Removal of the uterus

Contents

Your Hysterectomy Choices: Different Types and Methods of Uterus Removal

Hysterectomy type depends on which organs or structures, besides the uterus, are removed as well as how the surgery is performed.

Laparoscopic technique requires fewer incisions and less recovery compared with abdominal hysterectomy.

A hysterectomy is a surgical operation to remove the uterus, an organ located in the female pelvis.

Attached to the uterus on either side is a single fallopian tube and one ovary.

During pregnancy, a fertilized egg implants itself in the lining of the uterus where the developing fetus is nourished prior to birth.

The uterus is crucial for reproduction. After undergoing hysterectomy, a woman cannot become pregnant.

The Three Types of Hysterectomy

There are three types of hysterectomy, depending on which structures or organs are removed.

A Total Hysterectomy

A total hysterectomy is the removal of the entire uterus, including the cervix (the lower narrower portion of the uterus).

A Supracervical Hysterectomy

A supracervical hysterectomy is the removal of the upper part of the uterus. The cervix is left in place. This type of procedure may be done if you want to keep your cervix or if difficulties arise during surgery that make removal of the cervix complicated. On the other hand, if an unexpected cancer is detected during your operation, your surgeon may decide to remove the cervix.

There has been some controversy over whether it’s better to remove or keep the cervix in place during a hysterectomy. If you’ve had a history of abnormal pap smears, you may be at higher risk of developing cancer in the future, so you may decide that a total hysterectomy is the better personal choice. You should discuss these issues with your doctor well ahead of surgery.

A Radical Hysterectomy

A radical hysterectomy is a total hysterectomy that also involves removing tissues around the uterus called the parametrium. This procedure is usually reserved for cases where cancer is present. (1)

When Hysterectomy Includes Removal of More Than the Uterus

Sometimes a surgeon will perform additional surgeries at the time of hysterectomy.

One or both of the ovaries along with the fallopian tubes may be removed. This is called a salpingo-oophorectomy.

Oophorectomy is the surgical removal of just the ovaries.

A salpingectomy is the removal of the fallopian tubes. The ovaries or tubes may be removed for various reasons, for example when they are affected by endometriosis. (2)

Premenopausal Removal of Ovaries: Side Effects and Symptoms

If both ovaries are removed when a woman hasn’t already reached menopause, she will abruptly experience premature menopause along with menopausal symptoms such as hot flashes, vaginal dryness, and decreased sex drive.

Women who have not gone through menopause may opt to keep their ovaries so as to preserve their natural source of hormones including estrogen, progesterone, and testosterone.

The Role of the Ovaries in a Woman’s Health and Wellness

These hormones are important in reducing the risk of heart disease. In addition, these hormones help prevent loss of bone density (osteoporosis) and play a role in maintaining sexual interest.

Since there is evidence that ovarian cancer often originates in the fallopian tube, rather than the ovary, keeping the ovaries and removing the fallopian tubes may be a better option for some women who are at low risk for ovarian cancer.

Postmenopausal women (at higher risk of breast and ovarian cancer) are often advised to have their ovaries removed because of a small risk of developing ovarian cancer at some point. The benefits of removing or keeping ovaries is something you should discuss with your doctor.

How Is Hysterectomy Surgery Performed?

There are several approaches to hysterectomy or surgical removal of the uterus. The uterus can be removed through an open incision in the lower abdomen, through the vagina or with a laparoscopic technique in which the uterus is removed through a few small incisions made in the abdomen. Each option involves unique risks and benefits, and recovery time can vary depending on the method used. In some instances, a woman’s choice of procedure is limited — for example if she has a very large uterus, a vaginal or laparoscopic procedure may not be an option.

Abdominal Hysterectomy: Important Facts to Know

An abdominal hysterectomy offers the surgeon the most flexibility. It may be recommended over other types of hysterectomy if a woman has a large uterus, scar tissue from previous abdominal surgeries, is obese, or has cancer. In addition, it is the best option in cases of obstetric emergency such as postpartum hemorrhage. (3)

Abdominal hysterectomy is the most common method used in the United States.

The surgery takes approximately one to two hours. (1)

Risks and Complications Related to Abdominal Hysterectomy Surgery

Complications from this type of surgery are uncommon but include the following:

  • Excessive bleeding (hemorrhage)
  • Infection
  • Blood clots
  • Constipation
  • Urinary retention (the inability to pass urine)
  • Damage to adjacent organs including the bladder, ureters (the tubes that lead from the kidneys to the bladder) and the large and small intestines. These injuries are rare and can be surgically repaired.

