Hysterectomy is the term used for surgical removal of all or part of the uterus. The common causes for which hysterectomy may be performed are:
- Abnormal bleeding (that cannot be controlled by other means)
- Prolapsed uterus
- Pelvic inflammatory disease
- Cancer of cervix, ovaries or uterus
- Endometrial hyperplasia (pre-cancerous condition)
Types of hysterectomy
As you have seen, there are various conditions which may be the reason for a hysterectomy. Depending on the condition, the doctor has to decide the type of hysterectomy to be performed. The doctor may remove only the uterus or uterus along with other structures depending on the condition.
When the uterus is removed without the cervix it is called as subtotal hysterectomy. When the uterus and cervix are removed it is called total hysterectomy.
A procedure called as salpingo oophorectomy may be combined along with hysterectomy. This means removal of fallopian tubes and ovaries.
For cancer of the uterus and /or cervix a more extensive surgery called radical hysterectomy is required. In this case a wider resection of tissues is done. Even chain of lymph nodes and part of vagina are removed.
Salient steps of the surgery
The uterus is attached to the other organs and the pelvis. The uterus has to be separated from all the supporting structures. The urinary bladder and the rectum also needs to be separated from the uterus, cervix and vagina
Thus the uterus is made free and delivered. Depending on the route of surgery, different surgical techniques are used to achieve the objective of separating the uterus from other structures safely.
The surgery – Different Routes
Your doctor may perform a hysterectomy either through abdomen or vagina, based on the disease conditions:
For abdominal surgery, the doctor has to make adequate incision on the abdomen. In abdominal surgery, the doctor has better exposure to the abdominal organs and better room to work. Thus if the size of the uterus is big, and uterus is adherent to the other structures, the doctors prefer to choose the abdominal route.
In vaginal surgery, incision is made inside the vagina and it is not seen externally on the body. In vaginal surgery, the exposure is limited. Hence it may be difficult to tackle the uterus which is big, which is stuck or which is placed high in the pelvis.
Hysterectomy can also be performed by a laparoscopic technique.
Laparoscope is a telescope which is used to view inside of the abdomen. Through a small incision laparoscope is inserted in the abdomen and a camera is attached to it. The picture can be seen on the TV. The gas (usually carbon dioxide or air) is put into the abdominal cavity so that the skin is lifted up and other structures such as intestines are lifted back thus providing space for the doctor to work. The doctor looks at the image and operates in the abdomen. The doctor will make few more small incisions so that he can pass other small instruments. With the help of the instruments the doctor separates the uterus from all the supports and uterus is removed.
This type of surgery is technologically intensive. There are inherent limitations of the technique because the doctor cannot see three dimensional pictures nor can he feel the tissues which happen in the open surgery. The doctor uses particular type of electrical device called cautery to seal the bleeding points unlike sutures in open surgery.
Benefits of Laparoscopy
With smaller incision, lesser pain, faster return to normal activity, shorter hospital stay and lower risk of infection, laparoscopic surgery has some benefits over abdominal surgery.
However, there also are disadvantages. It often takes longer to perform laparoscopic surgery compared with abdominal or vaginal surgery. The risk of being under general anesthesia, for a longer period puts the patient at greater the risks for certain complications related to anesthesia. Also, there is an increased risk of bladder and bowel injury in this type of surgery.
How does one decide the route of surgery?
There are some inherent advantages and disadvantages of vaginal, abdominal and laparoscopic hysterectomies. The doctor based on his experience and your particular case will decide on the best route for you. Occasionally the doctor may need to convert vaginal or laparoscopic surgery into open abdominal surgery.
Let us now see the care that must be taken before the surgery.
On the evening before the operation, the patient should eat a light dinner.
Most doctors will advice the patients to stop taking anything orally about 6-8 hours prior to surgery.
Before the surgery the doctor will confirm that you are fit to undergo the surgery by ordering certain blood investigations, x rays and any other test required in your case. .
Anesthesiologist may evaluate any special conditions that might affect the administration of anesthesia.
Preparations for surgery
On the day of your surgery, the following things may happen:
- A needle is placed in your arm, wrist, or hand. It is attached to a tube called an intravenous (IV) line that will supply your body with fluids, medication, or blood.
- You will be given an antibiotic to prevent infection.
- Monitors will be attached to your body before anesthesia is given. You may be given general anesthesia, which puts you to sleep, or regional anesthesia, which blocks out feeling in the lower part of your body.
- Pubic hair may be clipped. You may be awake or asleep while this is done. This is not done after giving anesthesia it is done much earlier or even day prior to surgery or before taking the patient to OT.
- Before you are given anesthesia, you likely will be asked to state your name, the type of surgery you are having, or other information. This standard procedure, called a “time-out,” is done to ensure that the right surgery is being done on the right patient.
- A thin tube called a catheter will be placed in your bladder. The catheter will drain urine from your bladder during the surgery.
After surgery, the patient generally feels some degree of discomfort due to the incision.
Some women have emotional changes following a hysterectomy. No genuine scientific info supports this statement. With oophorectomy this may be possible. Women who have had their ovaries removed may be started on hormone replacement therapy.
Normally the patient takes around 3 to 5 days to return to her home. The length of your hospital stay will depend on the type of hysterectomy you had and your post operative recovery.
One can slowly resume the activities. You should discuss with the doctor about when can you start doing vigorous activity or return to your job.
In the post operative period, in the initial period your pulse, blood pressure and urine output shall be watched carefully. On confirming that your gut has started functioning properly, oral intake will be started slowly. You will be observed for signs of infection and the wound will be checked.
You can expect to have some pain for the first few days after the surgery. You will be given medication to relieve pain. You will have bleeding and discharge from your vagina for several weeks. Sanitary pads can be used after the surgery.
With the advent of medical science, this surgery has become much safer as compared to uterus removal surgeries carried out in the past. But although hysterectomy is a relatively safe operation, like all major surgeries it also carries some risks.
These include unanticipated reaction to anesthesia, bleeding during or after the surgery, inadvertent injury to the structures close by, such as urinary bladder, ureter, intestines, injury to nerves of the lower limb. All these complications are known but quite uncommon.
The surgical site may get infected and the healing of the wound may be poor or wound may gape.
In Indian patients the complication called as deep vein thrombosis is much rare as compared to the western world. In this the blood gets clotted in the veins of the legs and the clot may get lodged into some other organ such as lungs, heart or brain.
Special mention about Oophorectomy or Removal of ovaries
The ovaries are the factories to produce female hormones. They seize to work after the menopause is achieved. When the ovaries are removed during the surgery, the body gets deprieved of these hormones thus woman may start feeling all the symptoms such as changes in sex drive, weight gain, hot flashes and other symptoms of menopause.
On the other hand, after a particular age the chances of ovarian tumor increase. Sometimes these tumours can be cancerous as well. Thus if the ovarian tumours develop then the patient may require another surgery. All this can be avoided if the ovaries are removed at the time of hysterectomy. Thus based on the pathology or the problem for which hysterectomy is planned, the age of patient, , the doctor and you have to weigh the advantages and disadvantages of removing the ovaries during the surgery. You must discuss about this with your doctor before surgery. Thus a clear plan can be made out.