Hysterectomy

The definition of a hysterectomy is removal of the uterus.

The uterus is a hollow, pear-shaped muscular organ located in the lower abdomen or pelvis. One end of each fallopian tube is contiguous with and opens into the side of the uterus, at the upper end, and the other end lies next to an ovary. At its lower end, the uterus narrows and opens into the vagina. The lower end of the uterus is called the cervix. The ovaries lie lateral to and slightly behind the uterus.

A total hysterectomy includes removal of the uterus, cervix and sometimes, but not always, the ovaries. A partial hysterectomy means the cervix was not removed. A separate term, oophorectomy, is used for removal of the ovaries. If the fallopian tubes are removed with the ovaries, the term is salpingoophorectomy.

There are several ways to perform a hysterectomy, all dependent on the patient’s history, the indications for the procedure and the size of the organ itself.
 

Abdominal Hysterectomy

Abdominal hysterectomy is a surgical procedure in which the uterus is removed through an incision in the lower abdomen. One or both ovaries and fallopian tubes may also be removed during the procedure. Abdominal hysterectomy is a safe, routine procedure, but still a major operation. The patient typically stays in the hospital for two days and should plan a period of several weeks to recover at home, during which normal activities can gradually be resumed.

Vaginal Hysterectomy

Vaginal hysterectomy is a surgical procedure in which the uterus is removed through the vagina. One or both ovaries and fallopian tubes may be removed during the procedure as well. A vaginal approach may be chosen if the uterus is not greatly enlarged, and if the condition prompting the surgery is benign and limited to the uterus. Studies have shown that vaginal hysterectomy is associated with fewer complications, a shorter hospital stay and faster recovery than an abdominal hysterectomy.

Although infrequent, your surgeon may find conditions, such as extensive scar tissue, during a vaginal hysterectomy that make abdominal hysterectomy the better choice. Sometimes these conditions are not apparent before surgery. When this happens, the surgeon stops the vaginal procedure and changes to an abdominal approach.

Laparoscopically Assisted Vaginal Hysterectomy

Some surgeons use a laparoscope in conjunction with the vaginal hysterectomy procedure. A laparoscope is a surgical instrument inserted through a small incision in the abdomen. Using the scope, the surgeon can see structures within the abdomen and, if needed, perform procedures such as removing scar tissue to aid the vaginal surgery. It is generally believed that a woman can return to normal activities sooner after a vaginal hysterectomy than after an abdominal hysterectomy. As a result, sometimes patients who are candidates for abdominal hysterectomy may have laparoscopy done to mobilize the uterus and allow a vaginal hysterectomy to be done instead.
 

Supracervical or Subtotal Hysterectomy

There are situations in which the entire uterus is not removed. A supracervical, subtotal or partial hysterectomy refers to a procedure in which the cervix is left intact. Sometimes during hysterectomy difficulties arise that make the surgeon decide that leaving the cervix in place is safer. Also, some women prefer keeping the cervix, as they feel it will contribute to sexual satisfaction after hysterectomy. Prior to planned supracervical hysterectomy, tests should be performed to exclude any cervical abnormalities. In addition, the woman should discuss with her doctor the risks and benefits of leaving the cervix intact.

In rare cases of emergency hysterectomy to control bleeding following childbirth, the supracervical procedure may be performed because, in this setting, it can be difficult to identify the boundary of the cervix.

If the cervix is not removed, the woman remains at risk for cervical cancer and must continue to have routine Pap smears. In some women, the retained cervix is attached to the lower uterine segment and its endometrium, meaning they will continue to experience menstrual periods.
 

Conditions Treated

A hysterectomy treats a number of conditions, including:
 

• Fibroids: Noncancerous tumors of uterine muscle, which may occur in up to a third of all women and typically shrink after menopause
   

• Pelvic relaxation: Stretching and weakening of the pelvic muscles and ligaments that allow the uterus to sag (or prolapse) into the vagina, often associated with vaginal childbirth
   

• Abnormal uterine bleeding: Irregular or heavy uterine bleeding unresponsive to D&C or medical therapy
   

• Adnexal mass: A mass involving the ovaries or, rarely, the fallopian tubes
   

• Cervical abnormalities: Precancerous abnormalities or cancer of the cervix unresponsive to lesser procedures such as cone biopsy or treatments using laser or cryosurgery
   

• Endometrial hyperplasia: Excessive growth of the endometrium, or the tissue that lines the uterus. Some types of endometrial hyperplasia may be precursors of endometrial cancer.
   

• Malignancy: Cancer affecting the uterus or other reproductive organs
   

• Tubo-ovarian abscess: A collection of pus and inflamed tissue involving the ovaries and fallopian tubes
   

• Chronic pelvic pain: Chronic pelvic pain may be due to the effects of endometriosis or scarring (adhesions) in the pelvis and between pelvic organs

Other Treatment Options

In some cases, medication or limited surgery can be used to treat an underlying condition, and hysterectomy can be postponed or avoided. The decision to proceed with surgery should be made mutually by the patient and her doctor after careful consideration of the woman's particular medical problem, all available treatment options, and the risks and benefits of each type of treatment.

Possible Complications

Complications associated with hysterectomy, most of which can be easily managed, include:

• Hemorrhage: Excessive bleeding occurs in a small number of cases and may require transfusion and/or a return to the operating room to identify and correct the cause.
   

• Infection: Fever after hysterectomy is not uncommon. In some women, the fever may be due to an infection that can be treated with intravenous antibiotics. Rarely, serious infections that are not eliminated by antibiotics require further surgery.
   

• Damage to other abdominal structures or organs: The urinary bladder, ureters (small tubes leading from the kidneys to the bladder), and the large and small intestine are located in the lower abdomen and can be damaged during hysterectomy. If injury occurs, it may be detected and corrected at the time of surgery, usually without subsequent problems.
   

• Thromboembolism: Formation of a blood clot in a blood vessel is a rare complication after abdominal hysterectomy. Preventive treatment and postoperative ambulation help minimize this risk. Women taking oral contraceptives should discontinue them one month prior to planned surgery, and use alternative methods of birth control.
   

• Other more rare complications include protrusion of the small intestine or prolapse of the fallopian tube into the vagina. These can be corrected surgically. As with any abdominal operation, there is a possibility of developing a hernia in the incision site. Complications related to anesthesia can also occur.

Other Considerations

If the decision is made to proceed with a hysterectomy, there are additional aspects that need to be considered.

Oophorectomy is surgical removal of the ovaries. It is sometimes done in conjunction with hysterectomy. Some women have a condition that requires that the ovaries be removed. Others, however, may be asked to make a choice between keeping the ovaries or having them removed.

If the patient has not gone through menopause, keeping the ovaries allows for continued natural production of estrogen and progesterone and allows the woman to avoid the need for hormone replacement therapy immediately after surgery. Removal of the ovaries, however, essentially eliminates the risk of needing additional operations for future ovarian problems, and may be desired in some women.

In women who have completed menopause, the ovaries are frequently removed as part of the surgery because they are not producing large amounts of hormones, it is easily accomplished as part of the surgery, and avoids the need for future surgeries should ovary problems arise.