Can Hysterectomy Trigger Early Menopause if Ovaries Are Not Removed?

If you’ve had a hysterectomy but have kept your ovaries it’s possible that you may go through menopause earlier than the average age, which is 51, perhaps due to an interruption in blood flow to the ovaries.

Some Less Invasive Hysterectomy Options Are Available

Both vaginal and laparoscopic procedures are considered minimally invasive because they involve smaller incisions. During a vaginal hysterectomy, the uterus is removed through the vagina. No abdominal incision is made. Vaginal hysterectomy generally causes fewer complications that either abdominal or laparoscopic surgery. Elderly and medically compromised patients can benefit from a vaginal approach because it eliminates the risks that can accompany an abdominal incision. Typically, recovery is easier with less invasive methods of hysterectomy compared with abdominal surgery.

Vaginal hysterectomy is also a good option for women who have a small uterus and have already given birth vaginally and have no history of prior pelvic inflammatory disease or prior pelvic surgeries.

Vaginal Hysterectomy: How Surgery Is Performed to Remove the Uterus

During the procedure the surgeon detaches the uterus from the ovaries, fallopian tubes, and upper vagina. The uterus is also separated from the connective tissue and blood vessels that support it. Unless uterine cancer is suspected, the surgeon may cut an enlarged uterus into smaller pieces and remove it in sections with a surgical instrument called a morcellator.

Recovery time after a vaginal hysterectomy is also shorter for the most part than it would be for an abdominal procedure. Whenever possible, it is the preferred method.

You can expect to be in the operating room for about one to two hours.

Laparoscopic Hysterectomy: How Surgery Is Performed to Remove the Uterus

With this type of surgery only a few small (approximately half-inch) incisions are made in your abdomen. Then a laparoscope, a fiberoptic instrument, is inserted in one of these openings. The laparoscope allows the surgeon to see the pelvic organs. The uterus can be removed in small pieces through the incisions, through a larger incision made in the abdomen or through the vagina (a procedure known as laparoscopic vaginal hysterectomy, or LAVH). This procedure results in less infection than the abdominal option. The procedure takes about two hours. (4)

Another option is a robot-assisted laparoscopic hysterectomy, in which the surgeon is aided by a robotic machine. There can be an increased risk of injury to the urinary tract or other organs with this method. (5)

LAVH or robotic hysterectomy are usually good options for women who have scar tissue (pelvic adhesions) from prior surgeries or from endometriosis. (4)

Types of Hysterectomy, Hysterectomy Surgical Procedures

Types of Hysterectomy

All hysterectomies include removal of the uterus, but the type of procedure used often depends on the condition being treated:

  • In partial or supracervical hysterectomy, the upper portion of the uterus is removed, leaving the cervix intact.
  • Complete or total hysterectomy involves the removal of both the uterus and the cervix. This is the most common type of hysterectomy performed.
  • Hysterectomy with bilateral salpingo-oophorectomy is the removal of the uterus, cervix, fallopian tubes, and ovaries.
  • Radical hysterectomy is an extensive surgical procedure in which the uterus, cervix, ovaries, fallopian tubes, upper vagina, some surrounding tissue, and lymph nodes are removed.

Hysterectomy Surgical Procedures

Traditionally, hysterectomies have been performed using a technique known as total abdominal hysterectomy (TAH). However, in recent years, two less-invasive procedures have been developed: vaginal hysterectomy and laparoscopic hysterectomy.

In a total abdominal hysterectomy (TAH), the surgeon makes an incision approximately five inches long in the abdominal wall, cutting though skin and connective tissue to reach the uterus. The cut can be either vertical3running from just below the navel to just above the pubic bone, or horizontal—running across the top of the public bone (known as a bikini-line incision).

One advantage of total abdominal hysterectomy is that the surgeon can get a complete, unobstructed look at the uterus and surrounding area. There is also more room in which to perform the procedure. This type of surgery is especially useful if there are large fibroids or if cancer is suspected. Disadvantages include more pain and a longer recovery time than other procedures, and a larger scar.

