Patient Education

Surgery

Hysterectomy

WHAT YOU NEED TO KNOW ABOUT HYSTERECTOMY

A hysterectomy may be done to treat conditions that affect the uterus.Some are benign (not cancer), while others are precancerous lesions or even cancer.Some have symptoms that cause discomfort, while others can threaten your life.Commonly, other forms of medical treatment are tried first, and if this does not work, a hysterectomy may be suggested.

The following are some of the conditions for which hysterectomy may be performed:

1. Uterine fibroids (myomas):

Uterine fibroids are the most common type of growth found in a woman’s pelvis.They are benign growths of muscular fibers in the uterus, which can be of varying size.Fibroids tend to grow until menopause, after which most will begin to shrink.If a woman with fibroids is near menopause, she may want to see how it affects her fibroids before trying any treatments.

Fibroids can cause a number of problems, including heavy periods, painful periods, bladder pressure causing frequent urination or pressure on bowel.Most fibroids do not cause any symptoms or need to be treated.

The physicians of West Coast OB/GYN Inc. will often try a trial of hormones and possibly anti-inflammatories (for example, Advil or Motrin) if you have heavy and/or painful periods.There is a medication (Lupron or Zoladex) that is given as an injection for three to six months to shrink fibroids.This can cause bone loss if used for longer than six months, and when stopped, the fibroids often grow again.This is, however, an option for symptomatic patients near their menopause or to decrease the amount of bleeding in anticipation of surgery.

Surgical options include:

A: Myomectomy, which is removal of the fibroids but not the uterus.This is most commonly done by an open approach through an approximately five inch abdominal incision, or by laparoscopy if the fibroids are smaller.An exciting new option for patients who still want a minimally invasive approach is the use of the da Vinci robotic system. Larger fibroids can be removed with a shorter hospital and recovery time (see www.wcobgyn.com for more information). Blood loss in the surgery is typically more than for hysterectomy, and this is generally reserved for patients who request preservation of fertility.

B: Fibroid embolization.This is performed by an interventional radiologist. A catheter is inserted into a large vessel, and the vessels and therefore the blood supply to the fibroids is selectively blocked.The fibroids tend to shrink approximately 50% in size, and some patients have symptomatic improvement.

C: Hysterectomy.Once you and your doctor have decided that hysterectomy is a treatment that is best for you, a decision is then made as to how this is to be performed.

2. Dysfunctional Uterine Bleeding:

This is defined as heavy, prolonged or frequent vaginal bleeding, without any obvious cause.This can usually be managed with hormonal therapies (for example, the birth control pill).Occasionally, an endometrial biopsy is needed to exclude an endometrial pre-cancer or cancer.A hysteroscopy may be suggested to look for endometrial polyps (usually benign growths of the uterine cavity).If hormones do not control the bleeding, endometrial ablation or hysterectomy may be advised.

3. Pelvic Organ Prolapse:

The pelvic organs (bladder, uterus, rectum, and intestines) are supported by muscles, ligaments, and fascia (strong sheets of tissue).The ligaments and fascia may weaken due to childbirth, obesity, or a chronic cough.The organs that can sag or even stick out through the opening of the vagina are the bladder (cystocele), rectum (rectocele), bowel (enterocele), or uterus.This is a common indication for a vaginal hysterectomy.However, operative repair is only done if the patient has symptoms that are bothersome.Occasionally, a trial of a vaginal pessary (a device placed in the vagina that holds the organs in place) is attempted first to try and avoid surgery.

4. Pelvic Pain:

Common causes for this include endometriosis, adenomyosis, and pelvic adhesions due to previous surgery or pelvic infection.Non-gynecologic causes for pelvic pain are also common, and these include problems with the intestines, bladder, or back.Endometriosis is a condition where cells normally found lining the uterus are found on the ovaries, fallopian tubes, or other pelvic structures.This can cause pain, adhesions, and infertility.Most commonly, this can be effectively treated with hormones, but if this does not work, a laparoscopy to remove this tissue may be done.If all this fails, a hysterectomy may be performed.Adenomyosis is a condition where endometrial cells are found in the muscle of the uterus.

5. Cancers:   These include cervical cancer, endometrial cancer, and ovarian cancer.

Types of Hysterectomy

There are four different types of hysterectomy, each with its own variations:

1.      Abdominal hysterectomy:

This is the most common type of approach, with approximately 65% being performed this way in the United States.An abdominal incision (either a bikini cut or midline vertical/up and down incision) is required to remove the uterus (and ovaries if required).There are many instances where this is a good approach. The most common are large uterine fibroids.This, however, results in a longer stay in hospital (usually two to four days) with the incisional pain requiring more pain medication.The usual time to heal before returning to work is approximately six weeks.

