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Hysterectomy

Hysterectomy is the surgical removal of the uterus, or womb.
Depending upon the type of procedure that is performed and the reason for the surgery, hysterectomy may also include removal of the adjacent Fallopian tubes and ovaries. Hysterectomy is the most common major surgical procedure (unrelated to pregnancy) performed on women in general. Because of the advancing development of less invasive treatment options, the incidence of hysterectomy has declined in recent years.

Hospital Stay: Hospital Stay: 3 days
Duration: Duration: 1-3 Hrs
Cost Estimate: Cost Estimate: 2805 USD - 3493 USD These are indicative prices in Indian Hospitals

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.

A hysterectomy is surgery to take out a woman’s uterus, the organ in a woman’s belly where a baby grows during pregnancy. After a hysterectomy, you will not be able to get pregnant. Other organs might also be removed if you have severe problems such as endometriosis or cancer. These organs include the cervix (the lower part of the uterus that opens into the vagina), the ovaries (glands on both sides of the uterus that release eggs for pregnancy), and the fallopian tubes (the passageway between the uterus and the ovaries).

Whether or not the ovaries are removed will depend on your age and risk for certain types of cancer. For example, removing the ovaries lowers the risk of ovarian cancer and some types of breast cancer. But if you have your ovaries removed before the age of menopause, you will go into early menopause, and you may be more likely to get heart disease or osteoporosis. Be sure to discuss with your doctor all the benefits and risks of removing your ovaries.

Most often, hysterectomy is done to treat problems with the uterus, such as pain and heavy bleeding caused by endometriosis or fibroid tumours. The surgery may also be needed if there is cancer in the uterus, cervix, or ovaries. Some women may have the surgery during childbirth to save their lives if there is heavy bleeding that cannot be stopped. Before you choose to have a hysterectomy, consider all of your treatment options. In many cases, this surgery is a last resort after trying other treatments for the problem.

There are many different ways to do hysterectomy surgery. The type of surgery you have depends on three main things: the reason for the surgery, the size of the uterus and its position in the belly, and your overall health. The most common types are:

  • 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

Feeling better after surgery takes time. Most women are in the hospital 1 or 2 days after the surgery. Some women stay in the hospital up to 4 days. When you get home, make sure you move around, but also be sure you don’t do too much. You can walk around the house and up and down stairs, but take it slow. During the first 2 weeks, it’s important to get plenty of rest. Even after you start to feel stronger, you should not lift heavy things (anything over 20 pounds). Also, you should not have sex until your doctor says it’s okay. It usually takes 4 to 8 weeks to get back to a normal routine.

You may want to have a say in this decision, or you may simply want to follow your doctor’s recommendation. Either way, this information will help you understand what your choices are so that you can talk to your doctor about them.

Your options

  • Have your uterus and your ovaries removed (hysterectomy with oophorectomy).
  • Have your uterus removed, but keep your ovaries (hysterectomy only).

Key points to remember

The main reason doctors recommend removing the ovaries during hysterectomy is to lower the risk of ovarian cancer. Studies show that if you are at high risk, surgery greatly lowers your risk. If you aren’t at high risk for cancer, having your ovaries removed isn’t recommended. It’s important to know your risk for cancer when deciding whether to have your ovaries removed during your hysterectomy. Your doctor will help you find out your risk by talking to you about your medical history and your family history. Removing the ovaries if you’re at risk is a different decision than if you’re not at risk. Removing the ovaries may increase your risk of heart disease and osteoporosis. If you have your ovaries removed before menopause, you will go into early menopause. You may get hot flashes and other symptoms.

Surgery to remove the ovaries is called oophorectomy. The ovaries are an important part of the female reproductive system. They store eggs and produce sex hormones, including oestrogen. Of women who have a hysterectomy, about half of them have their ovaries removed at the same time. The main reason doctors recommend removing the ovaries along with the uterus is to reduce the risk of ovarian cancer. Studies show that if you are at high risk, surgery greatly lowers your risk.