A vaginal hysterectomy is done through a small incision at the top of the vagina. Through the incision, the uterus (and cervix, if necessary) is separated from its connecting tissue and blood supply and removed through the vagina. If the cervix is not being removed, the incision is made around the cervix, which is then reattached when the surgery is finished.

This procedure is often used for conditions such as uterine prolapse. However, the surgeon has less room in which to operate and is not able to observe other organs in the pelvic region. Vaginal hysterectomy heals faster than abdominal hysterectomy, results in less pain, and generally does not cause external scarring.

In laparoscopic hysterectomy, special surgical tools are used to operate through small incisions in the abdomen and vagina. There are two types of laparoscopic hysterectomy: laparoscopically assisted vaginal hysterectomy (LAVH) and laparoscopic supracervical hysterectomy (LSH).

LAVH is similar to vaginal hysterectomy, and the uterus and cervix are removed through an incision at the top of the vagina; however, the surgeon also uses a laparoscope (miniature camera) inserted into the abdomen to see the uterus and surrounding organs. Other laparoscopic tools are inserted into abdominal incisions to detach the uterus before removing it.

LSH is performed entirely through small abdominal incisions, using laparoscopic tools to remove just the uterus. Since the cervix is not removed, the uterus is detached and removed in small pieces through the incisions. No incision is made at the top of the vagina.

Both types of laparoscopic hysterectomy cause less pain and have faster recovery times than TAH and produce minimal scarring.

Publication Review By: Stanley J. Swierzewski, III, M.D.

Published: 10 Jun 2001

Last Modified: 17 Sep 2015

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Types of Surgical Procedures Performed

Myomectomy:

Myomectomy is the surgical removal of uterine fibroids without the removal of the uterus. There are several techniques that may be used, and the choice of the technique depends on the location and size of the fibroids as well as the characteristics of the woman. It is sometimes impossible to remove all the fibroids, and new fibroids may grow after a myomectomy. Though myomectomy is the only accepted procedure for fibroids in a woman who wants to maintain fertility, a myomectomy may lead to scarring that can negatively affect future fertility. Following a myomectomy, cesarean delivery is frequently recommended to prevent the myomectomy scar from breaking open during labor. Types of myomectomies include:

  • Laparoscopic myomectomy (removal of uterine fibroids) **Also see our section below on Robotic Assisted Laparoscopic Removal of Fibroids
  • Abdominal myomectomy
  • Hysteroscopic myomectomy

Hysterectomy:

Hysterectomy is a surgery to remove the uterus. It prevents future pregnancy and eliminates fibroid-related bleeding and pressure symptoms.
There are two categories of hysterectomy:

  • Total hysterectomy is removal of the entire uterus, including the cervix (the lower part of the uterus)
    Vaginal hysterectomy
    Laparoscopic total hysterectomy (removal of uterus and cervix)
    Robot-assisted laparoscopic hysterectomy
    Abdominal hysterectomy
  • Supra-cervical hysterectomy is removal of the upper part of the uterus, but not the cervix. This type of surgery is not recommended for women with a history of an abnormal Pap smear or certain types of pelvic pain. Up to 5-10% of women may continue to have chronic cyclic bleeding after surgery, similar to a period. It was previously thought that a supra-cervical hysterectomy would preserve sexual function better than a total hysterectomy, but research does not support this theory. Benefits to supra-cervical hysterectomy include slightly faster surgery and shorter recovery time.
    Laparoscopic supracervical hysterectomy (removal of uterus, preservation of cervix)

Other Surgical Procedures:

  • Diagnostic laparoscopy
  • Microlaparoscopic pain mapping
  • Laparoscopic removal of endometriosis
  • Laparoscopic removal of ovarian cysts
  • Laparoscopic removal of adhesions (scar tissue)
  • Laparoscopic removal of a tube and ovary
  • Laparoscopic uterine suspension
  • Hysteroscopic surgery (removal of polyps or fibroids from the inside of the uterus)
  • Laparoscopic bladder support surgery
  • Endometrial ablation (for heavy periods)
  • Robotic Assisted Laparoscopic Removal of Fibroids

Diagnostic laparoscopy – What is laparoscopy?

In this surgical procedure, a person is in the operating room, under general anesthesia (totally asleep). Through a small (half inch or less) incision in the belly button, carbon dioxide gas is placed inside the belly to create a space through which the surgeon can see the organs inside. This is done by putting a small “telescope” (laparoscope) through this small incision and into the bubble of gas.

