Total abdominal hysterectomy

This is the most common type of hysterectomy. During a total abdominal hysterectomy, the doctor removes the uterus, including the cervix. The scar may be horizontal or vertical, depending on the reason the procedure is performed, and the size of the area being treated. Cancer of the ovary(s) and uterus, endometriosis, and large uterine fibroids are treated with total abdominal hysterectomy. Total abdominal hysterectomy may also be done in some unusual cases of very severe pelvic pain, after a very thorough evaluation to identify the cause of the pain, and only after several attempts at non-surgical treatments. Clearly a woman cannot bear children herself after this procedure, so it is not performed on women of childbearing age unless there is a serious condition, such as cancer. Total abdominal hysterectomy allows the whole abdomen and pelvis to be examined, which is an advantage in women with cancer or investigating growths of unclear cause.

Vaginal hysterectomy
During this procedure, the uterus is removed through the vagina. A vaginal hysterectomy is appropriate only for conditions such as uterine prolapse, endometrial hyperplasia, or cervical dysplasia. These are conditions in which the uterus is not too large, and in which the whole abdomen does not require examination using a more extensive surgical procedure. The woman will need to have her legs raised up in a stirrup device throughout the procedure. Women who have not had children may not have a large enough vaginal canal for this type of procedure. If a woman has too large a uterus, cannot have her legs raised in the stirrup device for prolonged periods, or has other reasons why the whole upper abdomen must be further examined, the doctor will usually recommend an abdominal hysterectomy (see above). In general, laparoscopic vaginal hysterectomy is more expensive and has higher complication rates than abdominal hysterectomy.

Hysterectomy Related Diseases & Conditions

Medical tests and procedures are used to diagnose and treat a wide variety of conditions. Our doctors have compiled a list of ailments related to the topic of Hysterectomy that may be used to diagnose or monitor the status of the diseases and conditions listed below. Endometriosis Endometriosis is the growth of cells similar to those that form the inside of the uterus, but in a location outside of the... Ovarian Cancer There are many types of ovarian cancer, epithelial carcinoma is the most common. Women with a family history of ovarian cancer Uterine Cancer Though uterine cancer's cause is unknown, there are many factors that will put a woman at risk, including: over age 50 Uterine Fibroids (Benign Tumors of the Uterus) Uterine fibroids are benign tumors that originate in the uterus and are usually round or semi-round in shape. The most common... Vaginal Bleeding Normal vaginal bleeding (menorrhea) occurs through the process of menstruation. Abnormal vaginal bleeding in women who are. Cervical Cancer Cervical cancer is cancer of the entrance to the womb (uterus). Regular pelvic exams and Pap testing can detect precancerous... Cervical Dysplasia Cervical dysplasia is a condition in which the cells of the inner lining of the cervix have precancerous changes. There are two... Uterine Growths Benign uterine growths are tissue enlargements of the female womb (uterus). Three types of benign uterine growths are uterine.

Bladder Spasms People who have bladder spasms, the sensation occurs suddenly and often severely. A spasm itself is the sudden, involuntary.. Sexual Problems (Sex) in Women Sexual dysfunction refers to a problem that arises during any phase of the sexual response cycle, preventing an individual or... Premature Menopause Premature menopause is when menopause occurs in a woman before the age of 40. Causes of premature menopause include premature...

uterus before hysterectomy

laparoscopical hysterectomy

transvaginal extraction of the uterus in total laparoscopical hysterectomy

cervical stump (white) after removal of the uterine corpus at laparoscopic supracervical hysterectomy

end of an laparoscopical hysterectomy

Indications
Hysterectomy is a major surgical procedure that has risks and benefits, and affects a woman's hormonal balance and overall health for the rest of her life. Because of this, hysterectomy is normally recommended as a last resort to remedy certain intractable uterine/reproductive system conditions. Such conditions include, but are not limited to:

Certain types of reproductive system cancers (uterine, cervical, ovarian, endometrium) or tumors, including uterine fibroids that do not respond to more conservative treatment options.[9] Severe and intractable endometriosis (growth of the uterine lining outside the uterine cavity) and/or adenomyosis (a form of endometriosis, where the uterine lining has grown into and sometimes through the uterine wall musculature), after pharmaceutical or other surgical options have been exhausted.[9] Chronic pelvic pain, after pharmaceutical or other surgical options have been exhausted.[9] Postpartum to remove either a severe case of placenta praevia (a placenta that has either formed over or inside the birth canal) or placenta percreta (a placenta that has grown into and through the wall of the uterus to attach itself to other organs), as well as a last resort in case of excessive obstetrical haemorrhage.[10] Several forms of vaginal prolapse.[9]

Types of hysterectomy

Schematic drawing of types of hysterectomy

Hysterectomy, in the literal sense of the word, means merely removal of the uterus. However other organs such as ovaries, fallopian tubes and the cervix are very frequently removed as part of the surgery.

