Laparoscopic Hysterectomy Surgery Treatment | Uterus Treatment | Aastha Healthcare | Super Speciality Center Hospital | India

What is uterus?

Uterus is a hollow, muscular, pear shaped organ often referred to as Womb since Biblical times. It has two tubes called fallopian tubes connected to it at one end and to the ovary at the other. When an egg cell is released from an Ovary it travels to the uterus via these fallopian tubes. It is a very remarkable organ capable of expanding to contain a full-grown baby and of shedding its lining up to 500 times during the life that is during the time of monthly period. The resultant stresses and strains on its supporting structures during pregnancies and the repeated shedding and re-growth of its lining may lead to problems.

What is hysterectomy?

Hysterectomy merely means surgical removal of uterus. It is the second most common major operation performed today. Hysterectomy involves removal of the uterus, and sometimes the ovaries too (oophorectomy). Often one or both ovaries and fallopian tubes are removed at the same time a hysterectomy is done. So depending upon what is removed, hysterectomy can be classified as:

Sub-total or partial hysterectomy It involves the removal of Fallopian tubes and the upper two-thirds of the uterus only, preserving the cervix. Hysterectomy with ovarian conservation It involves the removal of the Fallopian tubes, uterus and the cervix, while preserving the ovaries. Hysterectomy with oophorectomy It involves the removal of the Fallopian tubes, uterus and cervix, together with one or both sets of ovaries. Radical or Wertheim's hysterectomy It involves the removal of the Fallopian tubes, uterus, cervix, ovaries as well as nearby lymph nodes and the upper portion of the vagina. This type of hysterectomy is used in the treatment of some gynaecological cancer cases.

Before having a hysterectomy, it is very important to discuss the implications you're your gynaecologist and partner. Your doctor may recommend a hysterectomy if none of the treatments for the various conditions have worked. Ofcourse in some cases, there is no other choice than hysterectomy.

Why should one go for hysterectomy?

Hysterectomy is used to treat :

Fibroids- This is the most common reason for which hysterectomies are done. For many women with fibroids, symptoms are minimal and require no treatment. Also, the fibroids often shrink after menopause. But in some cases, fibroids can cause heavy bleeding or pain in some women. Endometriosis- This happens when the tissue lining the inside of your uterus grows outside the uterus on your ovaries, fallopian tubes, or other pelvic or abdominal organs. The surrounding tissue may become scarred, and often other organs such as the uterus, bladder or the rectum may become stuck down in these scars (adhesions). When medication and surgery do not cure endometriosis, a hysterectomy often is performed. Uterine prolapse- This is when the uterus moves from its usual place down into the vagina. This can lead to urinary problems, pelvic pressure, or difficulty with bowel movements. Cancer- Cancer of the uterus, cervix, or ovary, is another cause for hysterectomy. Persistent vaginal bleeding- If menstrual flow is heavy, not regular, or last for many days and non-surgical methods have not helped to control bleeding, a hysterectomy may bring relief. But ofcourse the physician screens the candidate if she is suitable for the surgery. Chronic pelvic pain- Surgery is a last resort for women who have chronic pelvic pain that clearly comes from the uterus.

Often a doctor will have a fairly good idea of the type of the problem after examining and listening to the patient's symptoms. The doctor will make detailed notes of medical history and the patient's concerns. The physician will then inform the patient about different types of hysterectomy procedures. It is important that women understand the full implications of the removal or certain reproductive organs so that they can be properly prepared for any resultant side effects.

