Minimally Invasive Surgery & Procedures Laparoscopic Hysterectomy

A hysterectomy is an operation to remove a woman’s uterus (womb) and this can be done in different ways:

Total Laparoscopic Hysterectomy (TLH)

A TLH is an operation to remove the womb including the cervix and fallopian tubes through four small cuts on the lower abdomen. This is known as keyhole surgery. Sometimes one or both ovaries are removed at the same time (oophorectomy). In a total laparoscopic hysterectomy (TLH) the surgeon will remove the womb and the cervix (neck of the womb). You will discuss with Dr McMurray the advantages and disadvantages of removing your ovaries or leaving them (conserving them).

Laparoscopic Subtotal Hysterectomy (LASH)

A LASH is an operation to remove the womb but preserving the neck of the womb (cervix). This is a form of keyhole surgery performed through four small cuts on the lower abdomen. Sometimes one or both ovaries are removed at the same time, both fallopian tubes will be removed during surgery. The actual uterus is cut up within the abdominal cavity using a special device called a morcellator, before being removed in strips. A LASH should not be performed in women who either don’t attend for regular smears or have a history of abnormal smears. The operation should not be performed on women in whom malignancy is suspected.

The operation tends to be quicker, have less blood loss and less pain that other forms of hysterectomy. The risk of complications is also less as it does not require surgery to the cervix which has adjacent structures which can sometimes be damaged during surgery. By leaving the cervix behind ligaments which support the womb are not damaged and this theoretically may reduce the risk of prolapse in the future. There was a suggestion by some research some years ago that a when the cervix was conserved post hysterectomy women had better bladder and sexual function more recent research is conflicting. About 5% of women in whom the cervix is conserved will continue to have cyclical spotting. You will discuss with Dr McMurray the advantages and disadvantages of removing your ovaries or leaving them (conserving them). The procedure has become controversial in the United States of America because of a handful of high profile cases when the operation was performed inadvertently in women who turned out to have uterine cancer. Dr McMurray believes that it is still an excellent choice of procedure for most women who require a hysterectomy.

Laparoscopic Assisted Vaginal Hysterectomy (LAVH)

This is keyhole form of hysterectomy where through 3 small cuts in your abdomen a hysterectomy is started and the operation completed vaginally. The whole uterus including the cervix and both fallopian tubes are removed. The ovaries can be conserved if wished. This type of surgery is performed if there is a degree of uterine prolapse present. It has the same advantages as the other forms of laparoscopic hysterectomy.

Total Abdominal Hysterectomy (TAH)

Abdominal Hysterectomy is the removal of the uterus (body and cervix), through a surgical incision made on the abdominal wall. The incision is normally between 15 – 20 cm in length usually below the bikini line. You may need removal of one or both ovaries but this depends on the reason for your hysterectomy. This can be discussed with Dr McMurray.

Why do I need a hysterectomy?

A hysterectomy may be carried out to treat many different conditions especially if other treatments have failed for:

  • Painful Heavy or irregular periods
  • Ovarian Cysts
  • Fibroids
  • Suspected or proven cancer of the womb or cervix or ovaries.

If you have a had a hysterectomy

  • You won’t have any more periods, if you have had a LASH you won’t have any more periods but 5% of woman may have spotting
  • You can’t become pregnant- so there is no need for contraception

A hysterectomy does NOT mean:

  • Premature ageing
  • Becoming less of a woman or losing your sex drive
  • A space left inside your body, this does not happen as the bowel naturally moves to fill the space.

How will a hysterectomy help me?

  • The benefits of hysterectomy depend of the type and severity of problems that you are having. Your hysterectomy may be part of a continuing treatment or it may mean the end of a health problem.
  • Dr McMurray will discuss with you the chances of a hysterectomy leading to a cure or improvement in your condition. You should weigh this against the severity of your condition and other available treatments and also against the risk of not having the operation.
  • Overall, 90% of women who have a hysterectomy are satisfied with the operation.
  • Problems like very heavy periods and any related pain will be cured by a total hysterectomy.
  • The benefits of a laparoscopic procedure include less pain, quicker recovery, reduced risks from infection and clot formation and less scarring both inside and outside on the abdomen as compared to an abdominal hysterectomy.

Sub-total hysterectomy or total hysterectomy?

In a sub-total hysterectomy the cervix is not removed. There are several potential benefits to this:

  • The operation is easier and quicker
  • The risk of damage to your bladder or ureters (tubes from your kidney to your bladder) is lower
  • The risk of you suffering a prolapse of the vagina in future may be reduced
  • You will lose less blood during the operation
  • You are likely to spend less time in hospital
  • You are less likely to develop a fever after your operation

However, there are some possible disadvantages of sub-total hysterectomy:

  • You may still experience spotting every month at the time of your periods- this occurs in about 5% of women
  • The cervix continues to be a potential site for cancer in the future and you will need regular smears

The risks of hysterectomy

There are risks associated with all operations. Although a hysterectomy is a relatively safe operation and serious side effects are not very common, it is still a major operation. You need to be aware of the risks when deciding on the right treatment for you. We will help you weigh up the risks and benefits and what the alternatives may be for you.

