Hysterectomy
Hysterectomy is the surgical removal of the uterus without removing the ovaries. It is the ultimate solution for persistent and heavy uterine bleeding, symptomatic fibroids, adenomyosis, and endometriosis and is performed after conservative pharmacological (medical) and minimally invasive procedures are exhausted or contraindicated. It is also recommended to remove the uterus during certain surgical procedures for pelvic organ prolapse such as laparoscopic sacrocolpocervicopexy and colpectomy/colpocliesis.
The surgical approach to remove the uterus with or without the cervix mainly depends on the size of the uterus, patient’s history of previous abdominal surgeries, history of abnormal pap tests, indications for the procedure, as well as the surgeon’s level of skill and comfort. Abdominal Hysterectomy (TAH) and Vaginal Hysterectomy (TVH) are the standard of care. The definitive minimally-invasive solution is provided by out-patient Laparoscopic Hysterectomy or Robotic Hysterectomy. Most of our cases here at AMIGS are performed laparoscopically, even when the uterus is very large or there is a large amount of scar tissue/adhesions. The advantages of a laparoscopic procedure are many and are discussed below. Removing the ovaries is a separate procedure from a hysterectomy and is called bilateral salpingo-oophrectomy (BSO). The decision to keep or remove the ovaries should be discussed at the time of the preoperative visit.
Total Abdominal Hysterectomy (TAH)
Total Abdominal Hysterectomy (TAH) is the traditional way to remove the uterus and is still the most common surgical approach despite the increasing availability over the last 15 years of the minimally invasive laparoscopic approach which, without a doubt, should be the most preferred approach. The cervix can be spared or taken depending on what is decided between the patient and surgeon.
An abdominal hysterectomy requires general anesthesia and a long abdominal incision measuring several inches. If the cervix is also removed, a vaginal incision is required. This long abdominal incision increases post-operative pain and healing time, and it takes longer to return to a full spectrum of normal activities. It also creates a more prominent scar with higher risk of infection and herniation. In order to achieve proper exposure (the surgeon can see the area he/she is working on), retractors and bowel packing are usually used. This may in turn lead to increased post-operative pain, as well as slow down the return of normal bowel function. Vaginal retractors are not needed in these cases. Postoperative recovery necessitates a two to four night hospital stay and about six week recuperation at home.
Total Vaginal Hysterectomy (TVH)
Total Vaginal Hysterectomy (TVH) requires only a vaginal incision to remove the uterus and can be done either under general anesthesia or regional anesthesia (spinal or epidural). Thus it can be performed in patients who cannot undergo general anesthesia for medical reasons. In addition, there are obvious benefits of not having a large abdominal incision. However, since the surgeon is working in a small space, vision is limited in this surgical approach and much of the surgery is done by blindly feeling where to place the instruments to detach the uterus from its ligaments and blood supply. It is more difficult to remove the ovaries in this approach vs. the abdominal and laparoscopic approaches. In addition, vaginal retractors are used throughout the case which can increase post-operative pain. Pain and recovery are improved as compared to abdominal hysterectomy (TAH). The patient usually stays one to two nights in the hospital and recovery is about four weeks at home.
Laparoscopic hysterectomies may be subdivided into the following categories:
- Laparoscopically Assisted Vaginal Hysterectomy (LAVH)
- Total Laparoscopic Hysterectomy (TLH)
- Laparoscopic Supracervical Hysterectomy (LSH)
- Robotically Assisted Laparoscopic Hysterectomy (RALH)
Laparoscopically Assisted Vaginal Hysterectomy (LAVH)
Laparoscopically Assisted Vaginal Hysterectomy (LAVH) requires general anesthesia and vaginal and laparoscopic incisions to remove the uterus and cervix. The laparoscopic incisions are small. The largest is about 12mm (1/4 inch) in the belly button (umbilicus). There are usually 2-3 additional 6mm incisions in the abdominal cavity. Vaginal retractors are used for the vaginal portion of the case and the uterus is removed through the vagina before it is sutured closed. Hospital stay and post-operative recovery are similar to vaginal hysterectomy (TVH).