Before the surgery

The doctor will once again examine the patient thoroughly. The blood will probably be tested for hormone levels and also a pelvic ultrasound scan may be recommended. If the scan shows any abnormalities or is unclear, the doctor may want to investigate further using hysteroscopy, a procedure in which a viewing device is inserted into the uterus. A sample of the lining of the womb (endometrium) may be taken. Endometrial sampling is done either as an outpatient procedure, or by D&C-dilatation and curettage, usually when under a general anaesthesia. In a D&C, the cervix is opened (dilatation) and the lining of uterus (the endometrium) will be systematically scraped (curettage) with a long, thin instrument. The strips of the lining will then be examined under a microscope. Preparation for both vaginal and abdominal hysterectomy is similar. She will be given a suppository to empty the bowels the night before. She will be told not to eat or drink anything on the day of the surgery about 6 to 8 hours before the surgery. Anaesthesia is given. It can be general, epidural or spinal anaesthesia. A catheter (a narrow silicon tube) is inserted into the bladder to empty it. The operation area is cleaned thoroughly with antiseptic before the operation.

The surgery

The actual hysterectomy operation can be performed in several different ways. The method chosen will depend on the surgeon's skills, expertise and preference, the reason for the hysterectomy and the woman's characteristics (e.g. weight, previous pelvic surgery, if she has had children). There are presently following ways to perform a hysterectomy:

Abdominal hysterectomy Vaginal hysterectomy Laparoscopic method

Abdominal hysterectomy

Initially this used to be the only method to remove the uterus. Ofcourse now options like laparoscopy have become the preferred choice of surgeons all over the world. But in some cases this method is still employed e.g. When there is a need for extensive exploration (in the case of cancer)or if the uterus is enlarged or if the woman has never had children or is obese. This surgery requires a four to eight inch abdominal incision to remove the uterus, and ovaries, if needed. An abdominal hysterectomy can be performed in two ways, with a vertical incision or a bikini line cut. A vertical incision generally involves a cut from the navel to the pubic hairline. The bikini line cut, as its name suggests, is done horizontally, directly above the pubic hairline. It leaves a less obvious scar and results in a shorter recovery time. The presences of large fibroids, extensive adhesions or endometriosis are other examples where this procedure is often preferred. The advantages of an abdominal hysterectomy are lower incidence of damage to the urinary tract and blood vessels. It also allows the repair of a prolapse at the same time. But it is the least preferred route by patients because of the hospital stay, abdominal scar, pain, and disability; but it is sometimes the only route possible.

Vaginal hysterectomy

This is the next most frequently employed technique of hysterectomy. The surgeon operates entirely through the vagina, pulling the uterus down through the vagina into view, disconnecting the cervix and then the rest of the uterus. To use the vaginal route, a woman must usually have had a baby or two which widens the vagina and relaxes the connections of the uterus so it can be pulled down into the vagina to do the operation. There is no abdominal scar. It usually requires only two days in the hospital and about two weeks away from work. Vaginal hysterectomy is always preferred route if all the specific requirements are met-i.e. small uterus, no cancer, and vaginal laxity. It can not always be done for massive uterus. It is also not always possible to remove the ovaries because they are attached much higher in the pelvis than the uterus and cannot always be pulled down into the vagina for surgical removal.

The advantages of this method are less pain, a shorter hospital stay and recovery time and the absence of a visible scar. A review of different surgical approaches to hysterectomy for non-cancerous conditions concluded that a vaginal hysterectomy should be performed in preference to an abdominal hysterectomy where possible.

Laparoscopic hysterectomy

This merely means a hysterectomy in which any part of the operation is performed laparoscopically. Laparoscopy is a minimally invasive approach that involves specialized video equipment and instruments that allow a surgeon to remove the uterus through four tiny incisions, most of which are less than a half-centimetre in size. It allows the uterus to be detached from inside the body by laparoscopic instruments while the doctor is viewing the uterus, tubes, and ovaries through a camera attached to a telescope. All laparoscopic surgery is performed under general anaesthesia with endotracheal intubation. The use of a naso-gastric tube avoids injury to the stomach and reduces bowel distension. The patient is placed in the dorso-lithotomy position, with the legs supported by stirrups and adjusted to permit mobilization of the uterus by the nurse or the assistant surgeon. Now in this case also, just like in conventional methods, uterus can be removed via abdomen or through vagina. But while performing laparoscopic surgery, if the surgeon at any time feels that it is not possible to remove the uterus laparoscopically, he can convert into an open procedure. This type of surgery involves passing from one to five small plastic tubes through half-inch incisions in the abdominal wall, providing a video picture of the inside of the abdominal cavity. Long slender surgical instruments can be used through these tiny "ports" to perform operations, such as removing the uterus, ovaries or performing biopsies. After the uterus is detached, it is removed through a small incision at the top of the vagina.