The surgeon can then look around inside and get a very good view of everything there, especially all the reproductive organs, especially the womb, ovaries, and tubes. With good technique, this surgery can be done safely in women who are significantly overweight or have had prior abdominal or gynecologic surgery.

When the diagnostic part is done, and something has been found that requires surgery, additional small instruments (a quarter of an inch in diameter) are then inserted through one or more small incisions at other locations in the belly wall between the belly button and the groin areas.

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Microlaparoscopic pain mapping

Finding the cause for pain in the pelvic area can sometimes be difficult. This is especially true because all the conditions that can cause pain in some women, do not cause pain in all women. This is true for endometriosis, pelvic scar tissue, fibroids, and other problems. When laparoscopy is done with the patient totally asleep, it can sometimes be difficult to be sure that the diseased tissue seen (such as endometriosis) is really causing the pain. In some situations, pain mapping can help.

In a pain mapping procedure, a woman is brought to the operating room and given some strong medication that puts her asleep, but wears off quickly when it is stopped. After injecting local anesthetic medicine in the navel, the surgeon can put a small bubble of gas inside the belly, and then insert a very small (less than 1/8 of an inch) diameter laparoscope inside to look around. Another small instrument can then be inserted lower down on the belly and used to touch organs inside after the sleep medication is allowed to wear off. During this touching of internal organs, the surgeon can ask if a person’s pain is reproduced when an organ is touched. In most cases, for example, if the endometriosis seen is causing pain, it is tender when touched by the instrument.

Another example is when a person feels pain on the right side, but it’s hard to tell if the ovary or the appendix is responsible for the pain. Pain mapping can help figure this out, and help the surgeon pick the right procedure.

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Laparoscopic removal of endometriosis

Our clinical experience tells us that better results are obtained when endometriosis is excised (cut out), rather than cauterized or lasered, whenever there is the slightest hint that the disease goes deeper than the most superficial layers of pelvic tissue. We have extensive experience with this technique, including in cases of very advanced (stage IV) disease. We perform about 200 surgeries per year on endometriosis.

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Laparoscopic removal of ovarian cysts

Ovarians cysts up to 10 cm (3.5 inches) in diameter are routinely removed laparoscopically in our division. In some cases in which careful preoperative testing has shown that the risk of a cancer is very low, even much larger cysts have been removed laparoscopically. Once separated from the healthy ovary tissue, the cyst is put in a plastic bag which is removed through a small incision at the navel.

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Laparoscopic removal of adhesions (scar tissue)

When careful evaluation has shown that adhesions may play a role in a person’s abdominal or pelvic pain, we sometimes recommend laparoscopic surgery to try to reduce the amount of adhesions present. This type of procedure is most often helpful when adhesions are mild or moderate in degree.

When adhesions are very severe, long term results are often disappointing. We do find that even if relief is incomplete or temporary, the benefits of the surgery provide an opportunity to more effectively address other parts of the pain problem such as muscle disorders, bowel function problems, deconditioning, excess weight, and depression.

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Laparoscopic removal of a tube and ovary

When an ovary is too involved with a disease process to salvage, it is almost always possible to remove it using laparoscopic techniques. In some cases, it is necessary to divide adhesions between the bowel and the ovary in order to remove the ovary.

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Laparoscopic myomectomy (removal of uterine fibroids)

Some fibroids can be removed laparoscopically. Laparoscopic surgical repair of incisions made in the uterus to remove the fibroids heal just as well as similar incisions performed through open laparotomy (large incision) surgery.

Laparoscopic myomectomy is a myomectomy performed with minimally-invasive techniques, using a narrow telescope-like instrument (laparoscope) to see inside the abdomen. The abdomen is first inflated with carbon dioxide gas to create space for operating. Four or five small (1/4 – 1/2 inch) incisions are made in the navel and lower abdomen to allow insertion of both the laparoscope and long, narrow instruments through tubes called “ports”. Using the laparoscope to see, the fibroid is shelled out of the uterus, and the uterine incision is repaired. Laparoscopic myomectomy usually requires one night of hospitalization. Recovery time is approximately 2-3 weeks.