2.Vaginal hysterectomy:

Nationally, approximately 25% of all hysterectomies are done vaginally.This is an excellent approach if there is uterine prolapse and/or the patient has a hernia of the bladder (cystocele) or rectum (rectocele), which must be repaired at the same time.Generally, a vaginal hysterectomy is not performed if the patient has a large uterus, a narrow pelvis, has had previous abdominal surgery with possible scarring, has pelvic pain including endometriosis, or if the ovaries need to be removed.Ovarian removal can sometimes be done vaginally, but this cannot be guaranteed.Postoperative recovery and pain is less than a total abdominal hysterectomy, with the usual hospital stay of two to three days.Postoperative recovery is approximately four to six weeks.

3.      Laparoscopic hysterectomy:

This approach was started more than a decade ago.It involves utilizing a laparoscope, an instrument that allows the surgeon to see into the abdominal cavity. This is placed through a small incision in the belly button, and then three smaller incisions are made into the abdomen to allow the surgeon to perform the operation using sophisticated instruments to coagulate and cut the tissue.The uterus (and ovaries if indicated) is removed through the vagina.The top of the vagina where the cervix was attached (the cuff) is now sutured either laparoscopically (total laparoscopic hysterectomy) or vaginally (laparoscopic-assisted vaginal hysterectomy).

A laparoscopic hysterectomy has many benefits over the traditional types of hysterectomy.The hospital stay is usually one to two days and patients require less pain medication.The time taken to resume activities of daily living, for example, driving a car, is four to five days, which is much shorter than the traditional (two to three weeks).Many patients return to full-time work in three weeks.

4.      da Vinci hysterectomy

This is an innovative and minimally invasive procedure using a state-of-the-art surgical system designed to help your doctor perform the surgery. This system is designed to provide your surgeon with enhanced capabilities, including a high definition 3D vision and magnified view. Your doctor controls the da Vinci System which translates his or her hand movements into smaller, more precise movements of tiny instruments inside your body. It has all the advantages of a laparoscopic hysterectomy which include significantly less pain, less blood loss and need for transfusion, shorter hospital stay, quicker recovery and return to normal activities and small incisions for minimal scarring.

Total vs. Supracervical hysterectomy:

Some patients request a supracervical hysterectomy (removing the uterus but leaving the cervix).There has been some literature suggesting that this may help in future sexual activity.It is not clear whether this is true, but it has been well documented that patients who have had this procedure laparoscopically resume sexual activity quicker than with other methods. After a supracervical hysterectomy, patients need to continue cervical surveillance with regular Pap smears, some may have cyclical spotting and/or discharge and on the rare occasion, may require removal of the cervix in the future.

This procedure is done through either an abdominal incision (similar to a total abdominal hysterectomy), laparoscopically or with the da Vinci system.The recovery time depends on the approach.If this is done abdominally, recovery is similar to a total abdominal hysterectomy and if done laparoscopically or da Vinci assisted, recovery is rapid.

What To Expect Before and After Hysterectomy:

Before the Procedure:

‣ Your blood and urine will be tested.

‣ You may require an EKG, x-rays, and other tests, depending on your medical status.

‣ You may need to have a bowel preparation diet at your physician’s request.

‣ Your abdominal and pelvic areas may be shaved.

‣ An IV line will be placed, and antibiotics may be given to prevent infection.

‣ Monitors will be placed on your body in the operating room to monitor vital signs.

Possible risks:

Bleeding, infection, injury to surrounding structures, including bowel, bladder, and ureters, problems related to anesthesia, possible death.Although the risks for hysterectomy are among the lowest of any major surgery, you and your doctor must weigh the risks and benefits before proceeding.

After the Procedure:

Your length of hospital stay will vary according to the type of hysterectomy done.You can expect to have some pain for the first few days.As you recover, you can gradually increase the daily activities, such as driving (usually after two weeks), walking, sports, and light physical work.It is generally recommended that there should be no heavy lifting for six weeks after the procedure.After a hysterectomy, you cannot get pregnant, and you will not menstruate. Occasionally, however, monthly spotting can occur if you have had a supracervical hysterectomy.

Hysterectomy and Sexual Intercourse:

Some women notice a change in their sexual response after hysterectomy.Many women have a heightened response after hysterectomy, as the reason for hysterectomy, for example, bleeding and pain, may now be resolved.Patients also do not have to worry about getting pregnant.If the ovaries are removed prior to menopause, vaginal dryness may be a problem.This can be relieved with vaginal lubricants or estrogen.

For more information on da Vinci hysterectomy, please go to www.wcobgyn.com/davinci_hysterectomy.aspx.

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