Laparoscopic surgeries have become the preferred choice for physicians all over the world. The first laparoscopic hysterectomy (LH) was performed in January 1988 by Harry Reich in Pennsylvania. This new procedure was designed to be an alternative to abdominal hysterectomy. Laparoscopic hysterectomy can be of two types:

Laparoscopic Assisted Vaginal Hysterectomy (LAVH): Total Laparoscopic Hysterectomy

Laparoscopic Assisted Vaginal Hysterectomy (LAVH):

This also involves removal of the pelvic organs through the vagina but includes starting with cutting the ovarian attachments by working through the laparoscopes in the abdomen. This surgery is done under general anaesthesia. After the patient is "asleep," a retractor is placed through the vagina into the cervix. This helps to move the uterus around so that different areas of the uterus can be visualized. LAVH may be performed through 3 incisions: one 10-12 mm umbilical incision and two 5 mm lateral incisions. Carbon dioxide gas is used to fill the abdomen so that organs within the abdominal cavity are not injured when the instruments are placed inside. The laparoscope (which is similar to a periscope) is placed through the belly button incision. The instrument that grasps, coagulates, and cuts is placed through one of the other small incisions and the third incision is used for the retractor held by the assistant surgeon. The uterus with or without the tubes and ovaries are released from their blood supply and released from the cervix. The cervix is then supported by placing permanent sutures in the ligaments holding up the cervix to avoid falling later on. The canal in the centre of the cervix is also coagulated in order to avoid any monthly bleeding. Harmonic scalpel is the most preferred tool for coagulation. The uterus and tubes and ovaries (if they are being removed) are brought out in strips and sent to pathology to be evaluated for disease. After the abdomen is thoroughly checked for any bleeding, the instruments are removed and the gas that was used to fill the abdomen is emptied. The incisions are closed with sutures.

Usually two days in the hospital are needed with two weeks away from work. This is the next most preferred route for qualifying women. Most operating OB/GYN doctors can do this procedure, but not all. The doctor has to be especially trained in this procedure.

Total Laparoscopic Hysterectomy

This procedure involves disconnecting the uterus, and other structures as needed, by operating only through the laparoscopes in the abdomen, starting at the top of the uterus. The entire uterus is disconnected from its attachments using long thin instruments through the "ports." The early stages of total laparoscopic hysterectomy are performed in the same way as LAVH. When the broad ligament has been dissected the surgeon ties the uterine pedicle It is essential at all times to be aware of the position of the ureters and to ensure that all haemostatic procedures are carried out at a distance from them. Elevation of the uterus allows the ureters to separate further from the uterus. Then all tissue to be removed is passed through the vagina or through the tiny half-inch abdominal incisions. A massive ovarian cyst can be removed without rupturing it inside the abdominal cavity by placing it in a sturdy surgical-grade pouch and passing the pouch out the vagina or, after collapsing the cyst inside the pouch, passing it out through the "port" incision. If the uterus is massively enlarged it can be disconnected from its attachments, then cut into tiny pieces and passed down the vagina.

Abdominal scars consist of two to four tiny one-half inch incisions, one inside the belly-button, one in the top portion of the pubic hair just above the pubic bone, and one each just to the middle side of the front of the hip bone. Additionally hospitals with modern technology offer alternative methods of achieving haemostasis( stopping of blood). These include haemostatic clips. Automatic stapling is popular with some surgeons. These devices consist of two jaws each containing a triple row of micro-titanium staples which produce haemostasis.

