HYTERECTOMY

Hysterectomy specimen

Hysterectomy may be total hysterectomy or partial hysterectomy.

A total hysterectomy is the operation to remove of the uterus and cervix which is the bottom part of the uterus. A partial hysterectomy is the operation to remove the uterus without the cervix. This operation is not so commonly done though there is a trend to revive this type of operation.

Indication

The exact indications for hysterectomy have been the focus of much debate among the doctors. The operation is useful and even life-saving in certain circumstances.

One may need a hysterectomy in conditions like cancer of the uterus or pre-cancerous condition of the uterus and cervix, cancer of the ovary, very large fibroids, severe endometriosis, pelvic adhesions which bind the uterus to neighboring organs, severe and uncontrollable bleeding, or if the uterus has dropped down and is protruding from the vagina.

Route

Hysterectomy may be performed by

1. Abdominal hysterectomy - operation through an incision in the abdomen. It is generally done for large ovarian or uterine tumour or cancer. Many surgeons prefer this approach, because it gives them a better look at various pelvic organs.
   
   
2. Vaginal hysterectomy - in selected cases where the uterus is generally not too enlarged, when there is certain degree of descend (prolapsed) and no necessity to remove the ovaries and preferably patients had previous vaginal delivery.
   
   
3. Laparoscopic assisted vaginal hysterectomy (LAVH) - with the aid of laparoscope combined with vaginal hysterectomy, patients recovered much faster and return home and back to normal activity within much shorter time. This operation is preferred to the unassisted vaginal route in cases where there are pelvic adhesions, removal of ovaries is indicated, when the uterus is large, mobility poor or there is associated narrowing of the vaginal canal.

Advantages of laparoscopic hysterectomy

1. Small punctures instead of one long incision
2. Reduced post-operative pain
3. Shortened hospital stay (home in one to two days)
4. Shortened convalescence and faster return to work and normal activity
5. Reduced risk of adhesions
6. Reduced risk of infection

Alternative treatment

Alternative treatments depend on the indication for the surgery. Small and asymptomatic fibroids may be observed rather than removed. Abnormal uterine bleeding may be controlled by hormones - estrogen, progesterone, or a combination of the two. Other less radical method may be used for abnormal uterine bleeding like ablation or heating up of the endometrial lining.

To remove or not to remove the ovaries at hysterectomy

Although some surgeons routinely advise removal of the ovaries to prevent ovarian cancer in women older than 40, this is a controversial issue. On the one hand, ovarian cancer is associated with high motality due to late diagnosis. It has a cure rate of only 10 to 20 %. On the other hand, cancer of the ovaries is uncommon.
Many of the surgeon would preserve the ovaries if they are below 45 and remove the ovaries if they are over 48.

Complications

All types of hysterectomy, like all other surgery, carry risks of infection. Blood loss, anesthesia problems, and injury to the other organs such as the ureter, bladder and the intestines are remote possibilities.

Recovery

After the patients get home, the main instructions for recovery are rest and plenty of fluids. Pain medication may be needed. The patient should refrain from using tampons or douches and from having sexual intercourse. Activities should be increased gradually as tolerated. Most women are healthy and feel capable of returning to a normal routine in six weeks. It would be faster in patients undergo LAVH.