A hysterectomy(hystero = uterus or womb, ectomy = to remove) is performed for many reasons:
- To treat menstrual problems
- For chronic pelvic pain e.g. endometriosis and pelvic inflammatory disease (PID)
- For fibroids
- For prolapse (incontinence and prolapse, pelvic floor repair)
- For cancer
A total hysterectomy involves removal of the uterus and the cervix. The vagina is closed over at the top and remains the normal length. In some cases the ovaries are also removed at the time of the hysterectomy (bilateral salpingo-oophorectomy). This is sometimes carried out when there is cancer, sometimes after the menopause to reduce the risk of cancer, and sometimes when there is a lot of pain e.g. severe endometriosis.
The two procedures are carried out in one operation, which involves the removal of the uterus, fallopian tubes, cervix and ovaries. The vagina is closed over at the top and remains the normal length. A myomectomy is where the fibroids are taken away, but the uterus is left with the woman.
Total versus subtotal
A subtotal hysterectomy involves removal of the uterus only. The cervix is left intact and the vagina remains the normal length. This operation is performed only if a woman wishes to keep her cervix (neck of the womb) or there are technical difficulties with the operation. This operation was hardly ever used until recently, because of concerns over the possibility of developing cancer in the cervix later in life. With regular cervical smears the risks of developing cervical cancer is very low.
More recently concerns have been raised about damage to the pelvic floor if the cervix is taken, as the main ligaments that support the womb and the top of the vagina are attached to the cervix.
The other concern raised is the fact that after a total hysterectomy some women complain that their sex life is not the same.
In the past this would be as a result of taking the ovaries at the time of the hysterectomy (the ovaries produce the female hormones). A lack of hormones would cause a ‘surgical menopause’, which would cause a number of problems for the patient.
Nowadays women express concern that the internal sensation when having sex is not the same when the cervix is taken. As yet we do not have the evidence to say whether leaving or taking the cervix is a good idea, except where there is a good reason for a full hysterectomy (cancer, prolapse).
Vaginal versus abdominal hysterectomy
Traditionally the abdomen (tummy) is opened for a hysterectomy, except where there is prolapse, when the operation is performed via the vagina. The available evidence suggests that where possible, the vaginal route is much better for the patient, as there is less pain and immobility after surgery. This means the patient usually goes home earlier and gets back to a more normal ife much more quickly. Sometimes the vaginal hysterectomy requires keyhole surgery (laparoscopically assisted vaginal hysterctomy), especially if the ovaries are also to be removed. Where there are big fibroids, where there is spread of cancer, or where there is likely to be a lot of adhesions, the abdominal route is usually preferred.
The operation can be performed under general (asleep) or regional (awake) anaesthetic and takes about 1 hour. The abdomen (abdominal) or vagina (vaginal) is opened so that the ligaments and blood vessels attached to the uterus can be visualised. The bladder and bowel are then dissected free of the uterus. The vessels and ligaments are then placed in a clamp and the tissue cut. The ‘pedicle’ (the tissue contained within the clamp) is then sutured (stitched) to prevent bleeding. When all the tissue is clamped and sutured the uterus is removed and sent to the laboratory for microscopic investigation.
During the operation, a catheter will be passed into the bladder to drain off the urine (so the bladder doesn’t get in the way of the operation). A plastic tube may also be inserted into the wound to remove any slight bleeding. These tubes will be left in place for 24 – 48 hours.
Although there will be some discomfort following the surgery, this will be controlled with pain killers. The average length of stay in hospital is 3- 5 days and normal activities can be resumed within 6 – 8 weeks. There should be no problem with sexual intercourse following the operation.
As with all surgery, there are risks, and the benefits of having the operation must always be balanced against the potential harm from the operation. The vast majority of women who have surgery will have very few problems and the operation will result in a great improvement in the quality of the patient’s life. However there are potential complications that you should know about.
The common complications of a hysterectomy are infection (bladder infection, wound infection), bleeding (blood transfusion may be required), and bladder damage. If the bladder damage is repaired at the time of surgery, there should be no long term problems. Antibiotics are given at the time of the surgery to reduce the risk of infection. Anticoaguulants (thin the blood) are usually given to reduce the chance of a clot forming in the leg (we also use special stockings and get you mobilised out of bed early to reduce the risk).
Fortunately the number of serious complications associated with hysterectomy are uncommon, but can include life threatening haemorrhage, bowel damage and a clot on the lung. Where a patient has fasted (nothing to eat or drink for 6 – 8 hours before surgery), the risk of an accident with the anaesthetic are very low. The risk of dying as a result of having a hysterectomy is approximately 10,000:1.