problems. Normal diet is encouraged
as soon as possible after bowel function returns. The
physician may advice to take some precautions like avoiding
lifting heavy things etc. th epatient may also be recommended
to take Hormone Replacement Therapy (HRT) which means
replacing the missing female hormone oestrogen with tablets. |
| |
|
|
|
| |
| Benefits
and drawbacks of laparoscopic hysterectomy |
| |
| One advantage of laparoscopic hysterectomy
is that the incisions are smaller (1/2 inch) and much
less uncomfortable than that of abdominal hysterectomy.
So people are able to resume normal activity in about
2 weeks. So Laparoscopic hysterectomy has many advantages
like: |
| |
- Less postoperative pain
- May shorten hospital stay
- May result in a quicker return to bowel function
- Quicker return to normal activity
- Better cosmetic results
|
| |
| However, the surgeon must be experienced
in the procedure before these benefits can be seen or
else complications may occur. Disadvantages include a
possible longer operating time (depends on how much of
the operation is performed laparoscopically), higher costs
and an increased risk of damage to the urinary tract.
So, if we were to compare an open surgery with a laparoscopic
surgery, we can display it in a nutshell as under: |
| |
| |
|
LAPAROSCOPIC
|
OPEN
|
|
Small Incisions (less than ½ an inch)
|
Large Incision
|
|
Hospital stay is 1 to 3 days
|
Hospital stay of about 5 days
|
|
Patients usually return to work in 5 to 10
days
|
Return to work in about 4 weeks
|
|
Lesser risk of Infection
|
Greater risk of infection
|
|
Less pain
|
More painful
|
|
Less chance of hernias
|
More chance of hernias
|
|
| |
|
|
|
| |
| |
