Hysterectomy is one of the frequent surgeries in gynecology. The main indications for hysterectomy are uterine cancer and endometriosis.
Hysterectomy is an operation to remove a uterus. Sometimes a hysterectomy can be combined with the removal of the ovaries (ovarectomy) and fallopian tubes (tubovarectomy).
Indications for hysterectomy
- Uterine cancer, cervical cancer. Depending on the stage of cancer and its prevalence, hysterectomy can be combined with other treatments, such as chemotherapy and radiation therapy;
- Uterine fibroids. Myoma is a benign tumor of the uterus, the main manifestations of which can be abundant uterine bleeding, anemia, pelvic pain, etc. In some cases, hysterectomy is the only method that radically solves this problem;
- Endometriosis. In this disease, the inner lining of the uterus (endometrioid) begins to develop in the woman’s body: in the ovaries, fallopian tubes, abdominal organs, etc. In the case of failure of conservative treatment and typical surgical interventions, the uterus is removed;
- Constant and profuse vaginal bleeding. If these bleedings are not amenable to conservative treatment, hysterectomy can give a positive result.
Laparoscopic hysterectomy methods do not involve any large incisions in the abdomen when the operation is performed. The whole surgery is performed using laparoscopic equipment when tubes are inserted into the abdominal cavity through small incisions, and through them appropriate instruments are inserted, as well as a video camera. A gas is introduced into the abdominal cavity through a cannula inserted at the very beginning. The gas raises the abdominal wall above the organs, giving the surgeon an overview and the opportunity to gain access to the uterus.
Laparoscopically assisted transvaginal hysterectomy
Laparoscopically assisted vaginal hysterectomy (LAVH) is the most frequently performed and most effective of the three procedures. With the help of three or four ports, a surgeon inspects the abdominal cavity and, if necessary, separates the commissures. Then, funnel-pelvic or own ligaments of the ovary are sutured, depending on whether the ovaries are removed. The round ligament is dissected, the peritoneum is separated and the bladder is separated from the uterus. At this stage, there is a greater risk of bladder damage compared with abdominal or vaginal hysterectomy. At this stage, the uterine arteries sometimes coagulate and intersect laparoscopically, although this also increases the risk of damage to the ureter compared to abdominal or vaginal hysterectomy. And, finally, a surgeon opens up behind the space. Next, the operation is performed from the part of the vagina. The surgeon cuts the anterior vesicovaginal septum anteriorly in order to get into the anterior cystic-uterine cavity, ligates the uterine vessel, if this has not been done before, removes the uterus and ovaries, if appropriate, and sutures the vaginal stump.
Laparoscopic hysterectomy is the second most common method. The beginning of the operation is similar to a laparoscopically assisted vaginal hysterectomy, except that the entire hysterectomy is performed laparoscopically. This approach is often used with a slight omission of the uterus or when a vaginal approach is not possible. After the ligaments of the ovaries and the round ligaments are tied and crossed, the bladder is separated from the anterior surface of the uterus. The ureters are identified, after which the uterine vessels and the sacro-uterine ligaments are coagulated and dissected. The postoperative space is opened, the vagina is separated circumferentially from the cervix, the surgical material is removed. The stump is sutured laparoscopically or transvaginally.
Supracervical hysterectomy is the third most common approach to laparoscopic hysterectomy for benign processes. The beginning of the operation is similar to laparoscopically assisted vaginal hysterectomy and laparoscopic hysterectomy. The body of the uterus is cut from the cervix at the level of the isthmus. To minimize residual cyclic vaginal bleeding and reduce the risk of dysplasia and cervical cancer, the glandular tissue of the mucous membrane of the cervical canal is removed or cauterized. The body of the uterus is removed through a 12 mm abdominal port using an electric morcellator. This approach eliminates both vaginal and abdominal dissection, thereby reducing the risk of infectious complications. The risk of damage to the ureter is also reduced, as the procedure stops above the level of the internal os. However, the risk of subsequent development of dysplasia and cervical cancer remains due to the presence of a cervical stump. For this reason, Papanicolaus smears need to be taken from patients, and some women may need additional surgery related to cervical pathology. In addition, at least two randomized clinical trials failed to capture changes in bladder function or sexual function. The same studies indicate a high frequency of repeated operations due to bleeding and stump loss. And although few studies have been conducted to assess the value of laparoscopic hysterectomy, the role of the operation was proven after a large multicenter randomized study that compared laparoscopic hysterectomy with abdominal and vaginal. The results of the study showed that the laparoscopic approach has no advantages over the vaginal one. It was also noted that laparoscopic access does not cause severe postoperative pain, reduces the woman’s stay in the hospital and contributes to a more rapid recovery compared with abdominal access. Studies have also shown a slight increase in the risk of damage to the urinary tract when using the laparoscopic approach. A shorter hospital stay after laparoscopic hysterectomy compensates for some of the additional costs for a longer operation and use of equipment.
Preoperative examination includes standard clinical and laboratory studies for planned operations in gynecology. These are general blood and urine tests, biochemical blood tests, blood tests for clotting, ECG, ultrasound. Preoperative preparation of patients who are preparing for laparoscopic hysterectomy and have a large uterus size may consist in prescribing gonadotropin releasing hormone preparations. They allow, in particular, to reduce the size of the uterus and nodes in myoma. Such treatment usually lasts 3 to 6 months. In addition, in anemia associated with bleeding, hemoglobin levels in the blood are improved.
Usually, the day before or during surgery, a broad-spectrum antibiotic is administered to the patient to prevent infectious complications intravenously. A patient should not eat 8 hours before the operation. On the evening before the operation, bowel cleansing is performed with enema. Before surgery, a catheter is inserted into the bladder, which is removed a day later.
Possible complications of laparoscopic operations
Among the possible complications of laparoscopic interventions are the accidental injury of internal organs, injury of blood vessels, the effect of the injected gas on the body, the formation of adhesions in the pelvis, the formation of hematomas or seromas, infectious complications. However, in general, the frequency of complications during laparoscopic operations is less than with traditional ones.
Contraindications for laparoscopic operations
- Prolapse of the uterus. In these cases, it is easier to perform the removal of the uterus by vaginal access;
- The large size of the uterus is a relative contraindication for laparoscopic access, as an experienced surgeon can perform a laparoscopic hysterectomy for sizes greater than 20 weeks of gestation;
- Cystic formations of the ovaries, the dimensions of which do not allow their removal intact.
Life after surgery
Some doctors believe that leaving the cervix during surgery can help preserve sexual function or avoid problems with pelvic support (bladder prolapse, urinary incontinence). Several good studies, however, showed that these hypotheses are not entirely correct – no particularly sensitive difference was found in this matter. However, if there is a good medical reason for an organ-sparing surgery, the woman certainly needs to leave the cervix. A contraindication may be a poor PAP test and severe endometriosis.
In recent years, more and more gynecologists have been offering their patients the opportunity to leave the cervix and at least one of the ovaries in place when performing a hysterectomy. Only valid medical reasons serve as the basis for the removal of any organ. Before the surgery, you will receive all the explanations about the necessary surgery and alternative treatment options.