TLH can thus be performed on women who have never had children, women with narrow or long vaginas, women with previous surgeries, women with cancer, and women with massive organs. This technique is the least painful and least debilitating route of surgery for women who need hysterectomy but do not qualify to have a vaginal hysterectomy. Laparoscopic hysterectomy has been shown to be associated with a shorter hospital stay and recovery than abdominal hysterectomy. Women having laparoscopic subtotal hysterectomy may have an even faster recovery.

Total Abdominal Hysterectomy (TAH) Vaginal Hysterectomy (VH) Large incision or "bikini cut" (4-6 inches) Tissues of the abdominal wall are stretched and uterus is removed Requires 3-5 day hospital stay; normal activity can usually resume in 6 weeks Incision (approximately 1 inch) made at the top of the vagina Uterus and cervix are separated from the body and removed through the vagina Abdominal walls are not stretched Requires 1-3 day hospital stay; normal activity can usually resume in 4 weeks

Laparoscopically Assisted Vaginal Hysterectomy (LAVH) Laparoscopic Supracervica l Hysterectomy (LSH) and Total Laparoscopic Hysterectomy (TLH) Laparoscope (miniature camera) is inserted through a small incision to view the uterus and surrounding orhans Uterus isdetached under view of the laparaoscope using special tools inserted through small incisions Incision (approx. 1 inch) made at the top of the vagina Uterus and cervix are removed through the vaginal incision Requires 1-3 day hospital stay; normal activity can usually resume in 4 weeks Using only laparoscopic tools, uterus is seperated from the body and removed through one of the abdominal incisions As LSH leaves the cervix in place; a TLH rem0oves both the uterus and the cervix Requires 1-3 day hospital stay; normal activity can usually resume in 4 weeks.

After the surgery

The average hospital stay depends on the type of hysterectomy performed, but is usually from 2 to 3 days. Complete recovery may require 2 weeks to 2 months. Recovery from a vaginal or laparoscopic hysterectomy is faster than from an abdominal hysterectomy, and may include less pain. Removal of the ovaries along with the uterus in premenopausal women causes immediate menopause, and oestrogen replacement therapy may be recommended. Some patients report that the incisions feel a little sore and the residual gas in the belly hurts a bit. This gas often collects under the right diaphragm and causes the sensation of right shoulder pain. Intravenous and oral medications are used after the surgery to relieve postoperative pain. A catheter may remain in place for 1 to 2 days to help the bladder pass urine. Moving about as soon as possible helps to avoid blood clots in the legs and other problems. Normal diet is encouraged as soon as possible after bowel function returns. The physician may advice to take some precautions like avoiding lifting heavy things etc. th epatient may also be recommended to take Hormone Replacement Therapy (HRT) which means replacing the missing female hormone oestrogen with tablets.

Benefits and drawbacks of laparoscopic hysterectomy

One advantage of laparoscopic hysterectomy is that the incisions are smaller (1/2 inch) and much less uncomfortable than that of abdominal hysterectomy. So people are able to resume normal activity in about 2 weeks. So Laparoscopic hysterectomy has many advantages like:

Less postoperative pain May shorten hospital stay May result in a quicker return to bowel function Quicker return to normal activity Better cosmetic results

However, the surgeon must be experienced in the procedure before these benefits can be seen or else complications may occur. Disadvantages include a possible longer operating time (depends on how much of the operation is performed laparoscopically), higher costs and an increased risk of damage to the urinary tract. So, if we were to compare an open surgery with a laparoscopic surgery, we can display it in a nutshell as under:

LAPAROSCOPIC OPEN Small Incisions (less than ½ an inch) Large Incision Hospital stay is 1 to 3 days Hospital stay of about 5 days Patients usually return to work in 5 to 10 days Return to work in about 4 weeks Lesser risk of Infection Greater risk of infection Less pain More painful Less chance of hernias More chance of hernias

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