Total Laparoscopic Hysterectomy (TLH)
Total Laparoscopic Hysterectomy (TLH) requires general anesthesia and vaginal and laparoscopic incisions to remove the uterus and cervix. The important difference is that in TLH vaginal retractors are not needed since the vagina is closed by suturing from inside the pelvic cavity under direct vision of the laparoscope (camera). This procedure is technically more difficult than TAH, TVH, LAVH, and LSH since it requires the surgeon to be trained in advanced laparoscopy. Special energy sources are used to seal and divide the blood vessels and to detach the uterus from its attachments. If the uterus in small, it is removed through the vagina. If the uterus is large, a special device called a morcellator is used to cut the uterus into small strips so it can be removed through the 12mm laparoscopic port/incision site. Usually, TLH is an outpatient surgery and patients usually go home six to eight hours after surgery. Post-operative recovery is normally two-three weeks and patients can usually resume intercourse after six weeks.
The benefits of laparoscopic surgery are many. To name a few, patients usually go home the same day, the recovery time is faster and less painful, and the cosmetic outcome is better. At AMIGS, we are trained in advanced laparoscopy and perform the overwhelming majority of our cases laparoscopically, even in patients that have a very large uterus or have had multiple abdominal surgeries in the past. We feel that the minimally invasive laparoscopic approach to removing the uterus is the best approach for the patient.
Laparoscopic Supracervical Hysterectomy (LSH)
Laparoscopic Supracervical Hysterectomy (LSH) requires general anesthesia and only laparoscopic incisions to remove the uterus. The cervix is spared thus there is no vaginal incision needed. LSH procedure is essentially sutureless and bloodless since special energy sources are used to seal and divide the blood vessels and to detach the uterus from the cervix and the ovaries. The uterus is removed using a morcellator through the belly button (umbilical) port/incision site. Having performed over 1500 Laparoscopic Supracervical Hysterectomy (LSH) procedures, Dr. Mordel notes that LSH avoids unpleasant scars and shortening the vagina, eliminates the need for retractors and bowel packing, and significantly reduces hospital stays, postoperative pain and recovery time. Laparoscopic Supracervical Hysterectomy (LSH) generates less pain than any other hysterectomy. It is usually an outpatient procedure and patients usually go home six to eight hours after surgery and return to normal activities in about two weeks. Preservation of the cervix maintains the integrity of the vagina so it does not become shortened. It also saves some of the blood supply and nerve network and therefore may preserve pelvic floor function, including sexual response. However this is not proven in the literature. After having a procedure where the cervix is spared, a patient will need to have routine Pap Tests per ACOG guidelines since the risk of cervical cancer still exists. Also we like to make patients aware that there is a very small possibility that occasional light vaginal spotting from the cervix can occur.
Robotically Assisted Laparoscopic Hysterectomy (RALH)
Robotically Assisted Laparoscopic Hysterectomy requires general anesthesia and laparoscopic incisions to remove the uterus. If the cervix is also removed, then a vaginal incision is required. This is called a Robotically Assisted Total Laparoscopic Hysterectomy (RATLH). If the cervix is removed, the procedure is called a Robotically Assisted Laparoscopic Supacervical Hysterectomy (RALSH). This approach is very similar to the TLH and LSH, but it usually requires more and slightly larger laparoscopic incisions than traditional laparoscopy. The post-operative recovery is essentially the same as with the traditional laparoscopic approach. The da Vinci Surgical System provides patients with new, minimally invasive surgical procedures that offer significant advantages over traditional "open" surgeries and advanced laparoscopic surgeries. It improves the surgeon’s ergonomics, allows for three dimensional (3D) visualization of the surgical field, and gives the surgeon superior control over the camera and instruments by mimicking his/her natural hand, wrist, and finger movements. Robotically-assisted and advanced laparoscopic minimally invasive procedures can benefit patients with less pain, discomfort, blood loss and a quicker return to normal activities.
For additional information about any of these procedures or to schedule an appointment, please call our office at (404) 355-4885.