Robot-assisted laparoscopic myomectomy is a type of laparoscopic myomectomy performed using robotic surgery techniques and the Da Vinci® Surgical System. As with traditional laparoscopic myomectomy, 4-5 small incisions are made and instruments are placed in the lower abdomen through “ports”. The robotic system translates the surgeon’s hand movements outside the woman’s body into precise surgical movements inside the abdomen. Some feel these instrument capabilities are advantageous for laparoscopic myomectomy and we do sometimes use robotics in this setting. It is important to note, however, that while there is a difference between laparoscopy and laparotomy in terms of patient outcomes, both traditional and robotic laparoscopy offer similar benefits. The experience and skill of the surgeon is much more important than whether the robot is employed as a tool.

As in any surgery, complications from myomectomy, such as bleeding, infection, or injury to nearby organs, may occur. There is a 1-8% chance of having to convert from a laparoscopic myomectomy to an abdominal myomectomy. During myomectomy, rarely (in less than 1%) an unplanned hysterectomy may be required, for instance, if the uterus bleeds excessively. Recurrent fibroids may follow up to one third of myomectomies. Pregnancy is not recommended during the first 3-6 months after surgery.

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Laparoscopic total hysterectomy (removal of uterus and cervix)

Laparoscopic hysterectomy involves removing the entire uterus with minimally-invasive techniques, using a narrow telescope-like instrument (laparoscope) to see the inside of the abdomen. Under complete general anesthesia, the abdomen is first inflated with carbon dioxide gas to create space for operating. Four or five incisions (1/4 to ½ inch each) are made in the navel and lower abdomen to allow insertion of both the laparoscope and long, narrow instruments through tubes called “ports.” (When using the robot, the incisions are higher up, at the level of the belly button and higher up towards the head.) A normal sized uterus, once it is detached from its supports, can be removed through the vagina. A large uterus can be reduced to smaller pieces using a laparoscopic morcellator. With our long experience and high volume, we are comfortable removing a uterus as large as a 30 week pregnancy.

Once the uterus is removed, the inside edges of the vagina are brought together using suture, which is readily done laparoscopically. We credit our extensive laparoscopic experience over the years for this achievement.

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Laparoscopic supracervical hysterectomy (removal of uterus, preservation of cervix)

In the last 10 years in the United States, more and more gynecologists have been offering their patients the option of leaving the cervix in place when performing a hysterectomy. The only medical reason for removing the cervix is to prevent cancer of the cervix. If a woman is at low risk for this problem, then the cervix may be left in place, as long as she agrees to continue having regular Pap smears performed.

Some physicians have suggested that leaving the cervix could help preserve sexual function or avoid problems with pelvic support (bladder dropping, bladder leakage). Several good studies, however, have demonstrated these hypotheses don’t seem to be the case. If there is not a good medical reason to remove the cervix, a woman certainly has the option of keep it if she wishes, but, without good evidence to suggest it makes a clinical difference, most women in our practice elect to have the cervix removed. If the cervix is not removed, there is a small chance (the published literature reports rates of 5-10%; our experience has been about 1%) of needing to remove the cervix because of persistent cyclic bleeding after supracervical hysterectomy. If a woman has a history of abnormal pap tests or endometriosis, it is generally not a good idea to leave the cervix.

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Laparoscopic uterine suspension

In about 15-20% of women, the top end of the uterus leans back toward the backbone, instead of leaning forward, toward the bladder. This is called a retroverted, or “tipped” uterus. In some women, this position of the uterus can be associated with pain, especially pain during sexual intercourse. A laparoscopic uterine suspension can fix this problem with a very high degree of success (over 90%).

Many years ago, this variation of normal anatomy was thought to produce infertility, and several different surgical procedures were developed to correct the problem. Unfortunately, all the techniques involved shortening ligaments that were known to be weak in the first place. As one might expect, the repair frequently failed after 1-2 years, and the uterus returned to the “tipped” position. As a result of these failures, the procedure fell out of favor.

A technique developed in 1998 has proven to be more effective and long lasting than those previously used. It involves placing a long suture through the entire length of the ligaments that hold the uterus up, and tightening the suture until the desired position of the uterus is produced. The repair depends on the strength of the suture, not the strength of the ligaments. The suture stays in place, and does not dissolve, but we use a type of suture (Gore-Tex®) that the body tolerates very well. This suspension procedure can be performed as outpatient surgery, with a few days to a week of recovery needed before returning to normal activities.