For women at average risk-this means no personal or family history of ovarian or breast cancer-there is no clear benefit to removing the ovaries at any age. Hysterectomy itself can reduce your risk of ovarian cancer. If you have severe premenstrual syndrome (PMS), removing the ovaries can stop hormone changes. This may help you feel better. If you are at high risk for breast or ovarian cancer, having your ovaries removed can greatly lower your risk. Women at high risk for these cancers include those who:

  • Have a BRCA gene change (BRCA stands for BReast CAncer).
  • Have a family history of ovarian cancer before age 50.

If you don’t know if you are at high risk for breast or ovarian cancer, talk to your doctor. If your doctor thinks you could be at risk, you may want to think about gene testing.

When your ovaries are removed, you lose the oestrogen that they produce. Without oestrogen, you will go into early menopause. This can cause hot flashes and other symptoms. Having your ovaries removed before age 65 may increase your chance of getting:

  • Osteoporosis, which can lead to broken bones and hip fractures.
  • Heart disease.

Women who choose to have their ovaries removed can take oestrogen therapy. This treatment doesn’t prevent heart disease, but it helps to lower your risk of osteoporosis. If you already have bone loss, other medicines can help protect your bones.

Your doctor may recommend having your ovaries removed when you have a hysterectomy if:

  • You have a BRCA gene change.
  • You have a strong family history of early ovarian cancer. You have a higher risk of ovarian cancer if a close family member, especially your mother or sister, has had breast cancer.
  • You have a type of breast cancer that oestrogen causes to grow.
  • You have severe premenstrual syndrome that could be helped by having your ovaries removed.
  • You have had pelvic pain that involved your ovaries.

Before a hysterectomy, you may have:

  • A physical exam, during which your doctor will ask you questions about your medical history.
  • A pelvic examination.
  • Blood tests.
  • An electrocardiogram (ECG or EKG), which measures the electrical signals that control the rhythm of your heartbeat, if you are over the age of 40 or have diabetes or high blood pressure.
  • A meeting with the doctor who will do the hysterectomy. During this meeting, the doctor will explain how the surgery will be done, where the surgical incisions will be made, and the risks and expected outcomes of the surgery. You will probably receive written instructions about how to prepare for surgery at this time.

Your doctor may order additional tests based on your physical exam and medical history. These tests may include:

  • A pregnancy test if you have not reached menopause.
  • Urine tests, such as urinalysis, to check for any signs of urinary tract infection.
  • A chest X-ray, for a general evaluation before using general anaesthesia.
  • Blood typing, in case you should need a blood transfusion (which is rare).
  • Blood clotting studies, if you tend to have excessive bleeding or a history of deep vein thrombosis.

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.

  • Pelvic weakness: After a hysterectomy, some women develop other physical problems that are related to weakness of the pelvic muscles and ligaments that support the vagina, bladder, and rectum. Kegel exercises may help strengthen the pelvic muscles and ligaments. But some women need other treatments, including additional surgery.
  • Vaginal dryness from low oestrogen levels may develop if your ovaries were removed (oophorectomy). This can also develop gradually after a hysterectomy. If sexual intercourse is painful because of vaginal dryness use a vaginal lubricant or a polyunsaturated vegetable oil that does not contain preservatives. If you are using condoms, use a water-based lubricant, rather than an oil-based lubricant. Oil can weaken the condom so that it breaks. Avoid petroleum jelly (for example, Vaseline) as a lubricant, because it increases the risk of vaginal irritation and infection. Use a low-dose vaginal oestrogen cream, ring, or tablet, which will reverse vaginal dryness and irritation by affecting only the vaginal area. If you are having other menopausal symptoms, talk to your doctor about systemic oestrogen therapy (ET) and other treatment options.

It is normal to have various concerns when faced with the possibility of having a hysterectomy. A woman’s emotions are often based on her beliefs about the importance of her uterus, her fears about her health or personal relationships after a hysterectomy, and concerns about her enjoyment of sexual activities after surgery. If you are considering a hysterectomy, talk with your doctor about your specific fears and anxieties concerning the surgery.

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