"Tell me about a Hysterectomy, Doctor"
If a doctor or health care professional recommends that a woman should have a
hysterectomy and she elects to proceed, then there are certain decisions that need to made in planning the surgery.
There are many reasons for deciding to have the uterus removed, and numerous articles and books have been written
on this topic. There are equally many books and articles outlining alternatives for hysterectomy, and there certainly
sources here on OBGYN.net as well as elsewhere on alternatives to hysterectomy. Always, if there is any doubt in
the woman's mind, she should most certainly seek a second opinion. No woman should ever proceed with surgery if
she is not fully comfortable with both her decision to have surgery as well as the doctor who will be performing
it. The surgery should be discussed with her, and she should be actively involved in that decision-making process.
The decision of whether to proceed with a hysterectomy and how to go about making that decision is beyond the intent
and scope of this article (perhaps a later article?). This article is designed for the woman who understands the
reason for the recommendation, has seriously considered the alternatives, and made the decision to proceed. Once
she is comfortable with that decision, then she needs to have an understanding of the terminology as well as what
is going to happen in the course of events.
Hysterectomy is defined as the surgical removal of the uterus. Once the decision
has been made, then there are other factors that must be considered. Certainly the expediency with which the surgery
should be performed should be understood. For instance, if a woman is having surgery for cancer, this is not a
surgery that should be put off six months until it is more convenient for her work schedule. On the other hand,
if it is for an improvement in her quality of life and not an emergency, then she may schedule it for her convenience.
So understanding the reason for proceeding with surgery is important for scheduling as well as making the decision.
There are two basic decisions to be made regarding a hysterectomy. One is how
much of the uterus (and tubes, or ovaries) to remove, and the other is the mode of removal. While the woman may
hear numerous phrases and descriptions of the procedure that may be very confusing to her, basically they can all
be covered in two categories.
How Much To Remove?
The first consideration is how much of the uterus is to be removed, and this is
often a source of confusion for the woman. Many people think that "complete hysterectomy" refers to removal
of the uterus and ovaries, but
this is not the way the term is used in the medical language. If the ovaries and tubes are to be removed then it
is called a hysterectomy and a
bilateral salpingo-oophorectomy, whereas complete hysterectomy refers to removal of "all" of the uterus
itself, or the uterus and cervix. This often causes confusion to the woman, and it should be clearly understood
prior to proceeding with surgery.
The Fallopian tube lies adjacent to the ovary, is loosely adherent to it, and
has a common blood supply. It is technically more difficult to remove a tube without removing the ovary (although
it certainly can be done), and occasionally the removal of a tube may compromise the blood supply to that ovary.
So the tubes are usually left inside with the ovaries if the ovaries are not removed. There are many pros and cons
to removal of the ovaries, and this decision should also be discussed with one's doctor. This is an extremely important
decision for a woman to make when a hysterectomy is going to be performed. But remember, a complete or total hysterectomy
means only removal of the uterus and
cervix; if the ovaries are to be removed, then this is called a salpingo-oophorectomy.
The second part of this decision as to what to remove is whether to remove the
cervix. Earlier this century when hysterectomies were performed, only the main body of the uterus would be removed,
and the cervix (or mouth of the uterus) would be left in place at the top of the vagina. However, cancer of the
cervix was a leading cause of death in women at this time. As surgical techniques improved it became more common
to remove the cervix with the uterus, thus eliminating the risk of cancer of the cervix. However, now there is
a resurgence in the popularity of removal of the uterus without removing the cervix. With the predictive value
of the Pap smear, advanced cancer of the cervix is not near as common as it once was. Some doctors feel that removal
of the cervix compromises the support structures of the upper vagina, and as a result a woman may become more susceptible
to such problems as urinary incontinence in the future. They also feel that removal of the cervix may compromise
the sexual response and enjoyment for a woman, and many recommend it be left in place because of this possibility.
On the other hand, if the cervix is not removed, then the woman continues to have
a risk of cancer of the cervix and needs to continue to have Pap smears on a regular basis. Certainly if there
is a precancerous condition of the cervix it should be removed. Also, there is a chance that the cervix itself
will bleed on a monthly basis, and some women want absolute reassurance that all bleeding will cease. The question
of whether or not to remove the cervix at the time of hysterectomy is a hot debate at national meetings at the
present time, with renowned doctors on either side of the argument. The confusing aspect is that there are studies
to support both opinions and approaches. It is certainly something to discuss with the doctor - expressing one's
feelings and concerns when discussing surgery is extremely important!