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Hysteroscopic surgery (removal of polyps or fibroids from the inside of the uterus)

When abnormalities such as polyps or small fibroids grow inside the uterus, irregular and heavy bleeding can result. In many cases, they can be removed by placing an instrument called a hysteroscope through the cervix to examine the inside of the uterus and then using various instruments to remove or vaporize the fibroid or polyp a little at a time. It takes between 30 and 90 minutes to accomplish, and usually the patient can go home the same day.

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Laparoscopic bladder support surgery

Many different surgeries have been developed to treat “stress incontinence,” or loss of urine during coughing, laughing, or any other physical activity. This problem most typically develops after childbearing, and is aggravated by age, smoking, obesity, and other factors. The surgeries are done to improve support for the bladder itself and for the valve mechanism at the bladder neck.

In some circumstances, it make sense to repair the bladder supports laparoscopically, usually when other surgical tasks need to be accomplished as well, such as removal of the uterus and/or ovaries. When bladder repair is all that is needed, then open surgical procedures that usually require a small incision, are almost the same in terms of the discomforts of post-operative recovery.

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Endometrial ablation (for heavy periods)

There are now about 8 different approved methods for applying some form of energy to the lining of the uterus (the endometrium) in order to reduce the amount of menstrual flow for a person who has regular, but quite heavy, periods. If irregular bleeding is the more troublesome part of the problem, then endometrial ablation techniques are less satisfactory. All of the techniques can be performed as outpatient surgery, and a few can be done in a clinic setting.

At UNC, we predominantly use the NovaSure® endometrial ablation system. In long-term follow-up studies, about 90% of women having this procedure are happy with the results after three years. However, in one study that randomly assigned women to endometrial ablation vs hysterectomy, those having hysterectomy were more satisfied when evaluated four years later. The reason is that a certain number of women having an ablation procedure will end up having further surgery for the bleeding problem. There are also some concerns that we may not be able to assess endometrial (uterus) cancer risk accurately in women who have had an ablation, and some women develop new pelvic pain as a result of this procedure, particularly when a tubal ligation has also been performed.

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Vaginal hysterectomy

When the cervix and the uterus are surgically removed by operating through the vagina, this is called a vaginal hysterectomy. This procedure has been a standard in gynecology for over 50 years. In the 1970’s it was commonly performed as a sterilization procedure, hence many gynecologists trained during that time gained a great deal of experience in performing the procedure. As the rate of hysterectomy has declined, and as other methods have been developed, more recently trained gynecologists have had less experience performing this procedure.

When it is surgically possible to perform vaginal hysterectomy, then the laparoscopic approach has few advantages when the surgeon is equally skilled at both. There are some situations which increase the risk of vaginal hysterectomy, however: multiple prior Cesarean sections, other major abdominal surgery, past pelvic infections, endometriosis, obesity, small pelvic bony canal, etc. Hospital stay is usually 1 night and recovery time is approximately 2-3 weeks.
In most circumstances, if a woman has not delivered a full-term baby vaginally, the hysterectomy is more easily accomplished by the laparoscopic route. There is now good evidence that less blood is lost in a laparoscopic hysterectomy than in a vaginal procedure.

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Robotic Assisted Laparoscopic Removal of Fibroids

As with traditional laparoscopic myomectomy, 4-5 small incisions are made and instruments are placed in the lower abdomen through “ports”. The robotic system translates the surgeon’s hand movements outside the woman’s body into precise surgical movements inside the abdomen. Some feel these instrument capabilities are advantageous for laparoscopic myomectomy and we do sometimes use robotics in this setting. It is important to note, however, that while there is a difference between laparoscopy and laparotomy in terms of patient outcomes, both traditional and robotic laparoscopy offer similar benefits. The experience and skill of the surgeon is much more important than whether the robot is employed as a tool.

We use both conventional and robotic assisted laparoscopic surgery in our practice. The choice to use the robotic assisted technology is based on the particular medical and surgical needs of individual patients.

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Abdominal myomectomy

Abdominal myomectomy is performed using a horizontal (“bikini”) or vertical incision in the abdominal wall. This type of operation is called a laparotomy and allows the surgeon to have direct access to the uterus. Traditional surgical instruments and techniques are used. Most patients have general anesthesia (go to sleep), and are usually hospitalized for two nights. Full recovery is expected by 4-6 weeks. Mini-laparotomy (an incision about 2 inches long) is sometimes possible in thin patients without significant scarring. Mini-laparotomy involves a smaller horizontal incision with advantages of less pain, a shorter hospital stay, and faster recovery.