  • Damage to the bladder or bowel: During the operation the surgeon may accidentally damage organs that are nearby. Damage to the bladder or one of the tubes which drain the kidneys (the ureters) occurs in about 1 in 150 women. Very rarely there can be damage to the bowel- 1 in 2500 women.
  • The risk of damage to the surrounding organs is higher in women who have had previous operations like caesarean sections or women with endometriosis. If such damage occurs, you may need an additional operation which was not planned. This happens in about 1 in 500 women.
  • Excessive bleeding – This may occur during the operation (about 1 in 50) women, or after the operation (about 1 in 75 women). If this happens you may require a blood transfusion or you may need to return to the operating theatre to stop the bleeding this will usually be apparent within the first 24 hours after surgery. Bleeding can occur a week or two after the operation and this is usually blood clots escaping from the vagina as the stitches used to close the vagina naturally lose their tension. Rarely heavy bleeding can occur several weeks after the surgery.
  • If you do not wish to have a blood transfusion under any circumstances, please discuss with your consultant before the operation.
  • Blood clots  in the legs  (deep vein thrombosis) or lungs (pulmonary embolus). Blood clots can form in a leg and this occurs in less than 1 in 250 women. A blood clot can move to the lungs causing a very serious condition called pulmonary embolism. You will be given preventative treatment to reduce the risk of blood clots forming (stockings to wear and injections to reduce the clotting capacity of your blood).
  • Infection– Infection may occur inside the abdomen or pelvis (1 in 500 women). Infection may also affect the bladder, lungs, or the cuts on your abdomen. Most infections are easily treated with a course of antibiotics, but others can be more severe. You will be given antibiotics following surgery to reduce the risk of infection.

What happens after the operation?

The first few days…

  • Most women experience some pain or discomfort for the first few days and we will give you painkillers (usually just tablets) to help with this. We will encourage you to take the painkillers, as being pain free will speed up your recovery. Have an anaesthetic, being in pain and having strong painkillers may make you feel nauseous or sick and we can give you an injection or tablets to help with this. Many women also get wind pains a few days after the operation, which can be uncomfortable and make the tummy look swollen. This should not last long and can be relieved by medicines, eating and walking about. Most women are up and about on their feet quickly. You may have some light vaginal bleeding and will need to wear a sanitary pad/linen for a couple of days.
  • Your vaginal loss should change to a creamy discharge over the next 2-3 weeks. (If you have any new plain, fresh bleeding or bad smelling discharge after you go home, you should contact the clinic. Patients having a TLH/LAVH/TAH may experience increased bleeding 10-14 days following surgery and this is usually because of the (dissolvable) vaginal stiches losing their tension and allowing clots to pass vaginally. This is nothing to be concerned about unless the blood loss is very heavy or very smelly (which might indicate an infection).

Going home and your longer term recovery

  • Women having a LASH can go home the same day of surgery providing it was done early in the day, the surgery was uncomplicated and the woman is keen to go home and has a supportive environment at home.
  • Most women will stay in hospital for about 2 days after a TLH/TAH, but it could be longer. Your exact day of discharge will depend on the reasons for your operation, your general health and how smoothly things go after surgery.
  • It is important to remember that everyone’s experience is different and so it is best not to compare your own recovery with that of others on the ward.
  • Some women can feel emotionally low or tearful for a few days after their operation. This is a natural reaction and you should try not to worry about it. It may take 4-8 weeks to recover and get back to your normal routine your body has been through a lot of stress and needs time to repair itself.

Longer term emotional reaction

Some younger women feel emotionally low for a longer period. This depends on many factors, including the reason for your operation, how emotionally prepared you are for it, timing of the operation, and whether your problem is cured. Some women feel depressed because they can no longer have children. However with proper pre-operative counselling and patient selection the risk of this is reduced. If these problems persist you should discuss them with your GP.

Sex after hysterectomy

We advise you to avoid penetrative intercourse for about 6 weeks, until everything has healed up and you’ve had your check-up with your doctor. You may experience a change in sexual response after the operation. Many women say their sex life is improved because there is no longer discomfort or the risk of pregnancy. If your ovaries have been removed, vaginal dryness may be a problem during sex. A lubricating gel, which you can buy from the chemist may help. Dr McMurray can also advise you about oestrogen cream or hormone replacement therapy. Because the womb has been removed, contractions that may have been felt during orgasm will no longer occur.

Exercise and weight gain

Initially, because you are feeling better, experiencing reduced levels of activity and increase in appetite, you might tend to put on weight. By paying attention to what you eat and increasing your activity level as you recover, weight gain need not be a problem. Walking is an excellent way to exercise. Gradually increase the length of your walks, but remember to only walk the distance you can achieve comfortably. Cycling and swimming are equally good.

Driving

We recommend that you do not drive for 2 weeks and then check with your doctor at your follow you appointment before starting to drive again. (It would be advisable to also check with your insurance company about when you can start to drive again). It may be helpful to first sit in the car while it is parked and see if you could do an emergency stop without it hurting.

Cervical Smears

If you have had a total hysterectomy (the cervix has been removed) you will no longer need cervical smear tests. If the cervix has not been removed, you will need to continue to have cervical smears.

Hormone Replacement Therapy (HRT)

The decision to use HRT is a personal one. If your ovaries are not removed, there is no need to use HRT. If your ovaries are removed, Dr McMurray will discuss HRT with you but would not recommend starting treatment for at least 6 weeks.