Hysterectomy is the removal of the uterus (womb), which is the body of the uterus and the cervix. The uterus is responsible for carrying a pregnancy and bleeds each month from puberty to menopause.
In normal circumstances hysterectomy does not include removal of the ovaries. The ovaries are responsible for ovulation and manufacture of important hormones. After menopause they become nonfunctional and may then be removed with the patients consent without affecting the body function.
Subtotal hysterectomy is the removal of the upper part of the uterus only. The cervix remains. It is rarely performed, as there is still the risk of cancer of the cervix in following years and other problems with this operation.
Laparoscopic hysterectomy involves removing the uterus through 4 small incisions instead of through a large cut.
Advantages of laparoscopic hysterectomy
- Small incisions and less scarring
- Better views of the disease process
- Gentler handling of the body tissues and organs during the operation
- Less blood loss during the operation
- Less postoperative pain
- Less postoperative narcotic use for pain relief
- Shorter hospitalisation
- Faster overall recovery with an earlier return to normal activity
How is laparoscopic hysterectomy performed?
- Preoperative preparation involves a shave and a small enema. Fasting for 6 hours preop is required.
- A general anaesthetic is administered.
- The laparoscope and other instruments are introduced as described.
- The blood vessels to the uterus are secured and divided to free the uterus and prevent loss of blood.
- The uterus is freed from the surrounding supports including the vagina to which it is attached.
- Any other disease process e.g. endometriosis is removed from the pelvis.
- The uterus is removed from the pelvis.
- The vagina is sutured and the abdominal wounds are closed.
Recovery after hysterectomy
Immediate post-operative recovery involves an average of two days in hospital. A fifth of patients can go home late the next day after surgery, and about 80% patients are home in two days. Patients are welcome to rest in hospital for as long as they need to.
One in five patients will only need tablets and not injections for postoperative pain relief. If injections are required about two are needed on average. Patients will be given as much pain relief as they request to make sure they are comfortable.
The first few days at home should be taken very easily. The patient should have someone to help. Plenty of rest and fluids are advisable. Exercise your calf muscles to prevent clots. Oral pain relief such as Panadeine or Panadol may be needed, especially at night.
Graded recovery over the next few weeks will occur. Gentle increasing exercise is helpful. Driving is permissible. Expect to tire easily. Bowel discomfort and some cramps are common. Return to normal activity occurs at about two to three weeks for many patients. All patients should individually assess their recovery rate. Some may need more time off work than others and certificates will always be provided. It is important not to have sexual intercourse for six weeks after surgery.
Risks of hysterectomy
These risks apply to the hysterectomy procedure and are unrelated to the technique used to approach the uterus.
Infection – Infection rates are low as preventative antibiotics are used at and after the surgery. In hospital rates are 1-2%. In the first few weeks a further 2-3% of patients can get vaginal infections and require antibiotics, usually as tablets taken at home without the need for readmission to hospital.
Bleeding – At the time of the operation some blood will be lost. Very rarely this can be serious and require some emergency treatment such as transfusion. In the first 500 cases of hysterectomy performed by the unit this has not occurred but the possibility does exist. In the first 4 weeks postoperatively a vaginal infection at the suture line can occur and cause vaginal bleeding. This can sometimes be heavy. Do not hesitate to call your doctor if this happens. Treatment is antibiotics, bed rest and sometimes readmission to hospital. The risk of this is a little under 1 in 100.
Damage to bowel, bladder and ureter – These structures are very close to the uterus and can be damaged as the uterus is removed. The risks are about 1 in 250-300 cases. Damage detected at the time of surgery is repaired immediately and will often not have serious consequences. Sometimes the injury can be undetected or develop over several days after surgery e.g. where a burn is made to stop bleeding. A fistula can then develop. This is a connection of bladder, bowel or ureter to skin or vagina. Further surgery will be required to fix this. The risk of this is about 1 in 500 cases.
Deep Venous Thrombosis or Pulmonary Embolus – A clot can form in the leg or pelvic veins and travel to the lungs. The risk it will happen is about 1 in 400-500. This is serious and can rarely be fatal. Tell your doctor if these have happened to you before or if you have a family history. During the surgery a number of precautions are taken to prevent these. Early mobilisation after laparoscopic surgery may also reduce the risk compared to larger incision operations.
Other risks of laparoscopy – As described in the page on Laparoscopic Surgery.
Conversion to open hysterectomy – During the course of the operation the doctor may decide your case is not suitably safe for a laparoscopic approach. A conventional hysterectomy as could be done elsewhere will then be performed. The risk of this is 1 in 100 cases.
Long-term effects of hysterectomy
If only the uterus has been removed the obvious effects are no periods or period pain. Your hormonal profile should be the same. Sometimes PMS will continue although is will often improve after hysterectomy. Surveys have shown high satisfaction rates with laparoscopic hysterectomy (>94%). Sexual satisfaction and libido are thought not to be any different post operation.
A small percentage of women can suffer emotional side effects if they are not ready psychologically for the operation, or have it for the wrong reasons. It is important to discuss with your doctor the outcomes you can expect and wish to achieve from the surgery to make sure they are attainable.
If the ovaries had to be removed or you are menopausal you should discuss hormone replacement therapy with your doctor.