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Hysteroscopic myomectomy

Hysteroscopic myomectomy is a different type of myomectomy which involves removing a submucosal fibroid from the inside wall of the uterus. To allow surgery inside the uterus, a narrow telescope-like instrument (hysteroscope) is passed through the cervix to visualize the uterine cavity. Hysteroscopic myomectomy is possible only for smaller fibroids (less than 5cm) and only if at least one half of the fibroid bulges into the uterine cavity. Often a laparoscopy is done during the hysteroscopy to make sure neither the fibroid nor the surgery extends through the uterine wall. This type of myomectomy is performed in the operating room under anesthesia and is usually an outpatient procedure. Most patients return to normal activities within 48 hours. Possible complications of hysteroscopy include: uterine perforation (puncture of the uterus), fluid overload (from absorption through the uterus), bleeding, and the formation of scarring inside the uterus. Attempts at pregnancy are best postponed for 60-90 days.

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Abdominal hysterectomy

Abdominal hysterectomy is the removal of the uterus performed through a horizontal (“bikini”) or vertical incision in the abdominal wall, using traditional instruments and surgical techniques. Most patients have general anesthesia (go to sleep) and are hospitalized for 1-2 nights. Full recovery generally takes 4-6 weeks during which time heavy lifting must be avoided. Driving should be avoided for 1-2 weeks, and sexual intercourse should be avoided for 6 weeks.

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Robot-assisted laparoscopic hysterectomy

Robot-assisted laparoscopic hysterectomy is the removal of the uterus using the Da Vinci® Surgical System (robot) to perform a laparoscopic hysterectomy. As with traditional laparoscopic hysterectomy, 4-5 small incisions are made and instruments are placed in the lower abdomen through “ports”. The robotic system translates the surgeon’s hand movements outside the woman’s body into surgical movements inside the abdomen. Hospital stay is usually overnight and recovery time is approximately 2-3 weeks.

We use both conventional and robotic assisted laparoscopic surgery in our practice. The choice to use the robotic assisted technology is based on the particular medical and surgical needs of individual patients.

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Keeping Your Ovaries if You Are Having a Hysterectomy

Leaving ovaries intact during hysterectomies for non-cancerous conditions may boost long-term survival rates for women under age 65, according to the results of a new study published in the August issue of Obstetrics and Gynecology.

More than 600,000 hysterectomies are performed yearly in the United States, and of those, about 90 percent are performed for benign conditions such as fibroids, heavy or irregular bleeding, endometriosis or abnormal pap smears. At least half of all women undergoing hysterectomy today are recommended to have their ovaries removed as a preventive measure against ovarian cancer, a practice known as “prophylactic oophorectomy”. The new study, by Dr. William Parker and colleagues, evaluated whether ovary removal was advantageous for women with no family history of ovarian cancer.

Their conclusion: women are better off in the long run if they keep their ovaries.

“For the last 40 years, the prevailing medical wisdom has been to remove the ovaries if women were 45 or older, in order to prevent ovarian cancer,” says Dr. Parker, Chair of Obstetrics and Gynecology at Saint John’s Health Center and clinical professor at the UCLA School of Medicine. “But our study suggests this practice may be doing more harm than good.”

Ovaries continue to make small amounts of estrogen for years after menopause, and they continue to make significant levels of two other hormones, testosterone and androstenedione, at least until age 80. Muscle and fat cells convert testosterone and androstenedione into more estrogen, which helps protect against heart disease and osteoporosis. The incidence of heart disease and osteoporosis has been shown to be lower in women who have intact ovaries than women who have had their ovaries removed. While 14,000 women die of ovarian cancer every year, heart disease kills 450,000 women a year, or 30 times more women.

Dr. Parker and his co-authors examined 20 years of published medical data to determine the risks for five conditions that have been linked to the presence or absence of ovaries: ovarian cancer, breast cancer, heart disease, hip fractures and stroke. The data was then entered into a sophisticated computer model to estimate age-specific risks of mortality.

To look at one analysis of the data in this study: if you took 20,000 women between ages 50 -54 who have a hysterectomy and compared 10,000 women who had their ovaries removed and 10,000 women who kept their ovaries, by the time the women reach 80 years old, 858 more women would have died from the group who had their ovaries removed.

