"Tell me about a Hysterectomy, Doctor"

If a doctor or health care professional recommends that a woman should have a hysterectomy and she elects to proceed, then there are certain decisions that need to made in planning the surgery. There are many reasons for deciding to have the uterus removed, and numerous articles and books have been written on this topic. There are equally many books and articles outlining alternatives for hysterectomy, and there certainly sources here on OBGYN.net as well as elsewhere on alternatives to hysterectomy. Always, if there is any doubt in the woman's mind, she should most certainly seek a second opinion. No woman should ever proceed with surgery if she is not fully comfortable with both her decision to have surgery as well as the doctor who will be performing it. The surgery should be discussed with her, and she should be actively involved in that decision-making process. The decision of whether to proceed with a hysterectomy and how to go about making that decision is beyond the intent and scope of this article (perhaps a later article?). This article is designed for the woman who understands the reason for the recommendation, has seriously considered the alternatives, and made the decision to proceed. Once she is comfortable with that decision, then she needs to have an understanding of the terminology as well as what is going to happen in the course of events.

Hysterectomy is defined as the surgical removal of the uterus. Once the decision has been made, then there are other factors that must be considered. Certainly the expediency with which the surgery should be performed should be understood. For instance, if a woman is having surgery for cancer, this is not a surgery that should be put off six months until it is more convenient for her work schedule. On the other hand, if it is for an improvement in her quality of life and not an emergency, then she may schedule it for her convenience. So understanding the reason for proceeding with surgery is important for scheduling as well as making the decision.

There are two basic decisions to be made regarding a hysterectomy. One is how much of the uterus (and tubes, or ovaries) to remove, and the other is the mode of removal. While the woman may hear numerous phrases and descriptions of the procedure that may be very confusing to her, basically they can all be covered in two categories.

How Much To Remove?

The first consideration is how much of the uterus is to be removed, and this is often a source of confusion for the woman. Many people think that "complete hysterectomy" refers to removal of the uterus and ovaries, but this is not the way the term is used in the medical language. If the ovaries and tubes are to be removed then it is called a hysterectomy and a bilateral salpingo-oophorectomy, whereas complete hysterectomy refers to removal of "all" of the uterus itself, or the uterus and cervix. This often causes confusion to the woman, and it should be clearly understood prior to proceeding with surgery.

The Fallopian tube lies adjacent to the ovary, is loosely adherent to it, and has a common blood supply. It is technically more difficult to remove a tube without removing the ovary (although it certainly can be done), and occasionally the removal of a tube may compromise the blood supply to that ovary. So the tubes are usually left inside with the ovaries if the ovaries are not removed. There are many pros and cons to removal of the ovaries, and this decision should also be discussed with one's doctor. This is an extremely important decision for a woman to make when a hysterectomy is going to be performed. But remember, a complete or total hysterectomy means only removal of the uterus and cervix; if the ovaries are to be removed, then this is called a salpingo-oophorectomy.

The second part of this decision as to what to remove is whether to remove the cervix. Earlier this century when hysterectomies were performed, only the main body of the uterus would be removed, and the cervix (or mouth of the uterus) would be left in place at the top of the vagina. However, cancer of the cervix was a leading cause of death in women at this time. As surgical techniques improved it became more common to remove the cervix with the uterus, thus eliminating the risk of cancer of the cervix. However, now there is a resurgence in the popularity of removal of the uterus without removing the cervix. With the predictive value of the PaP smear, advanced cancer of the cervix is not near as common as it once was. Some doctors feel that removal of the cervix compromises the support structures of the upper vagina, and as a result a woman may become more susceptible to such problems as urinary incontinence in the future. They also feel that removal of the cervix may compromise the sexual response and enjoyment for a woman, and many recommend it be left in place because of this possibility.

On the other hand, if the cervix is not removed, then the woman continues to have a risk of cancer of the cervix and needs to continue to have Pap smears on a regular basis. Certainly if there is a precancerous condition of the cervix it should be removed. Also, there is a chance that the cervix itself will bleed on a monthly basis, and some women want absolute reassurance that all bleeding will cease. The question of whether or not to remove the cervix at the time of hysterectomy is a hot debate at national meetings at the present time, with renowned doctors on either side of the argument. The confusing aspect is that there are studies to support both opinions and approaches. It is certainly something to discuss with the doctor - expressing one's feelings and concerns when discussing surgery is extremely important!