How to Remove the Uterus?
The next thing to decide upon is how the uterus is to be removed. There are basically
two ways to perform a hysterectomy, either through the vagina or through an abdominal incision. Each way has certain
benefits and shortcomings, and usually the woman's doctor will suggest the one that offers the most advantages
to her. Sometimes the woman may not be a good candidate for one particular approach, and the doctor can explain
why it may be more preferable to perform one type over another. Removal of the uterus through the vagina, or a
vaginal hysterectomy, is often preferred because the woman usually recovers more quickly because there are no large
abdominal incisions.
However, this approach depends upon both the doctor's ability to obtain access
to the uterus through the vagina, as well as the size of the uterus. For instance, it is easier to operate on the
uterus through the vagina when a woman has had children and vaginal deliveries. Also, the initial incisions are
made into the top of the vagina by knowing the normal anatomy above and where important structures usually lie.
So if the anatomy has been distorted, then there may be an increased risk of damaging a structure by approaching
the surgery vaginally. In addition, if the uterus is enlarged significantly, then it may be too large to take out
through the vagina. But, if the doctor can perform a vaginal hysterectomy and it is safe, this is usually the route
he or she will recommend.
If the surgery cannot be performed vaginally, then there may be a need for an
abdominal incision. In the past, this long incision in the lower abdomen required more time in the hospital and
a longer recovery time. However, it does offer some other advantages. For instance, with an abdominal incision
your doctor can see more of the upper abdomen and inspect it more thoroughly. Also, larger uteri can be removed,
and more difficult hysterectomies can be performed through an abdominal incision. For instance, this is often the
route that is recommended if there is advanced cancer so all the other abdominal structures can be seen and inspected.
In the last decade, another type of approach to a hysterectomy has been developed.
This is called a laparoscopic assisted vaginal hysterectomy, or LAVH. Part of the surgery is performed through
very small abdominal incisions, and once the upper part of the hysterectomy is completed, then the uterus can be
removed vaginally. So, part of the surgery is performed through very small incisions, and the remainder through
the vagina. The advantages here are that hysterectomies can be completed vaginally, thereby avoiding a large abdominal
incision, and thus the recovery time is much shortened.
The last type of approach is a total laparoscopic approach in which all of the
surgery is performed through small incisions. The uterus is then removed through these small incisions, but this
requires special techniques or equipment. So, basically there are four types of approaches: vaginal, abdominal,
laparoscopic, or a combination of laparoscopic and vaginal. Each approach has its own specific indications and
contraindications, and each should be discussed with the doctor.
Thus, when the decision to have a hysterectomy is made, these are the two major
considerations in planning the surgery. The doctor should explain why he or she may feel one type of hysterectomy
over another is appropriate in this particular situation, and the woman should understand why one kind is recommended
one over another. Often there may be reasons why only one kind of hysterectomy is safest, and a doctor may feel
more comfortable with one type of approach. It is the woman's body, and it is important to understand the surgical process and the reasons why certain recommendations
are made. Being knowledgeable and becoming involved in the decisions regarding a hysterectomy is important not
only for being comfortable with the procedure but in hastening the recovery and getting on to a healthy and productive
life after hysterectomy.
What is to be removed?
Complete or total hysterectomy - removal
of the uterus and cervix
Supracervical or partial hysterectomy
- removal of the uterus but not the cervix
Total (complete) hysterectomy and
salpingo-oophorectomy
- removal of the uterus, cervix, tubes and ovaries
Supracervical (partial) hysterectomy and
salpingo-oophorectomy - removal of the uterus (but not the cervix), tubes and ovaries
How it is to be removed?
Vaginal hysterectomy - removal of
the uterus through the vagina
Abdominal hysterectomy - removal of
the uterus through an open abdominal incision
Laparoscopically assisted vaginal hysterectomy (LAVH)
- Removal of the uterus through a combination both small abdominal incisions (laparoscope) and through the vagina
Laparoscopic hysterectomy - removal
of all of the uterus through the laparoscope or very small abdominal incisions |
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