Hysterectomy (Surgical removal of the uterus)

Removal of the uterus

Parts of the Body Involved

• Uterus (a partial or subtotal hysterectomy)
• Uterus and cervix, which is the opening of the uterus leading to the vagina (a total, complete, or simple hysterectomy)
• Uterus, ovaries, fallopian tubes, upper part of the vagina, and the pelvic lymph nodes (a radical hysterectomy)
• Ovaries and fallopian tubes (a salpingo-oophorectomy; may be combined with any of the above procedures)

Reasons for Procedure

A hysterectomy is performed in almost all cases of uterine cancer that have not spread beyond the uterus (metastasized).

Although controversial, a hysterectomy may also be done to treat these conditions of the uterus when they do not respond to other methods of treatment:

• Uterine fibroids (myomas) - non-cancerous growths in the uterus that, if they grow large enough, can cause pain and irregular or heavy bleeding.
• Abnormal uterine bleeding - may be caused by fibroids, hormonal changes, infection, or cancer.
• Endometriosis – the growth of tissue from the uterine lining outside of the uterus on the ovaries, fallopian tubes, and other organs. Endometriosis may cause pain, irregular bleeding, infertility, and painful intercourse.
• Uterine prolapse - the muscles and ligaments that normally support the uterus become weak and unable to provide support. This can be caused by obesity, chronic cough, excess stretching in childbirth, and aging.
• Chronic pelvic pain - this can result from a variety of conditions, and requires an accurate diagnosis before treatment is determined.
• Adenomyosis - benign tumors made of gland tissue and muscle.
• Adenomatous hyperplasia – excessive growth of the endometrial cells (lining the uterine cavity) that may progress to endometrial cancer.
• Cervical dysplasia – abnormalities of the cells that line the cervix, which may be a precursor for cervical cancer.
• Uncontrollable hemorrhaging after delivery.

Risk Factors for Complications during the Procedure

• Obesity
• Smoking
• Iron-deficiency anemia
• Heart or lung disease
• Diabetes
• Previous pelvic surgery or serious infection
• Use of some prescription and nonprescription drugs; inform your doctor of any drugs, medications, or supplements you are using or have used in the last month

What to Expect

Prior to Procedure

Your doctor will likely do the following:

• Blood and urine tests
• X-ray of abdomen and kidneys
• Pelvic ultrasound – a test that uses sound waves to visualize the inside of the body
• Dilation and curettage (D&C) - surgical removal of tissue from the lining of the uterus to diagnose or treat gynecologic or obstetric conditions

In the days leading up to the procedure:

• Arrange for a ride to and from the procedure
• Arrange for help at home after returning from the hospital
• In order to clean out your intestinal track, you'll take one or more enemas
• The night before, eat a light meal and do not eat or drink anything after midnight
• Antibiotics may be given to prevent infection
• Your abdominal and/or pelvic areas will be shaved

During Procedure - IV fluids and medications, a bladder catheter, and in rare cases, a blood transfusion may be required. Depending on the reason for the surgery, other organs and tissues may be removed and/or repaired.

Anesthesia - General or local, depending on the kind of procedure

Description of the Procedure - There are three different methods:

Abdominal hysterectomy: A cut is made in the lower abdomen to expose the tissues and blood vessels that surround the uterus and cervix. These tissues are cut and the blood vessels are tied off to remove the uterus. Stitches are placed in these deep structures, which will eventually dissolve and do not need to be removed. The uterus is removed from the top of the vagina and the vagina is closed to prevent infection and to keep the intestines from dropping downward.

Vaginal hysterectomy: The vagina is stretched and kept open by special instruments; no external incision is made. The doctor does, however, make an internal incision at the top of the vagina around the cervix. The uterus and cervix are cut free from their supporting ligaments and surrounding tissue, and connecting blood vessels are tied off. The uterus and cervix are removed through the vagina, which is then closed to prevent infection and to keep the intestines from dropping downward.

Laparoscopically assisted vaginal hysterectomy (LAVH): A laparoscope is inserted through a small cut near the navel. This small, telescope-like device, about the width of a pencil, with a light on one end and a magnifying lens on the other, helps the doctor see the pelvic organs. The abdomen is inflated with a harmless gas (carbon dioxide) to improve your doctor's visibility and room to work. Images from the laparoscope are viewed on a special monitor.