While 47 (out of 10,000) fewer women would have died from ovarian cancer, 838 more women would have died from heart disease and 158 more women would have died from complications of hip fracture.

“Our findings indicate that women clearly benefit from keeping their ovaries when undergoing hysterectomies before age 65,” said Dr. Parker. “Moreover, ovary removal could not be shown to have a health benefit at any age.” And, although not included in this study, the affects of ovary removal on sexuality, mood and cognitive function have been studied elsewhere and also need to be considered.

“The takeaways from this study are readily apparent,” Dr. Parker said. “We need to train several generations of gynecologists to counsel women differently. The decision to remove ovaries in women who are not at high risk of ovarian cancer should be made with great caution.”

More about this study can be found at www.ovaryresearch.com

Considerations


Hysterectomy

Removal of the ovaries (salpingo-oophorectomy)

The National Institute for Health and Care Excellence (NICE) recommends that a woman’s ovaries should only be removed if there’s a significant risk of associated disease, such as ovarian cancer.

If you have a family history of ovarian or breast cancer, removing your ovaries may be recommended to prevent you getting cancer in the future.

Your surgeon can discuss the pros and cons of removing your ovaries with you. If your ovaries are removed, your fallopian tubes will also be removed.

If you have already gone through the menopause or you’re close to it, removing your ovaries may be recommended regardless of the reason for having a hysterectomy.

This is to protect against the possibility of ovarian cancer developing.

Some surgeons feel it’s best to leave healthy ovaries in place if the risk of ovarian cancer is small – for example, if there’s no family history of the condition.

This is because the ovaries produce several female hormones that can help protect against health problems such as weak bones (osteoporosis). They also play a part in feelings of sexual desire and pleasure.

If you’d prefer to keep your ovaries, make sure you have made this clear to your surgeon before your operation.

You may still be asked to give consent to treatment for having your ovaries removed if an abnormality is found during the operation.

Think carefully about this and discuss any fears or concerns you have with your surgeon.

When a woman needs to have a hysterectomy (have her uterus removed), doctors often will recommend removing the ovaries (oophorectomy) at the same time. This is especially true for older women. In the United States, almost half of women over 40 who have a hysterectomy have their ovaries removed.

Women who have the abnormal breast cancer genes BRCA1 and BRCA2 have a higher than average risk of both breast and ovarian cancer. For these women, having their ovaries removed is an option they can choose that can lower the risk of breast and ovarian cancer, whether or not they need a hysterectomy.

Premenopausal women diagnosed with breast cancer also may choose to have their ovaries removed as part of their overall treatment plan because oophorectomy reduces the risk of the breast cancer coming back or a new breast cancer developing. But for most women who have an average risk of ovarian and breast cancer, the overall health benefits of opting to remove the ovaries isn’t clear.

Two small research studies that followed the health of more than 360 women who had a hysterectomy. Some of the women had their ovaries removed at the same time and some didn’t. The researchers found that there was no difference in overall health after the surgery between the women who did have their ovaries removed at the time of hysterectomy and the women who didn’t.

In women with an average risk of ovarian and breast cancer, removing the ovaries at the same time as hysterectomy greatly reduces the risk of ovarian cancer and somewhat lowers future breast cancer risk. But removing the ovaries also has some negative health effects. If the ovaries are still producing normal amounts of estrogen at the time of surgery, removing them can cause troublesome menopausal symptoms such as hot flashes to develop abruptly. Removing the ovaries also can contribute to more serious health problems in the future, including a higher risk of osteoporosis or having a heart attack.

Most medical decisions require you and your doctor to consider the overall health benefits of each option, weighing the benefits against the risks. If your doctor recommends that you have a hysterectomy, you should talk about the benefits and risks of removing the ovaries at the same time. Ask your doctor for an assessment of your unique situation and your individual risk of both ovarian and breast cancer. If your risk of ovarian or breast cancer is higher than average, removing your ovaries during hysterectomy surgery may make sense for you. If your risk of ovarian and breast cancer are considered average, the study reviewed here suggests that there may be no overall health benefit to removing the ovaries during hysterectomy. Together, you and your doctor can evaluate your choices and make the decision that’s best for YOU based on your overall health profile.

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