Treatments

The following are several possible causes or reasons for hysterectomy:

• Fibroid tumours: Non-malignant tumours may grow and become large, causing pressure on other organs and possibly heavy bleeding or pelvic pain.
• Endometriosis: Endometrial cells sometimes grow outside of the uterus, attach themselves to other organs in the pelvic cavity, and bleed each month in accordance with an ovarian cycle. This can result in chronic pelvic pain, pain during sex, and prolonged or heavy bleeding.
• Endometrial hyperplasia: A cause of abnormal bleeding, this over-thickening of the uterine lining is often due to the presence of continuous estrogen without progesterone. This is common during perimenopause when hormone levels are changing.
• Cancer: Approximately 10 percent of hysterectomies are performed to treat cancer-cervical, ovarian, or endometrial.
• Blockage of the bladder or intestines: A hysterectomy may be performed if there is a blockage of the bladder or intestines by the uterus or a growth.
• Uterine prolapse: Hysterectomy may also be performed when uterine prolapse (the uterus drops down into the vagina) occurs
• Chronic pelvic conditions:  Some chronic pelvic conditions such as pelvic pain or pelvic inflammatory disease, that do not respond to other treatment, may be treated with hysterectomy

Types of Hysterectomy

The types of hysterectomy include:

• Total hysterectomy:  Includes the removal of the entire uterus, including the fundus (the part of the uterus above the openings of the fallopian tubes) and the cervix, but not the tubes or ovaries. This is the most common type of hysterectomy.
• Hysterectomy with salpingo-oophorectomy: Includes the removal of one or both ovaries, and the fallopian tubes, along with the uterus.
• Radical hysterectomy: Includes the removal of the uterus, cervix, the top portion of the vagina, most of the tissue that surrounds the cervix in the pelvic cavity, and may include the removal of the pelvic lymph nodes. This is done in some cases of cancer.
• Supracervical hysterectomy (partial or subtotal hysterectomy): Removal of the body of the uterus while leaving the cervix intact

Surgical Techniques for Hysterectomy

A number of different procedures for hysterectomy are used. Some require standard surgical incisions while others are performed primarily via laparoscopy with small abdominal incisions for instruments.

• Total abdominal hysterectomy (TAH) is the removal of the uterus and cervix through an abdominal incision that is 6-8 inches in length.
• Supracervical or subtotal hysterectomy is removal of the uterus while sparing the cervix (the opening of the uterus into the vaginal or birth canal). This can be done laparoscopically or via standard surgical incisions.
• Radical hysterectomy is used in the treatment of cancer and includes removal of some surrounding tissues. This is performed via an abdominal incision, or can be done with laparoscopic or robot-assisted laparoscopy techniques.
• Vaginal hysterectomy is removal of the uterus and the cervix through the vagina. This procedure involves an incision in the upper vagina.
• Laparoscopic hysterectomy (LH) involves removal of the uterus by laparoscopic (minimally invasive) techniques. This procedure requires several tiny incisions below the area of the navel for insertion of the viewing laparoscope and the surgical instruments. In order for the surgeon to observe the inside of the body clearly, the peritoneal cavity is inflated with a gas (usually carbon dioxide). The uterus is then either extracted vaginally or through the small abdominal incisions by division into smaller pieces.
• Laparoscopy-assisted vaginal hysterectomy (LAVH) is vaginal hysterectomy with the assistance of laparoscopic techniques as described above.
• Oophorectomy is the surgical removal of the ovary(s); salpingo-oophorectomy is the removal of the ovary(s) and the Fallopian tube(s). These procedures may be performed at the same time as hysterectomy in some cases.

The type of hysterectomy performed and the technique used to perform the procedure will be determined by the treating physician, based upon the patient’s particular situation.

For women who have not yet reached menopause, having a hysterectomy means that menstruation will no longer occur, nor will pregnancy be possible.

