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What
is a Hysterectomy?
Hysterectomy means the excision of the uterus (womb).
It remains the commonest major surgical operation performed
by gynaecologists. Approximately 50,000 hysterectomies
are performed each year in the UK and 700,000 in the United
States. In the US it is estimated that one third of women
will undergo hysterectomy by the age of sixty. Hysterectomy
is most commonly performed for menstrual problems, including
the treatment of uterine fibroids or endometriosis, but
in approximately 20% of cases it is performed as treatment
for cancer.
A diagram of the womb and ovaries is shown in Figure
1. The uterus normally
lies in the centre of the pelvis and is quite a small
pear-shaped organ weighing approximately 50g. It may become
very distorted or enlarged, however, by diseases such
as uterine fibroids or endometriosis, as well as by pregnancy.
The uterus consists of two main parts: the corpus (body),
and the cervix (neck). The corpus of the uterus has thick
muscular walls and is designed to carry pregnancies. The
muscle of the uterus contains a lot of fibrous and elastic
tissue, and it is this that is responsible for the common
development of fibroids. The cavity of the uterus is normally
a very small slit-like potential space at its centre,
since the uterus contracts down when empty. The lining
of the cavity is called the endometrium. This is shed
together with blood during menstruation.
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Subtotal and Total Hysterectomy
A total hysterectomy involves removal of the corpus and
the cervix, and since the 1940s has become the standard
type of hysterectomy performed in the UK and USA, most
commonly through an abdominal incision (total abdominal
hysterectomy or TAH for short. The organs removed are
shown in Figure
2. A subtotal hysterectomy
involves removal of the body of the womb only, preserving
the cervix. Subtotal hysterectomy is also usually performed
through the abdomen, but lends itself well to a laparoscopic
surgical approach which has a much shorter recovery time.
Subtotal hysterectomy is probably best considered for
uterine fibroids or for dysfunctional uterine bleeding.
It is not ideal for women with endometriosis, as deposits
of endometriosis often lie immediately behind the cervix
in the pelvic cul-de-sac or in the space between the rectum
and vagina, and may continue to be a cause of pain if
the cervix is preserved. Rarely, a subtotal hysterectomy
is performed by gynaecologists because the planned removal
of the cervix is abandoned when the operation turns out
to be unexpectedly difficult technically.
Removal of the cervix in a total hysterectomy involves
more dissection of the bladder than required in a subtotal
hysterectomy, and therefore it is thought that performing
a subtotal may be less likely to cause injury to the bladder
or ureters, or to lead to less urinary symptoms than following
a total hysterectomy. However, this was not confirmed
in the only randomized controlled trial comparing these
two types of hysterectomy. There was also no difference
in sexual function post operatively between the two groups
of women in this study. Nevertheless, concerns over sexual
problems following hysterectomy probably remain the commonest
reason women consider a having a subtotal hysterectomy.
There is good evidence to suggest that women with significant
gynaecological problems who undergo hysterectomy as treatment
actually have an improvement in both their quality of
life and have greater enjoyment from their sex lives than
pre-operatively.
For many women, a subtotal hysterectomy may be very good
treatment for their particular problems, while for others
a total hysterectomy would be more appropriate, depending
on their individual circumstances. As the cervix is preserved
in a subtotal hysterectomy, it is of course essential
to continue to have cervical smear tests. For most women
having a total hysterectomy smears will no longer be necessary.
However, sometimes smears are taken from the top of the
vagina for follow-up surveillance following cancer treatment,
or if there were pre-cancerous cells in the cervix. Following
subtotal hysterectomy, it is normal to continue to notice
changes in cervical mucus secretion during one’s
monthly cycle, and occasionally you may have a very light
period or brown discharge at the time of menstruation.
This may occur because of a small remaining area of the
endometrium persisting at the top of the cervix after
the corpus has been excised.
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Abdominal Hysterectomy
Total abdominal hysterectomy is the most frequently performed
type of hysterectomy performed in the UK and USA, and
represents the standard form of hysterectomy surgery.