How to Remove the Uterus?

The next thing to decide upon is how the uterus is to be removed. There are basically two ways to perform a hysterectomy, either through the vagina or through an abdominal incision. Each way has certain benefits and shortcomings, and usually the woman's doctor will suggest the one that offers the most advantages to her. Sometimes the woman may not be a good candidate for one particular approach, and the doctor can explain why it may be more preferable to perform one type over another. Removal of the uterus through the vagina, or a vaginal hysterectomy, is often preferred because the woman usually recovers more quickly because there are no large abdominal incisions.

However, this approach depends upon both the doctor's ability to obtain access to the uterus through the vagina, as well as the size of the uterus. For instance, it is easier to operate on the uterus through the vagina when a woman has had children and vaginal deliveries. Also, the initial incisions are made into the top of the vagina by knowing the normal anatomy above and where important structures usually lie. So if the anatomy has been distorted, then there may be an increased risk of damaging a structure by approaching the surgery vaginally. In addition, if the uterus is enlarged significantly, then it may be too large to take out through the vagina. But, if the doctor can perform a vaginal hysterectomy and it is safe, this is usually the route he or she will recommend.

If the surgery cannot be performed vaginally, then there may be a need for an abdominal incision. In the past, this long incision in the lower abdomen required more time in the hospital and a longer recovery time. However, it does offer some other advantages. For instance, with an abdominal incision your doctor can see more of the upper abdomen and inspect it more thoroughly. Also, larger uteri can be removed, and more difficult hysterectomies can be performed through an abdominal incision. For instance, this is often the route that is recommended if there is advanced cancer so all the other abdominal structures can be seen and inspected.

In the last decade, another type of approach to a hysterectomy has been developed. This is called a laparoscopic assisted vaginal hysterectomy, or LAVH. Part of the surgery is performed through very small abdominal incisions, and once the upper part of the hysterectomy is completed, then the uterus can be removed vaginally. So, part of the surgery is performed through very small incisions, and the remainder through the vagina. The advantages here are that hysterectomies can be completed vaginally, thereby avoiding a large abdominal incision, and thus the recovery time is much shortened.

The last type of approach is a total laparoscopic approach in which all of the surgery is performed through small incisions. The uterus is then removed through these small incisions, but this requires special techniques or equipment. So, basically there are four types of approaches: vaginal, abdominal, laparoscopic, or a combination of laparoscopic and vaginal. Each approach has its own specific indications and contraindications, and each should be discussed with the doctor.

Thus, when the decision to have a hysterectomy is made, these are the two major considerations in planning the surgery. The doctor should explain why he or she may feel one type of hysterectomy over another is appropriate in this particular situation, and the woman should understand why one kind is recommended one over another. Often there may be reasons why only one kind of hysterectomy is safest, and a doctor may feel more comfortable with one type of approach. It is the woman's body, and it is important to understand the surgical process and the reasons why certain recommendations are made. Being knowledgeable and becoming involved in the decisions regarding a hysterectomy is important not only for being comfortable with the procedure but in hastening the recovery and getting on to a healthy and productive life after hysterectomy.

What is to be removed?

Complete or total hysterectomy - removal of the uterus and cervix

Supracervical or partial hysterectomy - removal of the uterus but not the cervix

Total (complete) hysterectomy and salpingo-oophorectomy - removal of the uterus, cervix, tubes and ovaries

Supracervical (partial) hysterectomy and salpingo-oophorectomy - removal of the uterus (but not the cervix), tubes and ovaries

How it is to be removed?

Vaginal hysterectomy - removal of the uterus through the vagina

Abdominal hysterectomy - removal of the uterus through an open abdominal incision

Laparoscopically assisted vaginal hysterectomy (LAVH) - Removal of the uterus through a combination both small abdominal incisions (laparoscope) and through the vagina

Laparoscopic hysterectomy - removal of all of the uterus through the laparoscope or very small abdominal incisions