Before the Surgery

• The doctor will explain the procedure to the patient/family and offer the opportunity to ask any questions about the procedure.
• The patient will be asked to sign a consent form that gives permission to do the surgery. The patient/family must read the form carefully and ask questions if something is not clear.
• In addition to a complete medical history, the doctor may perform a complete physical examination to ensure that the patient is in good health before undergoing the procedure. The patient may undergo blood tests or other diagnostic tests.
• The patient will be asked to fast for eight hours before the procedure, generally after midnight.
• In case of suspected pregnancy or confirmed pregnancy, a hysterectomy will not be performed.
• The patient / attendant should notify the doctor if she is sensitive to or allergic to any medications, iodine, latex, tape, or anaesthetic agents (local and general).
• The patient / attendant should notify the doctor of all medications (prescription and over-the-counter) and any herbal supplements that she may be taking.
• The doctor should be notified if the patient has a history of bleeding disorders or if she is taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary to stop these medications prior to the procedure.
• The patient will be given instructions on how to cleanse the bowels before the operation.
• The patient should avoid using a douche and tampons on the day of the procedure.
• All jewellery should be removed before the surgery
• The patient should change into hospital gown.  Any excessive hair at the surgical site will be clipped off or shaved.
• The patient will be sedated before being taken to the operating room and will be asleep for the procedure.
• An antibiotic may be given the day before the procedure.
• The patient should arrange for someone to help for a week or two after her discharge from the hospital.
• Based on the patient’s medical condition, the doctor may request other specific preparation.

During the Surgery

• An intravenous (IV) line will be started in the arm or hand of the patient.
• The patient will be positioned on the operating table, lying on her back. For a vaginal procedure, the patient’s legs will be placed in stirrups.
• The anaesthesiologist will continuously monitor heart rate, blood pressure, breathing, and blood oxygen level during the procedure.
• A catheter (thin, narrow tube) will be inserted into the bladder to drain urine.
• The skin over the surgical site will be cleansed with an antiseptic solution.
  • Total Abdominal Hysterectomy: The incision will be made vertically from the navel to the pubic bone or horizontally across the lower abdomen. The surgeon will discuss which incision is preferable in the particular situation prior to the procedure.
  • After the incision has been made through the layers of skin, muscle, and other tissue, the doctor will inspect the organs and other structures in the abdomen and pelvis.
  • The tissues connecting the uterus to blood vessels and other structures in the pelvis will be carefully cut away.
  • The uterus will be removed, along with any other structures such as the ovaries, fallopian tubes, and cervix, as required in each specific case.
  • The incision will be closed with surgical stitches or staples.
  • Vaginal Hysterectomy: The lower abdomen and perineum will be cleansed with an antiseptic solution. The rectum may be packed with an antiseptic-soaked sponge.
  • A speculum will be inserted into the vagina to spread the walls of the vagina apart to expose the cervix.
  • An incision will be made inside the vagina, near the cervix.
  • The tissues connecting the uterus to blood vessels and other structures in the pelvis will be carefully cut away.
  • The uterus will be removed through the vagina. If required, excess vaginal tissue and/or other tissue or structures may be removed.
  • The opening into the peritoneal cavity created by the removal of the uterus will be closed with stitches.
  • Laparoscopic Hysterectomy / Laparoscopic Assisted Vaginal Hysterectomy: The skin over the surgical site will be cleansed with an antiseptic solution.
  • A small incision will be made in the abdomen near the navel. Carbon dioxide gas will be introduced into the abdomen to inflate the abdominal cavity so that the uterus and surrounding organs can be more easily visualized. Depending on the type of laparoscope used, additional incisions may be made in the abdomen to accommodate other surgical instruments.
  • The operating table will be tilted so that the patient’s head is lower than the feet. This helps to move the other abdominal organs and structures out of the surgical field and make room for the laparoscopic surgical instruments.
  • The laparoscope will be inserted through the incision and the abdominal cavity will be examined. The tissues surrounding the uterus will be removed.
  • Once it is detached from the surrounding tissues, the uterus will be removed through the vagina or through the laparoscope. Other organs or structures, such as the ovaries and/or fallopian tubes, may be removed, depending on the particular situation.
  • When the procedure is completed, the laparoscope will be removed.
• The uterus and any other organs or tissues removed will be sent to the lab for examination.
• Any skin incision(s) will be closed with stitches or surgical staples.
• A sterile bandage or dressing or adhesive strips will be applied to skin incisions. A sanitary pad will be applied to the perineal area to absorb any drainage from the vagina.