Other small (1/4 to 1/2 inch wide) cuts are made in the abdomen, through which the doctor inserts instruments to help move organs and remove the uterus. A cut is also made where the uterus joins the vagina. The bladder and rectum are gently pushed off the uterus, which is removed through the cut made in the vagina. The vagina is closed to prevent infection and to keep the intestines from dropping downward. The cuts are all closed with stitches, which will likely leave small scars.

With each procedure, a vaginal "packing" dressing is placed in the vagina. This will be removed after a day or two.

After Procedure - All removed tissue is sent to a lab to be analyzed. IV fluids and medications will be continued in the recovery room

How Long Will It Take? 1-3 hours

Will It Hurt? Anesthesia prevents pain during the procedure. Expect some pain, pelvic fullness, bloating, and vaginal bleeding or discharge during the first few days after surgery. You'll be given pain medication to help relieve this discomfort.

Possible Complications:

Thrombophlebitis (blood clots in the veins or lungs)
Infection (at the wound site or deep inside the abdomen or pelvis)
Vaginal and/or internal bleeding
Bowel obstruction
Injury to the intestines, bladder, or urinary tract
Persistent pain
Anesthesia-related problems, such as breathing trouble, reactions to the drugs, and poor pain relief
Diminished sexual response
Fatigue
Weight gain
Depression
Nausea and vomiting (usually mild)
Fistula formation, which occurs when a hole forms between the bladder, intestines, and vagina
Urinary incontinence
Bleeding, which may require blood transfusions
For LAVH only - temporary shoulder pain due to the carbon dioxide gas used for the laparoscopy
Average Hospital Stay: 1-5 days

Postoperative Care:

The first night after the surgery, you may be asked to sit up in bed and walk a short distance.
The next morning, if there is no evidence of complications and you are able to drink fluids on your own, the catheter in your bladder and IV will be removed.
To promote healing, eat a balanced diet rich in fresh fruits and vegetables. Depending on how much blood loss occurred during surgery, you may require a daily iron supplement.
Try to avoid constipation. Eat high-fiber foods, drink plenty of water, and if necessary, use stool softeners.
Shower instead of taking a bath for at least the first 2 weeks after your surgery.
Keep your incision sites clean and dry.
Do not douche or put anything in your vagina, such as a tampon, until your doctor tells you otherwise.
Return to your normal activities gradually; most normal activities, including sex, can be resumed in about six weeks.
Take daily walks as tolerated.
Avoid heavy lifting for four to six weeks.
If you have a subtotal hysterectomy, and therefore still have your cervix, you will still need pap smears on a regular basis to check for cervical abnormalities.
Ask your practitioner when and how to perform Kegel exercises. These exercises can strengthen the muscles of the pelvic floor and prevent/improve urinary incontinence, as well as enhance sexual pleasure.

• Outcome
• Physical
• Removing the uterus ends abnormal bleeding, reduces pelvic pressure, and removes fibroids. Some other conditions, though, such as cancer, endometriosis, and pelvic adhesions may continue or return.
• After a hysterectomy, you will no longer have monthly periods and you can no longer get pregnant; birth control is not necessary. If your ovaries have been left in place, though, you will still produce hormones and eggs, but they will dissolve in your abdomen.
• If the ovaries are removed (oophorectomy), your body's main source of estrogen and other sex hormones is gone. If you were not already postmenopausal, this sends your body into an instant menopause and you will experience typical menopausal symptoms, such as hot flashes. Hormone replacement therapy is usually recommended.
• Emotional
• Some women have strong emotional reactions, including depression, in response to the loss of their uterus.
• Sexual
• Some women notice a change in their sexual response after a hysterectomy. Because the uterus has been removed, uterine contractions you may have felt during orgasm will no longer occur. If the ovaries have been removed, vaginal dryness may be a problem, but is usually relieved with the use of estrogen.
• Some women report an increase in their sexual enjoyment, possibly because they are relieved of the pain from the condition that prompted this procedure, or no longer need to worry about an unintended pregnancy.

Call Your Doctor If Any of the Following Occurs

• Signs of infection, including fever and chills
• Persistent or heavy vaginal bleeding or discharge, or foul-smelling vaginal discharge
• Calf pain
• Severe pain
• Redness, swelling, increasing pain, excessive bleeding, or discharge from the incision sites
• Problem with urination or bowel movements
• Cough, shortness of breath, chest pain, or severe nausea or vomiting
• Pain, burning, urgency, frequency of urination, or persistent bleeding in the urine
• Pain and/or swelling in your feet, calves or legs, sudden shortness of breath or chest pain

SOURCES:

American College of Obstetrics and Gynecologists

American Medical Association