Radical hysterectomy : complete removal of the uterus, cervix, upper vagina, and parametrium. Indicated for cancer. Lymph nodes, ovaries and fallopian tubes are also usually removed in this situation. Total hysterectomy : Complete removal of the uterus and cervix, with or without oophorectomy. Subtotal hysterectomy : removal of the uterus, leaving the cervix in situ.

Subtotal (supracervical) hysterectomy was originally proposed with the expectation that it may improve sexual functioning after hysterectomy, it has been postulated that removing the cervix causes excessive neurologic and anatomic disruption, thus leading to vaginal shortening, vaginal vault prolapse, and vaginal cuff granulations. These theoretical advantages were not confirmed in practice, but other advantages over total hysterectomy emerged. The principal disadvantage is that risk of cervical cancer is not eliminated and women may continue cyclical bleeding (although substantially less than before the surgery). These issues were addressed in a systematic review of total versus supracervical hysterectomy for benign gynecological conditions, which reported the following findings:[13]

Benefits
Hysterectomy is usually performed for serious conditions and is highly effective in curing those conditions. The Maine Women Health Study of 1994 followed for 12 months time approximately 800 women with similar gynecological problems (pelvic pain, urinary incontinence due to uterine prolapse, severe endometriosis, excessive menstrual bleeding, large fibroids, painful intercourse), around half of whom had a hysterectomy and half of whom did not. The study found that a substantial number of those who had a hysterectomy had marked improvement in their symptoms following hysterectomy, as well as significant improvement in their overall physical and mental health one year out from their surgery. The study concluded that for those who have intractable gynecological problems that had not responded to non-surgical intervention, hysterectomy may be beneficial to their overall health and wellness. Somewhat surprisingly, ovarian cancer risk after hysterectomy appears to be substantially lowered even when the ovaries are preserved.[35]

Adverse effects

Mortality and surgical risks

Short term mortality (within 40 days of surgery) is usually reported in the range of 16 cases per 1000 when performed for benign causes. Risks for surgical complications are presence of fibroids, younger age (vascular pelvis with higher bleeding risk and larger uterus), dysfunctional uterine bleeding and parity.[36]

Convalescence
Hospital stay is 3 to 5 days or more for the abdominal procedure and between 2 to 3 days for vaginal or laparoscopically assisted vaginal procedures. Time for full recovery is very long and largely independent on the procedure that was used. Depending on the definition of "full recovery" 3 to 12 months have been reported. Serious limitations in everyday activities are expected for a minimum of 4 months.

Unintended oophorectomy and premature ovarian failure

Removal of one or both ovaries is performed in a substantial number of hysterectomies that were intended to be ovary sparing.[40] The general extraction by surgery of an ovary and a fallopian tube is called unilateral salpingooophorectomy, but if both pairs of ovaries and fallopian tubes are surgically removed the process is called a bilateral salpingo-oophorectomy. The procedure is carried out to treat ovarian cancers or other gynecological cancers, also pelvic inflammatory disease or relative infections.

Effects on sexual life and pelvic pain

After hysterectomy for benign indications the majority of women report improvement in sexual life and pelvic pain. A smaller share of women report worsening of sexual life and other problems. The picture is significantly different for hysterectomy performed for malignant reasons, the procedure is often more radical with substantial side effects.[43][44] A proportion of patients who undergo a hysterectomy for chronic pelvic pain will continue to suffer from pelvic pain after a hysterectomy and will develop dyspareunia (painful sexual intercourse).[45]

Premature menopause and its effects

Estrogen levels fall sharply when the ovaries are removed, removing the protective effects of estrogen on the cardiovascular and skeletal systems.

Urinary incontinence and vaginal prolapse

Urinary incontinence and vaginal prolapse are well known adverse effects that develop with high frequency a very long time after the surgery. Typically, those complications develop 1020 years after the surgery.[

Adhesion formation and bowel obstruction

The formation of postoperative adhesions is a particular risk after hysterectomy because of the extent of dissection involved as well the fact the hysterectomy wound is in the most gravity-dependent part of the pelvis into which a loop of bowel may easily fall.[60] In one review, incidence of small bowel obstruction due to intestinal adhesion were found to be 15.6% in non-laparoscopic total abdominal hysterectomies vs. 0.0% in laparopscopic hysterecomies.[34]

Other rare problems

Hysterectomy may cause an increased risk of the relatively rare renal cell carcinoma. The increased risk is particularly pronounced for young women, the risk was lower after vaginally performed hysterectomies.[

Alternatives

Myomectomy

Sutured uterus wound after myomectomy

Depending on the indication there are alternatives to hysterectomy :

Heavy bleeding
Levonorgestrel intrauterine devices are highly effective at controlling dysfunctional uterine bleeding (DUB) or menorrhagia and should be considered before any surgery.[65]

Uterine fibroids
Further information: uterine fibroids Levonorgestrel intrauterine devices are highly effective in limiting menstrual blood flow and improving other symptoms. Side effects are typically very moderate because the levonorgestrel (a progestin) is released in low concentration locally. There is now substantial evidence that Levongestrel-IUDs provide good symptomatic relief for women with fibroids.[67]

Prolapse
Prolapse may also be corrected surgically without removal of the uterus.[70]