After the Surgery

After the surgery, the patient will be taken to the recovery room for observation. The recovery process will vary depending on the type of procedure performed and the type of anaesthesia that is given. Once the patient’s blood pressure, pulse, and breathing are stable and the patient is alert, she will be taken to the hospital room.

Abdominal cramping may occur after the surgery. The patient may receive pain medication as needed, either by a nurse or by self-administration through a device connected to the intravenous line.

If the performed procedure was an abdominal hysterectomy, the patient may have a thin, plastic tube inserted through the nose into the stomach to remove air that is swallowed. The tube will be removed when the bowels resume normal function. The patient will not be able to eat or drink until the tube is removed.

The patient may have small to moderate amounts of vaginal drainage for several days. The nurse will check the sanitary pads periodically to monitor the amount of drainage.

Depending on the patient’s situation, liquids may be given to drink a few hours after surgery. The patient’s diet may be gradually advanced to more solid foods as tolerated.

The patient should perform coughing and deep breathing exercises as instructed by the nurse.

Women are encouraged to get up and walk within a day of the operation (within hours after a laparoscopic procedure) to reduce the possibility of developing blood clots in the legs and to speed healing overall. Pain medications are given to control pain at the incision sites. Some women experience nausea after the procedure, particularly after a general anaesthesia. Full recovery from a total abdominal hysterectomy can take 4 to 6 weeks. Recovery times are shorter for a vaginal or laparoscopic hysterectomy. Sexual intercourse can resume 4 to 6 weeks after the procedure.

Rehabilitation

Once at home, it will be important to keep the surgical area clean and dry. The doctor will give specific bathing instructions. If stitches or surgical staples are used, they will be removed during a follow-up visit, if they were not removed prior to discharge from the hospital. If adhesive strips are used, they should be kept dry and generally will fall off within a few days.

The incision and the abdominal muscles may ache, especially after long periods of standing. If a laparoscope was used, the patient may experience shoulder pain from the carbon dioxide in the abdomen. Pain relievers can be taken for soreness as recommended by the doctor. Aspirin or certain other pain medications may increase the chance of bleeding. Hence only recommended medications should be taken.

Walking and limited movement are generally encouraged, but strenuous activity should be avoided. The doctor will give instructions about when the patient can return to work and resume normal activities. It is important to avoid becoming constipated by including fiber and plenty of liquids in the diet. A mild laxative is usually recommended. If a laparoscopic procedure was performed, carbonated beverages should be avoided for one to two days after the procedure. This will help minimize the discomfort associated with the carbon dioxide gas. In addition, drinking carbonated beverages may cause nausea.

The patient should not use a douche, tampons, engage in sexual intercourse, or return to work until the doctor advises so.

The patient should look out for the following symptoms and if found, should notify the doctor immediately:

• Fever and/or chill
• Redness, swelling, or bleeding or other drainage from the incision site(s)
• Increased pain around the incision site(s)
• Abdominal pain, cramping, or swelling
• Increased vaginal bleeding or other drainage
• Leg pain

Following a hysterectomy, the doctor may give some additional or alternate instructions that may vary from patient to patient.

Risks / Complications

As with any surgical procedure, complications can occur. Some complications may include, but are not limited to, the following:

• Haemorrhage
• Injury to the ureters (tubes that carry urine from the kidneys to the bladder) and urinary bladder
• Infection
• Injury to the bowel or other intestinal organs
• Difficulty with urination or urinary incontinence

Women who have not reached menopause prior to a hysterectomy may experience menopausal symptoms such as hot flashes, mood swings, and vaginal dryness after the procedure if the ovaries are removed. Women will no longer have menstrual periods after a hysterectomy.  Mood swings, depression, and feelings of loss of sexual identity may occur after hysterectomy. There may be other risks depending on the patient’s specific medical conditions.

Outlook

Hysterectomy is a common and generally very safe procedure. Most women recover fully with no complications. It is a very effective treatment for fibroid tumours, adenomyosis, and abnormal vaginal bleeding when less aggressive treatment options have not been successful. The outlook for hysterectomy when used as part of treatment for cervical or uterine cancer depends upon the exact type and stage (extent of spread) of cancer and varies according to the individual case.