Hysterectomy and Alternatives

What is a hysterectomy? A total hysterectomy involves removal of the entire uterus, including the cervix. A subtotal hysterectomy removes only the upper body of the uterus; this leaves the cervix in place still connected to the top of the vagina.

Laparoscopic hysterectomy allows the uterus to be disconnected from inside the body with the use of laparoscopic instruments. It was first performed in 1989, and has been performed more and more to reduce the risk of surgery. Typically 3-4 small incisions are made in the lower abdomen, each less than 1 cm through which the laparoscopic ports are inserted. It is through these ports that the instruments pass into the body for removal of the uterus. When total laparoscopic hysterectomy (TLH) is performed the uterus and cervix are removed through a small incision at the top of the vagina. Laparoscopic supracervical hysterectomy (LSH) is removal of the uterus while leaving the cervix intact; this method involves a slightly larger incision at one the port sites and demands the availability of a uterine morcellator to remove the uterus in piecemeal fashion through a port site after it is separated from its vascular supply. In either of these surgeries, the ovaries and/or fallopian tubes may or may not be removed. Laparoscopic assisted vaginal hysterectomy (LAVH) is a combined laparoscopic and vaginal hysterectomy approach where the uterus and cervix are detached from above with the use of the laparoscope and from below with the use of conventional vaginal surgery methods.

Who is a candidate for laparoscopic hysterectomy? Almost any patient needing a hysterectomy should be considered. Typically, patients present for hysterectomy due to abnormal or excessive menstrual bleeding, pelvic pain or pressure, and/or symptoms from fibroids. Hysterectomy is usually performed when less invasive methods of treatment fail or are not tolerable to the patient. TLH is an alternative to total abdominal hysterectomy and may be considered instead of vaginal hysterectomy. This procedure can often be performed for patients with a large fibroid uterus, patients with abnormal findings on endometrial biopsy (sampling of the uterine tissue) such as simple or atypical hyperplasia, patients with endometriosis or adenomyosis, patients with utero-vaginal prolapse (weakness in the muscles and ligaments that support the uterus in the pelvis causing the uterus to fall from its normal position in the pelvis, and slide into the vaginal canal), patients with adnexal masses and patients with cervical dysplasia (abnormal or precancerous cells of the cervix).

Who is not a candidate? Patients with endometrial cancer, invasive cervical cancer, and patients with medical conditions that disallow laparoscopy are not candidates for TLH. This procedure is contraindicated in patients with a mass, such as ovarian cyst, that is so large as to prevent safe entry and working room in the abdomen.

Why choose this route? Sometimes patients who have suspected endometriosis or who have a history of prior surgery, such as cesarean section, have dense scar tissue that cannot be seen using preoperative imaging. The laparoscopic approach gives the surgeon the ability to explore the abdomen and remove abnormal tissue during the course of the hysterectomy. This may prevent or minimize the risk of injury to other pelvic structures during surgery. Also, for patients who have fibroids that are large and might otherwise be difficult to remove by vaginal hysterectomy, laparoscopic hysterectomy allows the surgeon to detach the blood supply to the fibroids and uterus while viewing through the laparoscope. Then the fibroid uterus can be removed through the vagina more easily and with less blood loss.

How does it compare to vaginal hysterectomy? Vaginal hysterectomy, like laparoscopic hysterectomy, is considered minimally invasive surgery. It is best performed in patients who have some degree of utero-vaginal prolapse, which is often only present to a significant degree in patients who have experienced childbirth. In patients who have minimal or no prolapse, TLH or LAVH (laparoscopic assisted vaginal hysterectomy) may the safest and only options other than abdominal hysterectomy. Also, some women have a narrow or deep pelvis which can increase the risk of injury during a vaginal hysterectomy due to limitations in access to the vaginal fornices. The recovery time for a laparoscopic hysterectomy might be less than for a vaginal approach. It had been quoted at 1 to 2 weeks whereas for a vaginal hysterectomy, it is usually 4 to 6 weeks.