‘Abdominal’ refers to the approach to the
operation, which is performed through an incision on the
abdomen or tummy. The incision used is most commonly a
low transverse incision, which may be either straight
or curved (Pfannenstiel), or in a vertical line below
the umbilicus. In most cases a low transverse incision
is preferred, as these heal well with good cosmetic result.
Vertical incisions allow greater access for the surgeon,
and hence are preferred for hysterectomy for removing
a very large uterus or ovarian cyst. For the same reason
a vertical incision is often preferred when performing
a hysterectomy for cancer of the uterus or ovary. The
different incisions used are shown in Figure
3.
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Vaginal Hysterectomy
Vaginal hysterectomy involves removal of the corpus and
cervix through a circumferential incision around the cervix
in the vagina. The operation is essentially the same as
that performed trans-abdominally, but the steps in the
operation are performed in reverse order. This has the
advantage of avoiding an incision on the abdomen altogether
and as a result is much less painful and recovery is much
faster. Vaginal hysterectomy is most commonly performed
for uterine prolapse, often together with a pelvic floor
repair procedure. However, in skilled hands, even quite
a large fibroid uterus may be removed through the vagina
even when there is no prolapse. A large study co-ordinated
by the Royal College of Obstetricians and Gynaecologists
confirmed that this method is associated with less post-operative
pain, shorter hospital stay and faster return to normal
activities than abdominal hysterectomy, and was less prone
to complications than laparoscopic hysterectomy.
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The Ovaries and Fallopian Tubes
The fallopian tubes and ovaries are attached to the body
of the uterus and are often removed together with the
uterus at the time of hysterectomy. Removal of the tubes
and ovaries is called bilateral salpingo-oophorectomy
by doctors. Total hysterectomy refers to the cervix and
corpus of the uterus: it does not refer to the tubes and
ovaries, and is a common source of confusion. The organs
removed are shown in Figure
4. Specific consent
from you is required before the tubes and ovaries are
removed. As well as producing your eggs they produce the
majority of your oestrogen hormones. Your gynaecologist
should discuss this with you fully, together with its
implications.
Laparoscopy may be used in combination with a vaginal
hysterectomy to remove the tubes and ovaries at the same
time. In some cases it may be possible to remove the tubes
and ovaries through the vagina, but in many cases it is
easier and safer to perform this with laparoscopic assistance
from above.
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Laparoscopic Hysterectomy and
Laparoscopically Assisted Vaginal Hysterectomy (LAVH)
These techniques combine the advantages of the excellent
view of the pelvic organs offered by laparoscopy to the
surgeon, combined with the benefits of reduced post-operative
pain and faster recovery offered by vaginal hysterectomy.
The uterus is removed via the vagina as described previously,
but part of the surgery is performed viewed from above
under visual control via the laparoscope. The surgery
may be tailored to the individual, and differing proportions
of the operation may be performed from above or from below
depending on the individual circumstances. Technically
speaking, if the uterine blood vessels are divided laparoscopically
the operation is called a total laparoscopic hysterectomy,
and if they are divided through the vagina, this is called
a laparoscopically assisted vaginal hysterectomy (LAVH).
In practice the two names are often interchanged, and
there is very little difference between the two techniques.
The main advantage to the surgeon in performing a laparoscopy
at the time of hysterectomy is the superb view obtained
of the top surface of the uterus, the tubes and ovaries
and the other pelvic and abdominal organs. It is also
a safe way of detaching the tubes and ovaries under direct
vision if these need to be removed and any adhesions may
be divided. Other procedures such as treatment of deposits
of endometriosis can be performed at the same time in
this way.
Subtotal hysterectomy may also be performed laparoscopically,
preserving the cervix, using a laparoscopic morcellator
to remove the uterine corpus. Once the uterine corpus
has been divided from the cervix and its surrounding organs,
it is removed piecemeal in long strips using the morcellator
which is inserted through a small 15mm incision in the
tummy wall. This technique is suitable for either moderate
sized uterine fibroids or for dysfunctional uterine bleeding
for women who wish to preserve their cervix.
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